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Outcomes of an educational activity with Victorian GPs aimed at improving knowledge and practices in relation to sexually transmissible diseases

Outcomes of an educational activity with Victorian GPs aimed at improving knowledge and practices... Objective: To measure the effect of a simple educational strategy for general practitioners (GPs) on their knowledge and self-reported practice in relation to sexually transmissible disease (STD) management. Graeme Mulvey, Louise A. Keogh and Meredith J. Temple-Smith Centre for the Study of Sexually Transmissible Diseases, La Trobe University, Victoria Method: In 1995, we surveyed 520 Victorian GPs; 444 (85%) responded. A sub-sample of 242 was sent an educational package in relation to STD management that required them to reflect on their performance in the survey in relation to that of the sample as a whole. Two months after they had received the package, a brief follow-up questionnaire, using a selection of questions from the first survey, was sent to these GPs. Results: Practitioners showed statistically significant improvements in knowledge and self-reported practice for four of the six outcomes that were examined. Conclusion: A relatively simple educational package for GPs had a high participation rate and resulted in improvements in knowledge and selfreported practice that could contribute to increased STD case finding in the general practice setting. Implications: The key to enabling GPs to make a greater contribution to improved STD control is to encourage them to be more active in diagnosing and treating asymptomatic disease. For asymptomatic patients, sexual history-taking and selective screening are important skills but there are barriers to their implementation in the general practice setting. A key objective of GP educational programs in relation to STDs is to increase their likelihood of taking a sexual history and the significant increase in this measure for the whole sample was encouraging. (Aust N Z J Public Health 1999; 23: 76-8) exually transmissible diseases (STDs) are one of the major preventable health problems affecting the Australian population.1,2,3 Consultations involving STDs and other sexual health problems have been found to be particularly sensitive and difficult for general practitioners (GPs).4 While a small number of special interest GPs have high STD caseloads, the majority of practitioners diagnose very few patients with STDs.5 Many STDs are asymptomatic and so increasing case-finding activity by the majority of GPs has the potential to greatly reduce the rates of STDs.6 We now have evidence of the efficacy of selective screening in reducing the prevalence of infection over time.7,8 Developing effective educational strategies for GPs in relation to STDs, however, has been difficult. This paper reports the results of a simple educational strategy that resulted in significant improvements in GP knowledge and self-reported practices over a six-month period. Educational strategy All 444 survey respondents were asked if they wished to apply for continuing medical education (CME) points and 425 responded positively. Four months after completion of the questionnaire survey, the 444 respondents were sent an information package that contained their own completed questionnaire, a summary of all GP responses, ‘gold standard’ answers to the knowledge-based questions and a list of appropriate educational resources for GPs. To obtain CME points, participants were then required to write a brief ‘reflection’ on their own practice in the light of the material that they received. Ultimately, only 73 of the doctors who stated that they would like to apply for CME points fulfilled the requirements to obtain them. The followed-up sample consisted of 242 of the respondents to the original survey and comprised all 19 GPs who did not want CME points, the 73 GPs who wanted CME points and had completed their ‘reflection’ [see below] and a random sample of 150 of the remaining 358 GPs. A mailout of 242 with an assumed response rate of 70% results in a sample of 170. In a paired t-test over time, 170 respondents provide a power of approximately 80% to detect a difference in means of 0.30 standard deviations with an alpha of 0.05. There were three parts to the educational strategy: Methods An extensive questionnaire survey (55 items) of Victorian GP knowledge, attitudes, behaviour and practice (KABP) in relation to STDs was conducted in 1995.9 Of the 520 randomly selected doctors sent a questionnaire, 444 (85%) responded (a detailed report of the methods used to achieve this high response rate has been published previously).10 Submitted: February 1998 Revision requested: May 1998 Accepted: September 1999 Correspondence to: Ms Louise Keogh, Centre for the Study of STDs, Locked Bag 12, Carlton South, Victoria 3053. Fax: (03) 9285 5220. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2000 VOL. 24 NO. 1 Brief Report Improving STD knowledge of general practitioners (a) the initial survey on STD knowledge, attitudes, practices and behaviour; (b) a package of information about STDs; and (c) a written reflection on their STD knowledge in relation to the information received. Parts (a) and (b) comprised the passive component of the educational strategy whereas part (c) was the active component. A brief follow-up questionnaire was sent to the GPs who took part in the strategy six months after they had completed the initial survey, and two months after the feedback package had been sent to them. The questionnaire addressed both knowledge and self-reported practices in relation to STDs, using a selection of questions from the first survey. Results The overall response rate to the follow-up questionnaire was 83% (202/242). Table 1 shows the results for the five knowledge questions and changes in GP self-reported sexual history-taking practice following the educational program. There was improvement in knowledge for all five questions, and the improvement was statistically significant for three of the five questions. Two months after the educational strategy, GPs were significantly more likely to know the two groups in which HIV is most common than before. GPs were also significantly more likely to know the appropriate specimen for chlamydia testing, and the likelihood of a false positive result for this test. GPs were significantly more likely to take a sexual history after the strategy than before. In response to the general questions about the value of the feedback package, 48% (97/202) of the respondents said they had gained a great deal of knowledge of STDs through their participation in the project and 57% (109/191) said the feedback package had been useful to them. Follow-up questionnaire The follow-up questionnaire included five knowledge questions, three (closed) practice questions and three (open) questions on the overall benefit of the strategy package. The knowledge and practice questions were worded identically to those in the original survey questionnaire. One question tested knowledge of the asymptomatic nature of five STDs in both men and women. A knowledge score was constructed by allocating a mark for each correct response to the 10 parts of the question (alpha greater than 0.6). The paired t-test was used to determine if a significant improvement had occurred in the knowledge score. For the other four questions (three questions relating to investigation for chlamydia and one ascertaining knowledge of the groups in which HIV occurs), respondents had to choose the correct answer from several alternatives. The normal approximation to the binomial test of two proportions was used to determine if a significant improvement had occurred in the proportion of correct answers after the strategy. Differences were considered significant if the p value was less than 0.05. Respondents were also asked about their likelihood of taking or updating a sexual history as well as their likelihood of being embarrassed if they were to take a sexual history for a 26 year-old woman presenting for a routine pap smear. GPs were given a score out of six for likelihood and embarrassment associated with taking a sexual history; the paired t-test was used to determine if there was a significant change in these self-reported practices. Discussion While this educational strategy measured only self-reported behaviour (not actual consulting room practice), the results show that a simple educational program for GPs can bring about changes in STD knowledge and reported practice. Although it is difficult to identify the relative contributions made by each of the components of the strategy, research elsewhere suggests that the active component is particularly important in encouraging behaviour change. We acknowledge the limitations imposed on any conclusions from the study by the lack of a comparison group. Our original study design had included a comparison group of practitioners who had received the passive component only (those doctors who did not wish to apply for CME points) but this group was too small (19) to enable useful comparison with the educational strategy group. Nevertheless, there were no concurrent STD educational programs for GPs, published papers, government campaigns or other historical factors that could have explained the changes that were observed. It has been suggested that successful behavioural change Table 1: Answers to knowledge questions before and after educational activity. Question Groups in which HIV mostly occurs (gay and bisexual men ) Appropriate site for chlamydia test (cervix) Appropriate specimen for chlamydia test (endocervical cells) Likelihood of false positive result in a low-risk patient (likely) Mean score out of 10 Asymptomatic nature of a range of STDs Mean score out of 6 (where 1=very & 6=not at all) Likelihood of taking a sexual history (n=200) Embarrassment taking a sexual history (n=198) Pre-educational activity 54/202 189/199 123/191 51/196 6.35 3.54 3.38 28% 95% 64% 26% Post-educational activity 76/202 196/202 142/194 81/199 6.52 3.07 3.60 39% 97% 73% 41% 2000 VOL. 24 NO. 1 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Mulvey, Keogh and Temple-Smith Brief Report requires three stages: predisposing or priming activities to trigger considerations of change; enabling strategies to motivate or facilitate change; and reinforcing activities to sustain change.11,12 In reality, with nearly 5,000 GPs in Victoria, and in a climate of competing postgraduate medical educational opportunities