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The effectiveness of face to face education using catharsis education action (CEA) method in improving the adherence of private general practitioners to national guideline on management of tuberculosis in Bandung, Indonesia

The effectiveness of face to face education using catharsis education action (CEA) method in... Background: In many countries, private general practitioners are the first contact in health services for people with symptoms of tuberculosis. Targeting the private sector has been recommended in previous studies to improve tuberculosis control. A brief face-to-face intervention using Catharsis Education Action (CEA) method, repeated at periodic intervals, seems to change physicians’ attitudes, beliefs and practice. The objective of the study was to determine the effectiveness of CEA method in improving the private general practitioners’ (PPs) adherence to the national guideline on the management of tuberculosis patients in Bandung District, Indonesia. Method: A randomized controlled trial was done. For the intervention group, a session of the CEA method was delivered to PPs while brief reminder with provision of pamphlet was used for the comparative group. Results: A total of 82 PPs were included in the analysis. The intervention group showed some positive trends in adherence especially in the use of sputum as first laboratory examination (RR = 1.24) and follow up (RR = 1.37), though not reaching statistical significance. After intervention PPs in CEA group maintained the adherence, but PPs in pamphlets group showed deterioration (score before to after: -12.5). Conclusion: Face to face education using CEA method seems to be as effective as brief reminder with provision of pamphlet in improving the adherence. CEA offers additional information that can be useful in designing intervention programs to improve the adherence to guideline. Background age group (15-54 years). An adult with TB loses on Mycobacterium tuberculosis infects one-third of the average three to four months of work time [1,2]. world’s population and imposes a global burden of an Indonesia with a population of over 220 millions car- estimated 8 million new cases and 1.8 million deaths ries the heavy burden of TB. Indonesia still ranks third yearly [1]. More than 90% of global tuberculosis (TB) among the 22 high-burden countries [2]. In Bandung, cases and deaths occur in the developing world, where one of the cities in West Java Province, Indonesia, case 75% of cases are in the most economically productive detection rate (CDR) did not reach the Indonesia target of 70% [3]. The Government of Indonesia considers TB control to be a high priority within the health-care sys- tem [3-5]. A strategy for incremental involvement of the Correspondence: nitarisanti@yahoo.com Public Health Department, Faculty of Medicine, Universitas Padjadjaran Bandung Indonesia © 2012 Arisanti; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Arisanti Asia Pacific Family Medicine 2012, 11:2 Page 2 of 5 http://www.apfmj.com/content/11/1/2 private practitioners in DOTS (Directly Observed Treat- presumed that appropriate behavior changes will be ment) implementation had been developed. easier to accomplish after emotional burdens are Private General Practitioners (PPs) are the first contact released and new information and insight are provided. for TB patients. Their involvement is linked to the suc- Implementation of the needed behavioral changes her- cess of the TB control [6]. In Indonesia, it is generally alds the action phase [17]. believedthatabout athird of allTBcases might be partly or completely managed in the private sector [5]. Methods Many studies indicated that PPs tended to deviate from A randomized controlled trial was done to compare the recommended tuberculosis management guidelines [6]. effectiveness of the CEA method to the alternative Physicians’ adherence with guidelines varies with differ- method of brief reminders with provision of pamphlets ent types of “patient” and with the length of clinical on the management of tuberculosis. experience [6-10]. Adherence to program recommenda- The study was conducted in six primary health care tions such as National Tuberculosis Programs (NTPs) is centers in the Bandung District with the highest preva- important for TB control. lence of TB. With the sampling frame composed of 288 Many strategies can be used to improve the adher- PPs, the 86 PPs who met the inclusion criteria were ran- ence. Since clinical behavior is still a form of human domized according to a computer generated randomiza- behavior, psychological models of behavior change may tion schedule. The inclusion criteria for the PPs were be applied to modify practices of healthcare profes- (1) registered in the District Health Office; (2) had sionals [11-14]. patients with any of the following: features compatible Counseling, a face-to-face psychoeducation method with TB, sputum (+), chest X ray PA (+) and (3) willing can promote positive human interactions. The Catharsis to record and maintain TB registries. The allocation of Education and Action (CEA) method is a counseling PPs to either CEA or pamphlet group was done by con- technique that takes on many features of Carl Roger’s