Janneke Harting

Adherence to Clinical Practice Guidelines for Low Back Pain in Physical Therapy: Do Patients Benefit?

Background Various guidelines for the management of low back pain have been developed to enhance the effectiveness and efficiency of care. Evidence that guideline-adherent care results in better health outcomes, however, is not conclusive. Objective The main objective of this study was to assess whether a higher percentage of adherence to the Dutch physical and manual therapy guidelines for low back pain is related to improved outcomes. The study further explored whether this relationship differs for the individual steps of the process of care and for distinct subgroups of patients. Design This was an observational prospective cohort study (2005–2006) in the Netherlands that included a sample of 61 private practice therapists and 145 patients. Methods Therapists recorded the process of care and the number of treatment sessions in Web-based patient files. Guideline adherence was assessed using quality indicators. Physical functioning was measured by the Dutch version of the Quebec Back Pain and Disability Scale, and average pain was measured with a visual analog scale. Relationships between the percentage of guideline adherence and outcomes of care were evaluated with regression analyses. Results Higher percentages of adherence were associated with fewer functional limitations (β=−0.21, P=.023) and fewer treatment sessions (β=−0.27, P=.005). Limitations The relatively small self-selected sample might limit external validity, but it is not expected that the small sample greatly influenced the internal validity of the study. Larger samples are required to enable adequate subgroup analyses. Conclusions The results indicate that higher percentages of guideline adherence are related to better improvement of physical functioning and to a lower utilization of care. A proper assessment of the relationship between the process of physical therapy care and outcomes may require a comprehensive set of process indicators to measure guideline adherence.

A Qualitative Application of the Diffusion of Innovations Theory to Examine Determinants of Guideline Adherence Among Physical Therapists

Background: Evidence-based practice has become a major issue in physical therapy. Many evidence-based guidelines, however, are not used extensively after dissemination, and interventions aimed at increasing guideline adherence often have limited effects. Objective: As a prerequisite for changing this situation, the aims of this study were to gain an in-depth understanding of the determinants of guideline adherence among physical therapists in the Netherlands and to evaluate the opportunities of a theoretical framework in this respect. Design and Methods: This observational study consisted of 3 focus group interviews (n=12, 10, and 8) between November 2002 and January 2003. Physical therapists were asked to discuss their opinions about and experiences with the Dutch guidelines for low back pain. Data were analyzed qualitatively using a directed approach to content analysis. Both the interview route and the analysis of the interviews were informed by Rogers’ Diffusion of Innovations Theory. Results: Our study yielded in-depth insights into the various determinants of guideline adherence. Overall, the participants had rather unfavorable opinions about issues related to the dissemination of the guidelines (first phase of the diffusion process) and provided relatively little information on the subsequent adoption process (second phase of the diffusion process). The theoretical framework appeared to be a useful tool to properly structure the focus group interviews, to systematically analyze the data collected, and to determine that supplementary interviews would be necessary to cover the entire diffusion process. Conclusions: Our findings indicated that the diffusion process of guidelines among physical therapists was not yet completed. The use of theory can provide added value to guideline implementation studies.

Development of a theory- and evidence-based intervention to enhance implementation of physical therapy guidelines for the management of low back pain

BackgroundSystematic planning could improve the generally moderate effectiveness of interventions to enhance adherence to clinical practice guidelines. The aim of our study was to demonstrate how the process of Intervention Mapping was used to develop an intervention to address the lack of adherence to the national CPG for low back pain by Dutch physical therapists.MethodsWe systematically developed a program to improve adherence to the Dutch physical therapy guidelines for low back pain. Based on multi-method formative research, we formulated program and change objectives. Selected theory-based methods of change and practical applications were combined into an intervention program. Implementation and evaluation plans were developed.ResultsFormative research revealed influential determinants for physical therapists and practice quality managers. Self-regulation was appropriate because both the physical therapists and the practice managers needed to monitor current practice and make and implement plans for change. The program stimulated interaction between practice levels by emphasizing collective goal setting. It combined practical applications, such as knowledge transfer and discussion-and-feedback, based on theory-based methods, such as consciousness raising and active learning. The implementation plan incorporated the wider environment. The evaluation plan included an effect and process evaluation.ConclusionsIntervention Mapping is a useful framework for formative data in program planning in the field of clinical guideline implementation. However, a decision aid to select determinants of guideline adherence identified in the formative research to analyse the problem may increase the efficiency of the application of the Intervention Mapping process.

Area-based interventions to ameliorate deprived Dutch neighborhoods in practice: Does the Dutch District Approach address the social determinants of health to such an extent that future health impacts may be expected?