for doctors, few educational interventions will be able to comply with all of these stages. Nevertheless, the strategy described in this report does include elements of each stage: a preliminary priming activity (the survey questionnaire); an enabling strategy (the feedback package); and a reinforcing activity (the GP reflection). In our view, the findings in this study can be generalised to the wider population of Victorian GPs. The 202 respondents [63% of whom were randomly selected and 8% of whom had not requested CME points and were arguably less likely to show changes than the wider population] are unlikely to differ greatly from the population of 444 who completed the original survey and who were known to have the same age and sex distribution as the whole population of Victorian GPs.9 The high participation rate in this study is an important feature, given the much lower participation rate for more complicated educational interventions for GPs. For example, a recently published study of the results of an educational intervention with South Australian GPs (in a small group setting) showed significant, sustained improvement in knowledge and reported actions in relation to HIV/AIDS management,13 but as only 19% of invited practitioners in their study agreed to participate, the success of such an intervention is limited. The difficulty of STD case-finding in general practice relates not only to the low caseload that most GPs have, but also to the high proportion of STDs in the community that are asymptomatic. This means that approaches that concentrate on symptomatic disease will miss many infections. For asymptomatic patients, sexual history-taking and selective screening are more important, but there are significant barriers to doing this in the general practice setting.4 In view of this, a key objective of GP educational programs in relation to STDs is to increase the likelihood of the GP taking a sexual history. Consequently, the significant increase in this measure for the whole sample was encouraging. The key to enabling GPs to make a greater contribution to improved STD control is to encourage them to be more active in primary and secondary prevention and in diagnosing and treating asymptomatic disease. In this paper, we have described an educational strategy that has the advantage of wide GP coverage and which showed evidence of improvements in knowledge and selfreported practice that were sustained over at least a two-month period. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Outcomes of an educational activity with Victorian GPs aimed at improving knowledge and practices in relation to sexually transmissible diseases

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Publisher
Wiley
Copyright
Copyright © 2000 Wiley Subscription Services, Inc., A Wiley Company
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/j.1467-842X.2000.tb00727.x
Publisher site
See Article on Publisher Site

Abstract

Objective: To measure the effect of a simple educational strategy for general practitioners (GPs) on their knowledge and self-reported practice in relation to sexually transmissible disease (STD) management. Graeme Mulvey, Louise A. Keogh and Meredith J. Temple-Smith Centre for the Study of Sexually Transmissible Diseases, La Trobe University, Victoria Method: In 1995, we surveyed 520 Victorian GPs; 444 (85%) responded. A sub-sample of 242 was sent an educational package in relation to STD management that required them to reflect on their performance in the survey in relation to that of the sample as a whole. Two months after they had received the package, a brief follow-up questionnaire, using a selection of questions from the first survey, was sent to these GPs. Results: Practitioners showed statistically significant improvements in knowledge and self-reported practice for four of the six outcomes that were examined. Conclusion: A relatively simple educational package for GPs had a high participation rate and resulted in improvements in knowledge and selfreported practice that could contribute to increased STD case finding in the general practice setting. Implications: The key to enabling GPs to make a greater contribution to improved STD control is to encourage them to be more active in diagnosing and treating asymptomatic disease. For asymptomatic patients, sexual history-taking and selective screening are important skills but there are barriers to their implementation in the general practice setting. A key objective of GP educational programs in relation to STDs is to increase their likelihood of taking a sexual history and the significant increase in this measure for the whole sample was encouraging. (Aust N Z J Public Health 1999; 23: 76-8) exually transmissible diseases (STDs) are one of the major preventable health problems affecting the Australian population.1,2,3 Consultations involving STDs and other sexual health problems have been found to be particularly sensitive and difficult for general practitioners (GPs).4 While a small number of special interest GPs have high STD caseloads, the majority of practitioners diagnose very few patients with STDs.5 Many STDs are asymptomatic and so increasing case-finding activity by the majority of GPs has the potential to greatly reduce the rates