cealed allocation wherein group assignments were coded person-centered psychotherapy. This method brings out and placed in sealed envelopes. Written informed con- the psychological concerns that result from wrong per- sent was obtained from the participants of this study ception of reality and hinder appropriate behavior. These have been called emotionally critical mispercep- Intervention group tions (ECMs). If addressed appropriately, barriers are The intervention sessions were conducted in the PPs’ lifted and educational inputs are better received. This practice. The first session was about twenty minutes. A method focuses not only on the problems but also on protocol was developed to guide the investigator in con- the opportunities for improvement and development ducting this method (Appendix 1). At this time, the PPs’ [15-17]. As its name implies, the CEA method consists problems in their management of tuberculosis patients of three phases: catharsis, education and action. In the were clarified and defined (catharsis phase).The inter- catharsis phase, the counselor spends time to clarify or active case analysis and two-way communication for define the problem. In the process, hidden emotions scientific evidence were employed in the education surface and ventilated so that they do not disturb the phase. After the education phase, the PPs committed to analytical functions of the mind [17-19]. In this phase, implement the NTP (action phase). The second session the PPs’ problems in their management of tuberculosis was conducted for about ten minutes, three months patients are clarified and defined. Concerns about bar- after the first. At the sixth month, the outcomes were riers and enablers to adherence to NTP (such as perso- evaluated. nal interest, patient choice and availability of diagnostic equipment and treatment) are addressed and explored. Comparative group Through the utilization of active listening skills, genu- In the comparative group, the PPs received a brief ineness, empathy and unconditional positive regard, one reminder with pamphlet on the management of tubercu- can accurately pinpoint and correct the most anxiety- losis and NTP protocols. The number of sessions and provoking ECM. Once the ECM identified and cor- the evaluation of short-term effects were the same for rected, it will now be easier to objectively analyze the the intervention group. problem. In this study, the discussion focused on identi- The primary outcome was adherence to tuberculosis fying suspected TB patients, performing laboratory guideline (NTP). Checklist for reviewing the patient’s examination, treatment for TB patients, organizing fol- medical record was used by the investigator to assess low ups, maintaining TB registries and DOTS imple- adherence to NTP. This checklist covered the diagnosis mentation. It is in the education phase, that of TB, treatment and follow up in accordance to NTP misperceptions are corrected using scientific evidence or and the recording of treatment outcomes and all perti- the latest information available about the problem. It is nent data such as all medications given, laboratory Arisanti Asia Pacific Family Medicine 2012, 11:2 Page 3 of 5 http://www.apfmj.com/content/11/1/2 results, bacteriologic response, and adverse reactions Flow of Subjects during the Study (Appendix 2). This study assessed three medical charts in each practice to be chosen by the PP. Knowledge was Identification of potential study subjects assessed with aquestionnaireadapted from amanual developed by the WHO in 2006 [20]. It covered knowl- edge on the diagnosis, treatment, follow up in accor- Eligible subjects, n=86 4 PPs* refused dance to NTP and treatment outcomes. The to take part in the study questionnaire was validated prior to the study. The score for knowledge and adherence was calcu- Treatment group Comparative group lated based on correct answer and performance for each n=43 n=39 item. The mean scores from both groups were used for the cut off point describing the PPs’ knowledge and Intervention I Intervention I adherence. A score above the mean was regarded as 6 PPs lost to 4 PPs lost to good knowledge or adherence. Those who scored the follow up follow up cut-off point or above were considered as having good Intervention II and follow knowledge and the rest as poor knowledge. The Wil- Intervention II and follow up at 3 months up at 3 months n=37 coxon Signed Ranks test was used to assess the change n=35 of score before and after study in both groups. The level of significance was set at p < 0.05. Analysis was based Follow up at 6 months Follow up at 6 months on intention-to-treat. Results st The data collection was done from September 1 2007 Outcome measurements Outcome measurements until February 29, 2008. Of 86, four PPs refused to take n=37 n=35 part in the study (43 face to face education using CEA method group, 39 brief reminder using pamphlet group). All PPs who began an educational activity com- pleted all learning activities, and tests. In the final eva- *PPs= Private General Practitioners luation six PPs lost to follow up in the intervention Figure 1 Flow of the study. This figure gives a brief description group and four PPs in the control group (Figure 1). regarding the flow of study. The