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Barriers and Facilitators for Referrals of Primary Care Patients to Blended Internet-Based Psychotherapy for Depression: Mixed Methods Study of General Practitioners' Views.

ABSTRACT: BACKGROUND:Major depressive disorder (MDD) is highly prevalent and often managed by general practitioners (GPs). GPs mostly prescribe medication and show low referral rates to psychotherapy. Many patients remain untreated. Blended psychotherapy (bPT) combines internet-based interventions with face-to-face psychotherapy and could increase treatment access and availability. Effectively implementing bPT in routine care requires an understanding of professional users' perspectives and behavior. OBJECTIVE:This study aims to identify barriers and facilitators perceived by GPs in referring patients to bPT. Explanations for variations in referral rates were examined. METHODS:Semistructured interviews were conducted with 12 of 110 GPs participating in a German randomized controlled trial (RCT) to investigate barriers to and facilitators for referrals to bPT for MDD (10 web-based modules, app-based assessments, and 6 face-to-face sessions). The interview guide was based on the theoretical domains framework. The interviews were audio recorded and transcribed verbatim, and the qualitative content was analyzed by 2 independent coders (intercoder agreement, k=0.71). A follow-up survey with 12 interviewed GPs enabled the validation of emergent themes. The differences in the barriers and facilitators identified between groups with different characteristics (eg, GPs with high or low referral rates) were described. Correlations between referrals and characteristics, self-rated competences, and experiences managing depression of the RCT-GPs (n=76) were conducted. RESULTS:GPs referred few patients to bPT, although varied in their referral rates, and interviewees referred more than twice as many patients as RCT-GPs (interview-GPs: mean 6.34, SD 9.42; RCT-GPs: mean 2.65, SD 3.92). A negative correlation was found between GPs' referrals and their self-rated pharmacotherapeutic competence, r(73)=-0.31, P<.001. The qualitative findings revealed a total of 19 barriers (B) and 29 facilitators (F), at the levels of GP (B=4 and F=11), patient (B=11 and F=9), GP practice (B=1 and F=3), and sociopolitical circumstances (B=3 and F=6). Key barriers stated by all interviewed GPs included "little knowledge about internet-based interventions" and "patients' lack of familiarity with technology/internet/media" (number of statements, each k=22). Key facilitators were "perceived patient suitability, e.g. well-educated, young" (k=22) and "no conflict with GP's role" (k=16). The follow-up survey showed a very high agreement rate of at least 75% for 71% (34/48) of the identified themes. Descriptive findings indicated differences between GPs with low and high referral rates in terms of which and how many barriers (low: mean 9.75, SD 1.83; high: mean 10.50, SD 2.38) and facilitators (low: mean 18.25, SD 4.13; high: mean 21.00; SD 3.92) they mentioned. CONCLUSIONS:This study provides insights into factors influencing GPs' referrals to bPT as gatekeepers to depression care. Barriers and facilitators should be considered when designing implementation strategies to enhance referral rates. The findings should be interpreted with care because of the small and self-selected sample and low response rates.

SUBMITTER: Titzler I

PROVIDER: S-EPMC7463410 | biostudies-literature | 2020 Aug

REPOSITORIES: biostudies-literature

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Barriers and Facilitators for Referrals of Primary Care Patients to Blended Internet-Based Psychotherapy for Depression: Mixed Methods Study of General Practitioners' Views.