of STDs.6 We now have evidence of the efficacy of selective screening in reducing the prevalence of infection over time.7,8 Developing effective educational strategies for GPs in relation to STDs, however, has been difficult. This paper reports the results of a simple educational strategy that resulted in significant improvements in GP knowledge and self-reported practices over a six-month period. Educational strategy All 444 survey respondents were asked if they wished to apply for continuing medical education (CME) points and 425 responded positively. Four months after completion of the questionnaire survey, the 444 respondents were sent an information package that contained their own completed questionnaire, a summary of all GP responses, ‘gold standard’ answers to the knowledge-based questions and a list of appropriate educational resources for GPs. To obtain CME points, participants were then required to write a brief ‘reflection’ on their own practice in the light of the material that they received. Ultimately, only 73 of the doctors who stated that they would like to apply for CME points fulfilled the requirements to obtain them. The followed-up sample consisted of 242 of the respondents to the original survey and comprised all 19 GPs who did not want CME points, the 73 GPs who wanted CME points and had completed their ‘reflection’ [see below] and a random sample of 150 of the remaining 358 GPs. A mailout of 242 with an assumed response rate of 70% results in a sample of 170. In a paired t-test over time, 170 respondents provide a power of approximately 80% to detect a difference in means of 0.30 standard deviations with an alpha of 0.05. There were three parts to the educational strategy: Methods An extensive questionnaire survey (55 items) of Victorian GP knowledge, attitudes, behaviour and practice (KABP) in relation to STDs was conducted in 1995.9 Of the 520 randomly selected doctors sent a questionnaire, 444 (85%) responded (a detailed report of the methods used to achieve this high response rate has been published previously).10 Submitted: February 1998 Revision requested: May 1998 Accepted: September 1999 Correspondence to: Ms Louise Keogh, Centre for the Study of STDs, Locked Bag 12, Carlton South, Victoria 3053. Fax: (03) 9285 5220. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2000 VOL. 24 NO. 1 Brief Report Improving STD knowledge of general practitioners (a) the initial survey on STD knowledge, attitudes, practices and behaviour; (b) a package of information about STDs; and (c) a written reflection on their STD knowledge in relation to the information received. Parts (a) and (b) comprised the passive component of the educational strategy whereas part (c) was the active component. A brief follow-up questionnaire was sent to the GPs who took part in the strategy six months after they had completed the initial survey, and two months after the feedback package had been sent to them. The questionnaire addressed both knowledge and self-reported practices in relation to STDs, using a selection of questions from the first survey. Results The overall response rate to the follow-up questionnaire was 83% (202/242). Table 1 shows the results for the five knowledge questions and changes in GP self-reported sexual history-taking practice following the educational program. There was improvement in knowledge for all five questions, and the improvement was statistically significant for three of the five questions. Two months after the educational strategy, GPs were significantly more likely to know the two groups in which HIV is most common than before. GPs were also significantly more likely to know the appropriate specimen for chlamydia testing, and the likelihood of a false positive result for this test. GPs were significantly more likely to take a sexual history after the strategy than before. In response to the general questions about the value of the feedback package, 48% (97/202) of the respondents said they had gained a great deal of knowledge of STDs through their participation in the project and 57% (109/191) said the feedback package had been useful to them. Follow-up questionnaire The follow-up questionnaire included five knowledge questions, three (closed) practice questions and three (open) questions on the overall benefit of the strategy package. The knowledge and practice questions were worded identically to those in the original survey questionnaire. One question tested knowledge of the asymptomatic nature of five STDs in both men and women. A knowledge score was constructed by allocating a mark for each correct response to the 10 parts of the question (alpha greater than 0.6). The paired t-test was used to determine if a significant improvement had occurred in the knowledge score. For the other four questions (three questions relating to investigation for chlamydia and one ascertaining knowledge of the groups in which HIV occurs), respondents had to choose the correct answer from several alternatives. The normal approximation to the binomial test of two proportions was used to determine if a significant improvement had occurred in the proportion of correct answers after the strategy. Differences were considered significant if the p value was less than 0.05. Respondents were also