PPs’ characteristics are shown in Table 1. Thirty nine percent participants in CEA group and 38.5% in pamphlet group had attended training in tuberculosis and from physician factors like experience, motivation, and most of them attended once since they began prac- non-familiarity with guideline and lack of training. ticing. Meanwhile, most PPs were not involved in the TB control program. Discussion The study evaluated the knowledge and the adherence The findings of this study contribute to the benefit of of PPs in both groups. The mean scores from the psychoeducational strategies in influencing physician knowledgequestionnaireswere65 for theCEA group behavior. At the individual level the CEA method and and 76 for the pamphlet group. With these cut-off pamphlet produces better knowledge sustained in six points, 51.2% of CEA group had good knowledge while months. Acquisition of knowledge was provided in this 53.8% of the pamphlet group did. The corresponding study using discussion and case analysis conducted cut-off points in adherence to guideline were 79 for twice within six months. Based on the Linear Model of CEA group and 70 for pamphlet group (Table 2). Half Information Processing, for input to be transformed into of PPs in both groups had good adherence to guideline. long-term memory, the process of rehearsal such as After the intervention, there was no improvement in repeating the case analysis is very much needed. The the mean score of adherence to TB guideline in either result of this process is knowledge retention. group (Table 3). PPs in CEA group maintained the This study showed that CEA method has the same same mean score while PPs in pamphlets group showed effect as brief reminder with provision of pamphlet. The deterioration though not of statistical significance. possible explanation for the minimal difference between Some concerns and problems on tuberculosis control the two groups might be the limited time spent to com- were found during the CEA sessions. These included plete the CEA sessions for some PPs. For all PPs, con- patient factors like socioeconomic background, stigma cerns were elicited and addressed but time for education of TB in the community, and health seeking behavior; was occasionally shortened by the PPs themselves. Their Arisanti Asia Pacific Family Medicine 2012, 11:2 Page 4 of 5 http://www.apfmj.com/content/11/1/2 Table 1 Baseline Characteristics of Participants in the CEA and the Pamphlet Groups Private general practitioner characteristics CEA group (n = 43) Pamphlet group (n = 39) p-value Mean age (SD) 32.42 (6.99) 42.15 (12.68) < 0.001* Sex, No (%) 0.075** Male 18 (41.9) 24 (61.5) Female 25 (58.1) 15 (38.5) Number of training on tuberculosis attended 0.257** � Less than 1 39 (90.7) 39 (100) � More than 1 4 (9.3) - Provider, No (%) n = 17 n = 15 0.491** � Academic institution 5 (29.4) 3 (20) � District/Provincial Health office 11 (64.7) 12 (80) � Drug company 1 (5.9) Involvement in tuberculosis control program, No (%) 0.054** Yes 10 (23.3) 3 (7.7) No 33 (76.7) 36 (92.3) Mean estimated number of TB cases treated per year since starting of practice (SD) 6.49 (9.4) 2.05 (2.75) 0.006* Mean estimated number of TB patient completing the treatment per year (SD) 2.79 (7.76) 1.18 (1.6) 0.207* Practice population n = 31 n = 24 � Social economic status, No (%) 0.295** ✓ Upper class 1 (3.2) 0 ✓ Middle class 8 (25.8) 3 (12.5) ✓ Lower class 22 (71) 21 (87.5) � Educational level, No (%) 0.237** ✓ No school 3 (9.7) 0 ✓ Elementary school 13 (41.9) 9 (37.5) ✓ High school 15 (48.4) 15 (62.5) * Independent t-test ** Chi-square test; Statistically significant at p ≤ 0.05 busy schedule prompted the investigator to summarize characteristics of PPs such as training, experience in the NTP education phase of the CEA session. In deliver- treating TB patients and involvement in the TB ing education method to PPs, materials and methods program. needed to be adapted to their special needs and working During CEA sessions, PPs ventilated their reluctance conditions. At the baseline the PPs already had high to treat TB patient because of the high dropout rate. adherence to NTP and in the six-month follow up they They also regarded themselves not having enough did not have enough more TB patients. This fact might experience in treatment. Low motivation and lack of account for no improvement in adherence to NTP. If confidence were thus PPs’ ECM in tuberculosis control. the study was continued for a longer time, PPs would The CEA sessions brought to light these concerns and perhaps see more TB patients and showed more adher- could help to improve PPs’ adherence to NTP. The deterioration in adherence to NTP in the pamph- ence to NTP. The other possible reasons were the let group might be due to the PPs’ background. They were significantly older and saw less TB patients (Table Table 2 The knowledge and adherence of PPs in CEA 1). While longer years of clinical practice might be asso- group and pamphlet group ciated with more professional experience, routine work Knowledge Adherence over many years might also tend to blunt the physician’s CEA Pamphlet CEA Pamphlet readiness to accept new scientific evidence and conse- group group group group quently inhibit modification of practice. Mean score 64.95 76 (16.59) 79.17 69.64 (26.39) (SD) (19.39) (10.7) Limitation of Study Poor, no (%) 21 18 (46.15%) 10 9 (42.86%) (48.84%) (47.62%) This CEA method was conducted in PPs practice setting Good, no (%) 22 21 (53.85%) 11 12 (57.14%) where they should attend to patients as well. For some (51.16%) (52.38%) PPs, the CEA session was conducted in ten minutes Arisanti Asia Pacific Family Medicine 2012, 11:2 Page 5 of 5 http://www.apfmj.com/content/11/1/2 Table 3 Change in median score of knowledge and adherence before and after intervention CEA group Pamphlet group Before n = 43 After n = 37 Change p-value* Before n = 39 After n = 35 Change p-value* Knowledge 71.43 92.86 21.43 < 0.001 78.57 92.86 14.29 < 0.001 Adherence 87.5 87.5 0 0.501 87.5 75 -12.5 0.096 * Wilcoxon Signed Ranks test Statistically significant at p ≤ 0.05 9. Uplekar M, Juvekar S, Morankar S, Rangan S, Nunn P: Tuberculosis Patients only. It seems that for some PPs the intervention was and Practitioners in Private Clinic in India. Int J Tuberculosis Lung Disease less efficient and less effective because of the rather 1998, 2(4):324-329. short time of intervention. 10. Thakur JS, Kar SS, Sehgal A, Kumar R: Private Sector Involvement in Tuberculosis Control in Chandigardh. Indian J Tuberculosis 2006, 53:149-153. Conclusions 11. Halm EA, Atlas SJ, Borowsky LH, Benzer TI, Metlay JP, Chang Y, Singer DE: Face to face education using Catharsis Education Action Understanding Physician Adherence with a Pneumonia Practice Guideline. Arch Pediatr Adolesc Med 2000, 160:98-104. (CEA) method seems to be as effective as brief reminder 12. Chenot JF, Scherer M, Becker A, Banzhof N, Baum E, Leonhardt C, Keller S, with provision of pamphlet in improving the adherence Pfingsten M, Hildebrant J, Dieter Basler H, Kochen MM: Acceptance and to recommended national guideline on the management Perceived Barriers of Implementating a Guideline for Managing Low Back in General Practice. Implementation Science 2008, 3:7. of tuberculosis patients (NTP). CEA offers additional 13. James PA, Cowan TM, Graham RP, Majeroni BA: Family Physicians’ information that could be useful in designing interven- Attitudes About and Use of Clinical Practice Guidelines. J Fam Pract 1997, tion programs to improve NTP adherence. 45(4):341-7. 14. Hrisos S, Eccles M, Johnston M, Francis J, Kaner EFS, Steen N, Grimshaw J: Developing the content of two behavioral interventions. Using theory- based interventions to promote GP management of upper respiratory Acknowledgements tract infection without prescribing antibiotics. BMC Health Services The author would like to thank to Josefina S Isidro - Lapeña, MD. MFM for Research 2008, 8:11-8. her guiding and suggestions in all steps of this study. 15. Lukens EP, McFarlane WR: Psychoeducation as Evidence-Based Practice: All the doctors who took the time to participate in this study are also most Consideration for Practice, Research and Policy. Brief Treatment and Crisis gratefully acknowledged. Intervention 2004, 4:205-225. 16. Tu K, Davis D: Can we alter physician behavior by educational methods? Authors’ contributions Lessons learned from studies of the management and follow-up of NA was the principal investigator of the study and involved in designing the hypertension. J Contin Educ Health Prof 2002, 22(1):11-22. study, supervising the data collection, reviewing/analyzing the data and 17. Dionisio A: Active listening skills in health education: The CEA method. writing the paper. In Counseling Skills for Caring Physicians: Individual Intervention. Edited by: Dionisio. Department of Family and Community Medicine, University of the Competing interests Philippines Manila; 2005:40-7. The author declares that they have no competing interests. 18. Unknown, The Tunnel Therapy. , Downloaded from www.allpsychonline. com on October 30, 2007. Received: 25 August 2010 Accepted: 27 March 2012 19. Marcos AM: The Effectiveness of the Family Catharsis Education Action Published: 27 March 2012 (CEA) Counseling on Treatment Adherence and Clinical Improvement among Patients with Pulmonary Tuberculosis at the Family Medicine References Clinic of the Philippines General Hospital. University of the Philippines; 1. World Health Organization: World Health Organization Report 2006. Treatment of Tuberculosis. Guidelines for National Programes , Downloaded 20. World Health Organization: Strengthening the teaching of tuberculosis from www.who.int on June 18, 2007. control in basic training programmes: a manual for instructors of nurses 2. World Health Organization: World Health Organization Report 2006. and other health-care workers. WHO; 2006, Downloaded from www.who. Global Tuberculosis Control. Country Profile , Downloaded from www.who. int on June 10, 2007. int on May 28, 2007. 3. Ministry of Health Republic Indonesia: Country Profile: National doi:10.1186/1447-056X-11-2 Tuberculosis Program. 2004, Downloaded from www.depkes.go.id on June Cite this article as: Arisanti: The effectiveness of face to face education 28, 2007. using catharsis education action (CEA) method in improving the 4. World Health Organization: National Tuberculosis Control Programs - adherence of private general practitioners to national guideline on South East Asia Region. 