OBJECTIVE We studied the local manifestation of a national procedural program that addressed problems regarding employment, education, housing and the physical neighborhood environment, social cohesion, and safety in the most deprived neighborhoods in the Netherlands. We aimed to assess if such a program, without the explicit aim to improve health, results in area-based interventions that address the social determinants of health to such an extent that future health impacts may be expected. METHODS We used standardized questionnaires and face-to-face interviews with 39 local district managers. We analyzed the content of the area-based interventions to assess if the activities addressed the social determinants of health. We assessed the duration and scale of the activities in order to estimate their potential to change social determinants of health. RESULTS Most districts addressed all six categories of social determinants of health central to the procedural program. Investments in broad-based primary schools, housing stock, green space, and social safety seemed to have the potential to result in district-level changes in social determinants. The scale of activities aimed at employment, income, educational attainment, and the social environment seemed too small to expect an impact at the district level. CONCLUSION We conclude that the area-based interventions addressed the neighborhood environment to such an extent that future health impacts of the Dutch District Approach may be expected. The health effects in the long term might be more substantial when area-based interventions were devoted more to the improvement of the socioeconomic circumstances of residents.

Opportunities to reduce health inequalities by 'Health in all policies' in the Netherlands: an explorative study on the national level.

OBJECTIVES In the last few years the Dutch ministry of Health has been searching for a renewed Health in All Policies (HiAP) strategy. This study analyses the Dutch practices and explores opportunities to reduce health inequalities by HiAP. METHODS A qualitative screening on the Dutch national budget was performed to explore ongoing policy resolutions of ministries inside and outside the public health domain. Additionally, semi-structured (group) interviews were conducted with 19 policy officers of seven ministries to identify critical factors for intersectoral collaboration. RESULTS Using the Dutch model on health inequalities 38 policy resolutions were selected: 15 on improving the socioeconomic position of people; four on improving participation of people with health problems; 19 on improving living and working conditions and lifestyle; and four on accessibility and quality of care. To improve intersectoral collaboration, policy officers suggested to strengthen existing links between the ministries, create common interest of objectives as well as visible results, approach this theme in a coordinated way, and to achieve broad political agreement. CONCLUSIONS The main challenges for a formal HiAP strategy are to (a) cover the determinants of health inequalities in a balanced way linked to concrete objectives and visible results, (b) enhance high level agreement and coordinated mechanisms from the government in general and the ministry of Health in particular.

Measuring stages of health in all policies on a local level: The applicability of a maturity model

OBJECTIVES Many local governments are trying to establish health in all polices (HiAP), but no sensitive tool is available to measure HiAP growth processes. This study explores the applicability of a general maturity model to classify stages of HiAP and to characterize its manifestations and conditions. METHODS Based on other maturity models we have developed a maturity model for HiAP (MM-HiAP), which consists of six maturity levels and 14 corresponding key characteristics. This model was applied to assess HiAP growth processes within 16 municipalities in the Netherlands. We used municipal policies on health inequalities as a case. Empirical data was gathered based on document analysis, a questionnaire and interviews. RESULTS Using this model we were able to classify HiAP growth processes by several characteristics, such as the recognition of the importance of HiAP (Stage I; four municipalities), HiAP described in policy documents and collaboration with sectors present (Stage II; seven municipalities), concrete collaboration agreements and structural consultations forms (Stage III; four municipalities), and a broad, shared vision on HiAP (Stage IV; two municipalities). Examples of necessary conditions were sufficient support and resources. CONCLUSIONS This study shows that it is possible to apply a maturity model to classify stages of HiAP in municipalities. Use of the MM-HiAP as a formal measuring instrument depends on further operationalization and validation.

Manifestations of integrated public health policy in Dutch municipalities.

Integrated public health policy (IPHP) aims at integrating health considerations into policies of other sectors. Since the limited empirical evidence available may hamper its further development, we systematically analysed empirical manifestations of IPHP, by placing policy strategies along a continuum of less-to-more policy integration, going from intersectoral action (IA) to healthy public policy (HPP) to health in all policies (HiAP). Our case study included 34 municipal projects of the Dutch Gezonde Slagkracht Programme (2009-15), which supports the development and implementation of IPHP on overweight, alcohol and drug abuse, and smoking. Our content analysis of project application forms and interviews with all project leaders used a framework approach involving the policy strategies and the following policy variables: initiator, actors, policy goals, determinants and policy instruments. Most projects showed a combination of policy strategies. However, manifestations of IPHP in overweight projects predominantly involved IA. More policy integration was apparent in alcohol/drugs projects (HPP) and in all-theme projects (HiAP). More policy integration was related to broad goal definitions, which allowed for the involvement of actors representing several policy sectors. This enabled the implementation of a mix of policy instruments. Determinants of health were not explicitly used as a starting point of the policy process. If a policy problem justifies policy integration beyond IA, it might be helpful to start from the determinants of health (epidemiological reality), systematically transform them into policy (policy reality) and set broad policy goals, since this gives actors from other sectors the opportunity to participate.