Titzler Ingrid I Berking Matthias M Schlicker Sandra S Riper Heleen H Ebert David Daniel DD

JMIR mental health 20200818 8

<h4>Background</h4>Major depressive disorder (MDD) is highly prevalent and often managed by general practitioners (GPs). GPs mostly prescribe medication and show low referral rates to psychotherapy. Many patients remain untreated. Blended psychotherapy (bPT) combines internet-based interventions with face-to-face psychotherapy and could increase treatment access and availability. Effectively implementing bPT in routine care requires an understanding of professional users' perspectives and behavi ...[more]

PMID: 32673213

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Project description:Introduction:Blended therapies (BT) combine face-to-face (f2f) sessions with internet- and mobile-based interventions (IMIs). However, the use of blended interventions in routine care is still rare and depends on the acceptance of key health care professionals such as the therapists. Little is yet known about the therapists' perspective on and experiences with blended approaches. The aim of this pilot study was to identify barriers and facilitators, as perceived by psychotherapists, for implementing a blended therapy for depression. Methods:Semi-structured expert interviews were conducted with five therapists, who were part of the German study arm of the FP7-project E-Compared (www.e-compared.eu). All patients (N?=?173) were treated in the context of a registered RCT (DRKS00006866) in which the clinical and cost-effectiveness of BT for depression, consisting of ten internet- and mobile-based cognitive behavioral therapy modules and six f2f sessions, was compared to the treatment usually provided by general practitioners. To identify barriers and facilitators an interview guide based on the theoretical domains framework (TDF) was developed. The interviews were audio-recorded, transcribed verbatim and analyzed using a qualitative content analysis by two independent coders. Results:The results revealed 29 barriers and 33 facilitators, which are hindering or enabling factors on the levels of 'implementation in the health care system', 'therapy', 'therapists' and 'patients'. Key barriers stated by all therapists were 'Limited customizability and autonomy of decisions concerning blending the therapy' (number of statements, k?=?44); 'Disease-related contraindications for BT' (k?=?25); 'Negative affect was caused by burden through technical problems' (k?=?18); 'Limited number of f2f sessions hindered the therapy process'; and 'Establishment of therapeutic alliance was burdened by technical issues' (each k?=?15). Key facilitators stated by all therapists were: 'Patients' interest, willingness and motivation to participate' (k?=?22); 'Patients' access to online content between f2f sessions and after therapy end' (k?=?20); 'Preset structure of IMI-part guided the treatment course of BT' (k?=?18); and 'Effective help with BT in a short time frame' (k?=?15), as well as 'Reduction of the treatment gap' (k?=?13). Discussion:Therapists supported the implementation of BT for depression. Results indicated the consideration of a wide range of determinants: among others, the possibility of individualizing the treatment; the autonomy of decision making in respect to the ratio and number of online and f2f sessions; the necessity of providing training; the need to develop a concept of embedding BT in the health care system and funding the additional effort; and the use of sophisticated technical solutions.

Project description:ObjectiveThere has been an increase in testing of vitamins in patients in general practice, often based on irrational indications or for non-specific symptoms, causing increasing healthcare expenditures and medicalisation of patients. So far, there is little evidence of effective strategies to reduce this overtesting in general practice. Therefore, the aim of this qualitative study was to explore the barriers and facilitators for reducing the number of (unnecessary) vitamin D and B12 laboratory tests ordered.Design and settingThis qualitative study, based on a grounded theory design, used semistructured interviews among general practitioners (GPs) and patients from two primary care networks (147 GPs, 195?000 patients). These networks participated in the Reducing Vitamin Testing in Primary Care Practice (REVERT) study, a clustered randomized trial comparing two de-implementation strategies to reduce test ordering in primary care in the Netherlands.ParticipantsTwenty-one GPs, with a maximum of 1 GP per practice who took part in the REVERT study, and 22 patients (who were invited by their GP during vitamin-related consultations) were recruited, from which 20 GPs and 19 patients agreed to participate in this study.ResultsThe most important factor hampering vitamin-test reduction programmes is the mismatch between patients and medical professionals regarding the presumed appropriate indications for testing for vitamin D and B12. In contrast, the most important facilitator for vitamin-test reduction may be updating GPs' knowledge about test indications and their awareness of their own testing behaviour.ConclusionTo achieve a sustainable reduction in vitamin testing, guidelines with clear and uniform recommendations on evidence-based indications for vitamin testing, combined with regular (individual) feedback on test-ordering behaviour, are needed. Moreover, the general public needs access to clear and reliable information on vitamin testing. Further research is required to measure the effect of these strategies on the number of vitamin test requests.Trial registration numberWAG/mb/16/039555.