2006, Downloaded from www.who.int on January management of tuberculosis in Bandung, Indonesia. Asia Pacific Family 31, 2008. Medicine 2012 11:2. 5. World Health Organization: PPM DOTS in Indonesia: A Strategy for Action. Mission Report 2003, Downloaded from www.who.int on June 28, 2007. 6. Uplekar M, Pathania V, Paviglione M: Private Practitioners and Public Health: Weak Links in Tuberculosis Control. The Lancet 2001, 358:912-916. 7. Central TB Division: Directorate General of Health Services. Ministry of Health and Family Welfare. India. Involvement of Private Practitioners in the Revised National Tuberculosis Control Program. 2002, Downloaded from www.who.int on June 29, 2007 (5). 8. World Health Organization: Effective Partnership in TB Control., Downloaded from www.who.int on June 29, 2008. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

The effectiveness of face to face education using catharsis education action (CEA) method in improving the adherence of private general practitioners to national guideline on management of tuberculosis in Bandung, Indonesia

Arisanti, Nita
Asia Pacific Family Medicine , Volume 11 (1) – Mar 27, 2012
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Springer Journals
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Copyright © 2012 by Arisanti; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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1447-056X
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10.1186/1447-056X-11-2
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22449199
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Abstract

Background: In many countries, private general practitioners are the first contact in health services for people with symptoms of tuberculosis. Targeting the private sector has been recommended in previous studies to improve tuberculosis control. A brief face-to-face intervention using Catharsis Education Action (CEA) method, repeated at periodic intervals, seems to change physicians’ attitudes, beliefs and practice. The objective of the study was to determine the effectiveness of CEA method in improving the private general practitioners’ (PPs) adherence to the national guideline on the management of tuberculosis patients in Bandung District, Indonesia. Method: A randomized controlled trial was done. For the intervention group, a session of the CEA method was delivered to PPs while brief reminder with provision of pamphlet was used for the comparative group. Results: A total of 82 PPs were included in the analysis. The intervention group showed some positive trends in adherence especially in the use of sputum as first laboratory examination (RR = 1.24) and follow up (RR = 1.37), though not reaching statistical significance. After intervention PPs in CEA group maintained the adherence, but PPs in pamphlets group showed deterioration (score before to after: -12.5). Conclusion: Face to face education using CEA method seems to be as effective as brief reminder with provision of pamphlet in improving the adherence. CEA offers additional information that can be useful in designing intervention programs to improve the adherence to guideline. Background age group (15-54 years). An adult with TB loses on Mycobacterium tuberculosis infects one-third of the average three to four months of work time [1,2]. world’s population and imposes a global burden of an Indonesia with a population of over 220 millions car- estimated 8 million new cases and 1.8 million deaths ries the heavy burden of TB. Indonesia still ranks third yearly [1]. More than 90% of global tuberculosis (TB) among the 22 high-burden countries [2]. In Bandung, cases and deaths occur in the developing world, where one of the cities in West Java Province, Indonesia, case 75% of cases are in the most economically productive detection rate (CDR) did not reach the Indonesia target of 70% [3]. The Government of Indonesia considers TB control to be a high priority within the health-care sys- tem [3-5]. A strategy for incremental involvement of the Correspondence: nitarisanti@yahoo.com Public Health Department, Faculty of Medicine, Universitas Padjadjaran Bandung Indonesia © 2012 Arisanti; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Arisanti Asia Pacific Family Medicine 2012, 11:2 Page 2 of 5 http://www.apfmj.com/content/11/1/2 private practitioners in DOTS (Directly Observed Treat- presumed that appropriate behavior changes will be ment) implementation had been developed. easier to accomplish after emotional burdens are Private General Practitioners (PPs) are the first contact released and new information and insight are provided. for TB patients. Their involvement is linked to the suc- Implementation of the needed behavioral changes her- cess of the TB control [6]. In Indonesia, it is generally alds the action phase [17]. believedthatabout athird of allTBcases might be partly or completely managed in the private sector [5]. Methods Many studies indicated that PPs tended to deviate from A randomized controlled trial was done to compare the recommended tuberculosis management guidelines [6]. effectiveness of the CEA method to the alternative Physicians’ adherence with guidelines varies with differ- method of brief reminders with provision of pamphlets ent types of “patient” and with the length