asked about their likelihood of taking or updating a sexual history as well as their likelihood of being embarrassed if they were to take a sexual history for a 26 year-old woman presenting for a routine pap smear. GPs were given a score out of six for likelihood and embarrassment associated with taking a sexual history; the paired t-test was used to determine if there was a significant change in these self-reported practices. Discussion While this educational strategy measured only self-reported behaviour (not actual consulting room practice), the results show that a simple educational program for GPs can bring about changes in STD knowledge and reported practice. Although it is difficult to identify the relative contributions made by each of the components of the strategy, research elsewhere suggests that the active component is particularly important in encouraging behaviour change. We acknowledge the limitations imposed on any conclusions from the study by the lack of a comparison group. Our original study design had included a comparison group of practitioners who had received the passive component only (those doctors who did not wish to apply for CME points) but this group was too small (19) to enable useful comparison with the educational strategy group. Nevertheless, there were no concurrent STD educational programs for GPs, published papers, government campaigns or other historical factors that could have explained the changes that were observed. It has been suggested that successful behavioural change Table 1: Answers to knowledge questions before and after educational activity. Question Groups in which HIV mostly occurs (gay and bisexual men ) Appropriate site for chlamydia test (cervix) Appropriate specimen for chlamydia test (endocervical cells) Likelihood of false positive result in a low-risk patient (likely) Mean score out of 10 Asymptomatic nature of a range of STDs Mean score out of 6 (where 1=very & 6=not at all) Likelihood of taking a sexual history (n=200) Embarrassment taking a sexual history (n=198) Pre-educational activity 54/202 189/199 123/191 51/196 6.35 3.54 3.38 28% 95% 64% 26% Post-educational activity 76/202 196/202 142/194 81/199 6.52 3.07 3.60 39% 97% 73% 41% 2000 VOL. 24 NO. 1 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Mulvey, Keogh and Temple-Smith Brief Report requires three stages: predisposing or priming activities to trigger considerations of change; enabling strategies to motivate or facilitate change; and reinforcing activities to sustain change.11,12 In reality, with nearly 5,000 GPs in Victoria, and in a climate of competing postgraduate medical educational opportunities for doctors, few educational interventions will be able to comply with all of these stages. Nevertheless, the strategy described in this report does include elements of each stage: a preliminary priming activity (the survey questionnaire); an enabling strategy (the feedback package); and a reinforcing activity (the GP reflection). In our view, the findings in this study can be generalised to the wider population of Victorian GPs. The 202 respondents [63% of whom were randomly selected and 8% of whom had not requested CME points and were arguably less likely to show changes than the wider population] are unlikely to differ greatly from the population of 444 who completed the original survey and who were known to have the same age and sex distribution as the whole population of Victorian GPs.9 The high participation rate in this study is an important feature, given the much lower participation rate for more complicated educational interventions for GPs. For example, a recently published study of the results of an educational intervention with South Australian GPs (in a small group setting) showed significant, sustained improvement in knowledge and reported actions in relation to HIV/AIDS management,13 but as only 19% of invited practitioners in their study agreed to participate, the success of such an intervention is limited. The difficulty of STD case-finding in general practice relates not only to the low caseload that most GPs have, but also to the high proportion of STDs in the community that are asymptomatic. This means that approaches that concentrate on symptomatic disease will miss many infections. For asymptomatic patients, sexual history-taking and selective screening are more important, but there are significant barriers to doing this in the general practice setting.4 In view of this, a key objective of GP educational programs in relation to STDs is to increase the likelihood of the GP taking a sexual history. Consequently, the significant increase in this measure for the whole sample was encouraging. The key to enabling GPs to make a greater contribution to improved STD control is to encourage them to be more active in primary and secondary prevention and in diagnosing and treating asymptomatic disease. In this paper, we have described an educational strategy that has the advantage of wide GP coverage and which showed evidence of improvements in knowledge and selfreported practice that were sustained over at least a two-month period.

Journal

Australian and New Zealand Journal of Public HealthWiley

Published: Feb 1, 2000

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