Project description:BackgroundMusculoskeletal problems substantially impact the demand for and the finances of the United Kingdom's National Health Service. Some of this demand and cost could be alleviated if patients use self-directed-exercises. The present study aims first to establish whether general practitioners already recommend self-directed-exercises and second to describe barriers and facilitators to making such recommendations.MethodThe design of the current study included surveys and interviews. The surveys were designed to draw out participants' tendency to recommend self-directed-exercises and their behavioral drivers to do so. The drivers investigated include 14 domains described by the Theoretical Domains Framework. The surveys were completed online and the responses were analyzed using descriptive reports and regression analyses. The interviews were designed to more fully understand participants' experiences recommending self-directed-exercises according to the same framework. The interviews were audio-taped, transcribed, and thematically analyzed.ResultsThe survey found that the following domains significantly predicted participants' tendency to recommend self-directed-exercises: Environmental contexts and resources, Goals, Intentions, Knowledge, Memory attention and decision processes, and Social/professional role. The interviews brought out four themes that could be leveraged to increase general practitioners' tendency to recommend self-directed-exercises: (1) Practitioners' beliefs about self-directed-exercises being effective, (2) Patients' motivations to engage in self-directed-exercises, (3) Time constraints, and (4) The ease with which practitioners can recommend self-directed-exercises.ConclusionsMost general practitioners already recommend self-directed-exercises, though they note significant barriers that may prevent them from doing so. General practitioners' tendency to recommend self-directed-exercises would be bolstered by creating a respected central resource of exercise pamphlets. These pamphlets should clearly describe how different self-directed-exercises should be performed and evidence supporting their effectiveness.

Project description:ObjectiveTo examine the barriers to, and facilitators in, improving diabetes management from the general practice perspective, in advance of the implementation of an integrated model of care in Ireland.DesignQualitative using semistructured interviews.SettingPrimary care in the Republic of Ireland.ParticipantsPurposive sample of 29 general practitioners (GPs) and two practice nurses.MethodsData were analysed using a framework approach.ResultsThe main barriers and facilitators occurred at the level of the health system but had a ripple effect at an organisational, professional and patient level. The lack of targeted remuneration for diabetes management in the Irish health system created apathy in general practice and was perceived to be indicative of the lack of value placed on chronic disease management in the health system. There were 'pockets of interest' among GPs motivated by 'vocational' incentives such as a sense of professional duty; however, this was not sufficient to drive widespread improvement. The hospital service was seen as an essential support for primary care management, although some participants referred to emerging tension between settings. The lack of coordination at the primary-secondary interface resulted in avoidable duplication and an 'in the meantime' period of uncertainty around when patients would be called or recalled by specialist services. Facilitators included the availability of nursing support and serendipitous access to services. The lack of resources in the community was considered to be at odds with policy to shift routine management to general practice, which is fast reaching saturation.ConclusionsAt present, intrinsic motivation is driving the improvement of diabetes care in Ireland. This will not be sufficient to implement the proposed reform including a national model of integrated care. Policymakers need to assess and prepare for the disparate levels of interest and infrastructure in primary care in Ireland to support this change.