of clinical on the management of tuberculosis. experience [6-10]. Adherence to program recommenda- The study was conducted in six primary health care tions such as National Tuberculosis Programs (NTPs) is centers in the Bandung District with the highest preva- important for TB control. lence of TB. With the sampling frame composed of 288 Many strategies can be used to improve the adher- PPs, the 86 PPs who met the inclusion criteria were ran- ence. Since clinical behavior is still a form of human domized according to a computer generated randomiza- behavior, psychological models of behavior change may tion schedule. The inclusion criteria for the PPs were be applied to modify practices of healthcare profes- (1) registered in the District Health Office; (2) had sionals [11-14]. patients with any of the following: features compatible Counseling, a face-to-face psychoeducation method with TB, sputum (+), chest X ray PA (+) and (3) willing can promote positive human interactions. The Catharsis to record and maintain TB registries. The allocation of Education and Action (CEA) method is a counseling PPs to either CEA or pamphlet group was done by con- technique that takes on many features of Carl Roger’s cealed allocation wherein group assignments were coded person-centered psychotherapy. This method brings out and placed in sealed envelopes. Written informed con- the psychological concerns that result from wrong per- sent was obtained from the participants of this study ception of reality and hinder appropriate behavior. These have been called emotionally critical mispercep- Intervention group tions (ECMs). If addressed appropriately, barriers are The intervention sessions were conducted in the PPs’ lifted and educational inputs are better received. This practice. The first session was about twenty minutes. A method focuses not only on the problems but also on protocol was developed to guide the investigator in con- the opportunities for improvement and development ducting this method (Appendix 1). At this time, the PPs’ [15-17]. As its name implies, the CEA method consists problems in their management of tuberculosis patients of three phases: catharsis, education and action. In the were clarified and defined (catharsis phase).The inter- catharsis phase, the counselor spends time to clarify or active case analysis and two-way communication for define the problem. In the process, hidden emotions scientific evidence were employed in the education surface and ventilated so that they do not disturb the phase. After the education phase, the PPs committed to analytical functions of the mind [17-19]. In this phase, implement the NTP (action phase). The second session the PPs’ problems in their management of tuberculosis was conducted for about ten minutes, three months patients are clarified and defined. Concerns about bar- after the first. At the sixth month, the outcomes were riers and enablers to adherence to NTP (such as perso- evaluated. nal interest, patient choice and availability of diagnostic equipment and treatment) are addressed and explored. Comparative group Through the utilization of active listening skills, genu- In the comparative group, the PPs received a brief ineness, empathy and unconditional positive regard, one reminder with pamphlet on the management of tubercu- can accurately pinpoint and correct the most anxiety- losis and NTP protocols. The number of sessions and provoking ECM. Once the ECM identified and cor- the evaluation of short-term effects were the same for rected, it will now be easier to objectively analyze the the intervention group. problem. In this study, the discussion focused on identi- The primary outcome was adherence to tuberculosis fying suspected TB patients, performing laboratory guideline (NTP). Checklist for reviewing the patient’s examination, treatment for TB patients, organizing fol- medical record was used by the investigator to assess low ups, maintaining TB registries and DOTS imple- adherence to NTP. This checklist covered the diagnosis mentation. It is in the education phase, that of TB, treatment and follow up in accordance to NTP misperceptions are corrected using scientific evidence or and the recording of treatment outcomes and all perti- the latest information available about the problem. It is nent data such as all medications given, laboratory Arisanti Asia Pacific Family Medicine 2012, 11:2 Page 3 of 5 http://www.apfmj.com/content/11/1/2 results, bacteriologic response, and adverse reactions Flow of Subjects during the Study (Appendix 2). This study assessed three medical charts in each practice to be chosen by the PP. Knowledge was Identification of potential study subjects assessed with aquestionnaireadapted from amanual developed by the WHO in 2006 [20]. It covered knowl- edge on the diagnosis, treatment, follow up in accor- Eligible subjects, n=86 4 PPs* refused dance to NTP and treatment outcomes. The to take part in the study questionnaire was validated prior to the study. The score for knowledge and adherence was calcu- Treatment group Comparative group lated based on correct answer and performance for each n=43 n=39 item. The mean scores from both groups were used for the cut off point describing the PPs’ knowledge and Intervention I Intervention