Academic Collaborative Centre Limburg: a platform for knowledge transfer and exchange in public health policy, research and practice?

Research findings often fail to find their way into policy and practice, which is assumed to limit the effectiveness of public health policies and programmes. We evaluated to what extent the Academic Collaborative Centre Limburg (ACCL), a Dutch boundary organization linking policy, research and practice, has improved knowledge transfer and exchange between the three domains. We used a mixed-methods approach. First, stakeholders jointly defined the ACCLs programme theory, showing how the ACCL was supposed to achieve its intended effects. Second, we assessed the achievements of the ACCL in terms of knowledge transfer and exchange on the basis of the programme theory. The ACCL was found to provide a platform for interaction between actors from the policy, research and practice domains, facilitated by integrated network structures. The number of collaborative projects and actors involved in the ACCL increased, but actual cross-domain interaction patterns did not really change. Cross-domain knowledge transfer and exchange still require major boundary-spanning efforts by the ACCL programme leader. Boundary organizations do not automatically produce cross-domain interactions. In addition to infrastructural arrangements, cross-domain knowledge transfer and exchange could benefit from additional cultural changes, like adopting a deliberative approach to policy making and applying constructivist research designs.

Towards improved uptake of malaria chemoprophylaxis among West African travellers: identification of behavioural determinants

BackgroundMalaria is a potentially lethal illness for which preventive measures are not optimally used among all travellers. Travellers visiting friends and relatives in their country of origin (VFRs) are known to use chemoprophylaxis less consistently compared to tourist travellers. In this study, factors explaining the low use of chemoprophylaxis were pursued to contribute to improving uptake of preventive measures among VFRs.MethodsFollowing in-depth interviews with Ghanaians living in Amsterdam, a questionnaire was developed to assess which behavioural determinants were related to taking preventive measures. The questionnaire was administered at gates of departing flights from Schiphol International Airport, Amsterdam (the Netherlands) to Kotoka International Airport, Accra (Ghana).ResultsIn total, 154 questionnaires were eligible for analysis. Chemoprophylaxis had been started by 83 (53.9%) and bought by 93 (60.4%) travellers. Pre-travel advice had been obtained by 104 (67.5%) travellers. Those who attended the pre-travel clinic and those who incorrectly thought they had been vaccinated against malaria were more likely to use preventive measures. Young-, business- and long-term travellers, those who had experienced malaria, and those who thought curing malaria was easier than taking preventive tablets were less likely to use preventive measures.ConclusionAlmost half of the VFRs travelling to West Africa had not started chemoprophylaxis; therefore, there is room for improvement. Risk reduction strategies could aim at improving attendance to travel clinics and focus on young-, business and long term travellers and VFRs who have experienced malaria during consultation. Risk reduction strategies should focus on improving self-efficacy and conceptions of response efficacy, including social environment to aim at creating the positive social context needed.

The concept of sustainability and the use of outcome indicators. A case study to continue a successful health counselling intervention

BACKGROUND To ensure the continuation of a successful pilot programme, the change process and the concept of sustainability need to be elaborated. So far, there are different theories on organizational change and sustainability but its practical application stay far behind. OBJECTIVES To test the practical application of a theory-based concept of sustainability and to assess the role of the change agent. A health counselling programme for high-risk cardiovascular patients, called Heartbeat 2, was used as a case study. METHODS Outcome indicators were assessed based on the questions: Why should health counselling be sustained? How should this be done and by whom? How much needs to occur and by when? Data were derived from registrations, reports and focus group interviews. RESULTS The results indicate a need for a linkage system in the final stages of change so that the programme is maintained. Limitations of the external change agent are described. The outcome indicators appeared to be an adequate operationalization to monitor sustainability. The change process leading up to sustainability appeared to be highly complex due to unpredictable and unforeseen external factors. CONCLUSIONS Our concept of sustainability appeared to be an adequate tool for the change agent to assess the extent of sustainability. An external change agent has limited influence on the managements decision-making processes during the sustainability stage. As long as the context is changing, definite choices to sustain the innovative service of health counselling in hospitals will not be made, which inherently means an ongoing change process to sustainability.