Project description:BackgroundAntibiotic resistance is a leading global public health concern and antibiotic use is a key driver. Effective interventions are needed to target key stakeholders, including general practitioners (GPs). In Malta, little is known about factors that influence GPs' antibiotic prescribing, making it challenging to implement targeted interventions. We therefore aimed to explore GPs' understanding of antibiotic use and resistance, and describe their perceived barriers and facilitators to prudent antibiotic prescribing for acute respiratory tract infections in Malta.MethodsFace-to-face individual semi-structured interviews were held with a quota sample of 20 GPs in 2014. Interviews were audio recorded and transcribed verbatim, and later analysed iteratively using manifest and latent content analysis. Findings were collated in a socioecological model to depict how GPs as individuals are embedded within larger social systems and contexts, and how each component within this system impacts their prescribing behaviour.FindingsWe found that GPs' antibiotic prescribing decisions are complex and impacted by numerous barriers and facilitators at the individual, interpersonal, organisational, community, and public policy level. Predominant factors found to impact GPs' antibiotic prescribing included not only intrinsic GP factors such as knowledge, awareness, experience, and misconceptions, but also several external factors. At the interpersonal level, GPs' perceived patient demand and behaviour to be a persistent issue that impacts their prescribing decisions. Similarly, some GPs found pressure from drug reps to be concerning despite being considered an important source of information. Organisational and public policy-level issues such as lack of access to relevant antibiotic prescribing guidelines and current antibiotic resistance data from the community, were also considered major barriers to appropriate antibiotic prescribing. Utilisation of diagnostic testing was found to be low and GPs' perceptions on the introduction of rapid point-of-care tests to support antibiotic prescription decisions, were mixed.ConclusionThis study revealed the complexity of the antibiotic prescribing decision and the numerous barriers and facilitators that impact it, visualised through a socioecological model. Addressing GPs' antibiotic prescribing practices will require targeted and coordinated implementation activities at all levels to change behaviour and address misconceptions, whilst also improving the physical and social environment.Trial registration numberNCT03218930; https://clinicaltrials.gov/ct2/show/NCT03218930.

Project description:General dental practitioners (GDPs) regularly prescribe antibiotics to manage dental infections although most infections can be treated successfully by local measures. Published guidance to support GDPs to make appropriate prescribing decisions exists but there continues to be wide variation in dental antibiotic prescribing. An interview study was conducted as part of the Reducing Antibiotic Prescribing in Dentistry (RAPiD) trial to understand the barriers and facilitators of using local measures instead of prescribing antibiotics to manage bacterial infections.Thirty semi-structured one-to-one telephone interviews were conducted using the Theoretical Domains Framework (TDF). Responses were coded into domains of the TDF and sub-themes. Priority domains (high frequency: ≥50 % interviewees discussed) relevant to behaviour change were identified as targets for future intervention efforts and mapped onto 'intervention functions' of the Behaviour Change Wheel system.Five domains (behavioural regulation, social influences, reinforcement, environmental context and resources, and beliefs about consequences) with seven sub-themes were identified as targets for future intervention. All participants had knowledge about the evidence-based management of bacterial infections, but they reported difficulties in following this due to patient factors and time management. Lack of time was found to significantly influence their decision processes with regard to performing local measures. Beliefs about their capabilities to overcome patient influence, beliefs that performing local measures would impact on subsequent appointment times as well as there being no incentives for performing local measures were also featured. Though no knowledge or basic skills issues were identified, the participants suggested some continuous professional development programmes (e.g. time management, an overview of published guidance) to address some of the barriers. The domain results suggest a number of intervention functions through which future interventions could change GDPs' antibiotic prescribing for bacterial infections: imparting skills through training, providing an example for GDPs to imitate (i.e. modelling) or creating the expectation of a reward (i.e. incentivisation).This is the first theoretically informed study to identify barriers and facilitators of evidence-based management of patients with bacterial infections among GDPs. A pragmatic approach is needed to address the modifiable barriers in future interventions intended to change dentists' inappropriate prescribing behaviour.

Dataset Information

Barriers and Facilitators for Referrals of Primary Care Patients to Blended Internet-Based Psychotherapy for Depression: Mixed Methods Study of General Practitioners' Views.

Publications

Barriers and Facilitators for Referrals of Primary Care Patients to Blended Internet-Based Psychotherapy for Depression: Mixed Methods Study of General Practitioners' Views.

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