I adherence. A score above the mean was regarded as 6 PPs lost to 4 PPs lost to good knowledge or adherence. Those who scored the follow up follow up cut-off point or above were considered as having good Intervention II and follow knowledge and the rest as poor knowledge. The Wil- Intervention II and follow up at 3 months up at 3 months n=37 coxon Signed Ranks test was used to assess the change n=35 of score before and after study in both groups. The level of significance was set at p < 0.05. Analysis was based Follow up at 6 months Follow up at 6 months on intention-to-treat. Results st The data collection was done from September 1 2007 Outcome measurements Outcome measurements until February 29, 2008. Of 86, four PPs refused to take n=37 n=35 part in the study (43 face to face education using CEA method group, 39 brief reminder using pamphlet group). All PPs who began an educational activity com- pleted all learning activities, and tests. In the final eva- *PPs= Private General Practitioners luation six PPs lost to follow up in the intervention Figure 1 Flow of the study. This figure gives a brief description group and four PPs in the control group (Figure 1). regarding the flow of study. The PPs’ characteristics are shown in Table 1. Thirty nine percent participants in CEA group and 38.5% in pamphlet group had attended training in tuberculosis and from physician factors like experience, motivation, and most of them attended once since they began prac- non-familiarity with guideline and lack of training. ticing. Meanwhile, most PPs were not involved in the TB control program. Discussion The study evaluated the knowledge and the adherence The findings of this study contribute to the benefit of of PPs in both groups. The mean scores from the psychoeducational strategies in influencing physician knowledgequestionnaireswere65 for theCEA group behavior. At the individual level the CEA method and and 76 for the pamphlet group. With these cut-off pamphlet produces better knowledge sustained in six points, 51.2% of CEA group had good knowledge while months. Acquisition of knowledge was provided in this 53.8% of the pamphlet group did. The corresponding study using discussion and case analysis conducted cut-off points in adherence to guideline were 79 for twice within six months. Based on the Linear Model of CEA group and 70 for pamphlet group (Table 2). Half Information Processing, for input to be transformed into of PPs in both groups had good adherence to guideline. long-term memory, the process of rehearsal such as After the intervention, there was no improvement in repeating the case analysis is very much needed. The the mean score of adherence to TB guideline in either result of this process is knowledge retention. group (Table 3). PPs in CEA group maintained the This study showed that CEA method has the same same mean score while PPs in pamphlets group showed effect as brief reminder with provision of pamphlet. The deterioration though not of statistical significance. possible explanation for the minimal difference between Some concerns and problems on tuberculosis control the two groups might be the limited time spent to com- were found during the CEA sessions. These included plete the CEA sessions for some PPs. For all PPs, con- patient factors like socioeconomic background, stigma cerns were elicited and addressed but time for education of TB in the community, and health seeking behavior; was occasionally shortened by the PPs themselves. Their Arisanti Asia Pacific Family Medicine 2012, 11:2 Page 4 of 5 http://www.apfmj.com/content/11/1/2 Table 1 Baseline Characteristics of Participants in the CEA and the Pamphlet Groups Private general practitioner characteristics CEA group (n = 43) Pamphlet group (n = 39) p-value Mean age (SD) 32.42 (6.99) 42.15 (12.68) < 0.001* Sex, No (%) 0.075** Male 18 (41.9) 24 (61.5) Female 25 (58.1) 15 (38.5) Number of training on tuberculosis attended 0.257** � Less than 1 39 (90.7) 39 (100) � More than 1 4 (9.3) - Provider, No (%) n = 17 n = 15 0.491** � Academic institution 5 (29.4) 3 (20) � District/Provincial Health office 11 (64.7) 12 (80) � Drug company 1 (5.9) Involvement in tuberculosis control program, No (%) 0.054** Yes 10 (23.3) 3 (7.7) No 33 (76.7) 36 (92.3) Mean estimated number of TB cases treated per year since starting of practice (SD) 6.49 (9.4) 2.05 (2.75) 0.006* Mean estimated number of TB patient completing the treatment per year (SD) 2.79 (7.76) 1.18 (1.6) 0.207* Practice population n = 31 n = 24 � Social economic status, No (%) 0.295** ✓ Upper class 1 (3.2) 0 ✓ Middle class 8 (25.8) 3 (12.5) ✓ Lower class 22 (71) 21 (87.5) � Educational level, No (%) 0.237** ✓ No school 3 (9.7) 0 ✓ Elementary school 13 (41.9) 9 (37.5) ✓ High school 15 (48.4) 15 (62.5) * Independent t-test ** Chi-square test; Statistically significant at p ≤ 0.05 busy schedule prompted the investigator to summarize characteristics of PPs such as training, experience in the NTP education phase of the CEA session. In deliver- treating TB patients and involvement in the TB ing education method to PPs, materials and methods program. needed to be adapted to their special needs and working During CEA sessions, PPs ventilated their reluctance conditions. At the baseline the PPs already had high to treat TB patient because of the high dropout rate. adherence to NTP and in the six-month follow up they They also regarded themselves not having enough did not have enough more TB patients. This fact might experience in treatment. Low motivation and lack of account for no improvement in adherence to NTP. If confidence were thus PPs’ ECM in tuberculosis control. the study was continued for a longer time, PPs would The CEA sessions brought to light these concerns and perhaps see more TB patients and showed more adher- could help to improve PPs’ adherence to NTP. The deterioration in adherence to NTP in the pamph- ence to NTP. The other possible reasons were the let group might be due to the PPs’ background. They were significantly older and saw less TB patients (Table Table 2 The knowledge and adherence of PPs in CEA 1). While longer years of clinical practice might be asso- group and pamphlet group ciated with more professional experience, routine work Knowledge Adherence over many years might also tend to blunt the physician’s CEA Pamphlet CEA Pamphlet readiness to accept new scientific evidence and conse- group group group group quently inhibit modification of practice. Mean score 64.95 76 (16.59) 79.17 69.64 (26.39) (SD) (19.39) (10.7) Limitation of Study Poor, no (%) 21 18 (46.15%) 10 9 (42.86%) (48.84%) (47.62%) This CEA method was conducted in PPs practice setting Good, no (%) 22 21 (53.85%) 11 12 (57.14%) where they should attend to patients as well. For some (51.16%) (52.38%) PPs, the CEA session was conducted in ten minutes Arisanti Asia Pacific Family Medicine 2012, 11:2 Page 5 of 5 http://www.apfmj.com/content/11/1/2 Table 3 Change in median score of knowledge and adherence before and after intervention CEA group Pamphlet group Before n = 43 After n = 37 Change p-value* Before n = 39 After n = 35 Change p-value* Knowledge 71.43 92.86 21.43 < 0.001 78.57 92.86 14.29 < 0.001 Adherence 87.5 87.5 0 0.501 87.5 75 -12.5 0.096 * Wilcoxon Signed Ranks test Statistically significant at p ≤ 0.05 9. Uplekar M, Juvekar S, Morankar S, Rangan S, Nunn P: Tuberculosis Patients only. It seems that for some PPs the intervention was and Practitioners in Private Clinic in India. Int J Tuberculosis Lung Disease less efficient and less effective because of the rather 1998, 2(4):324-329. short time of intervention. 10. Thakur JS, Kar SS, Sehgal A, Kumar R: Private Sector Involvement in Tuberculosis Control in Chandigardh. Indian J Tuberculosis 2006, 53:149-153. Conclusions 11. Halm EA, Atlas SJ, Borowsky LH, Benzer TI, Metlay JP, Chang Y, Singer DE: Face to face education using Catharsis Education Action Understanding Physician Adherence with a Pneumonia Practice Guideline. Arch Pediatr Adolesc Med 2000, 160:98-104. (CEA) method seems to be as effective as brief reminder 12. Chenot JF, Scherer M, Becker A, Banzhof N, Baum E, Leonhardt C, Keller S, with provision of pamphlet in improving the adherence Pfingsten M, Hildebrant J, Dieter Basler H, Kochen MM: Acceptance and to recommended national guideline on the management Perceived Barriers of Implementating a Guideline for Managing Low Back in General Practice. Implementation Science 2008, 3:7. of tuberculosis patients (NTP). CEA offers additional 13. James PA, Cowan TM, Graham RP, Majeroni BA: Family Physicians’ information that could be useful in designing interven- Attitudes About and Use of Clinical Practice Guidelines. J Fam Pract 1997, tion programs to improve NTP adherence. 45(4):341-7. 14. Hrisos S, Eccles M, Johnston M, Francis J, Kaner EFS, Steen N, Grimshaw J: Developing the content of two behavioral interventions. Using theory- based interventions to promote GP management of upper respiratory Acknowledgements tract infection without prescribing antibiotics. BMC Health Services The author would like to thank to Josefina S Isidro - Lapeña, MD. MFM for Research 2008, 8:11-8. her guiding and suggestions in all steps of this study. 15. Lukens EP, McFarlane WR: Psychoeducation as Evidence-Based Practice: All the doctors who took the time to participate in this study are also most Consideration for Practice, Research and Policy. Brief Treatment and Crisis gratefully acknowledged. Intervention 2004, 4:205-225. 16. Tu K, Davis D: Can we alter physician behavior by educational methods? Authors’ contributions Lessons learned from studies of the management and follow-up of NA was the principal investigator of the study and involved in designing the hypertension. J Contin Educ Health Prof 2002, 22(1):11-22. study, supervising the data collection, reviewing/analyzing the data and 17. Dionisio A: Active listening skills in health education: The CEA method. writing the paper. In Counseling Skills for Caring Physicians: Individual Intervention. Edited by: Dionisio. Department of Family and Community Medicine, University of the Competing interests Philippines Manila; 2005:40-7. The author declares that they have no competing interests. 18. Unknown, The Tunnel Therapy. , Downloaded from www.allpsychonline. com on October 30, 2007. Received: 25 August 2010 Accepted: 27 March 2012 19. 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Journal

Asia Pacific Family Medicine – Springer Journals

Published: Mar 27, 2012

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