Family Practice Vol. 21, No. 1, 11-17
© Oxford University Press 2004, all rights reserved.
Article |
Integration of the recommendations of the Canadian Task Force on Preventive Health Care
Obstacles perceived by a group of family physicians
a Department of Family Medicine, University of Montreal, b Family Medicine Research Team, Cité de la Santé de Laval, c Evaluative Research Unit, CHUM Research Center, University of Montrea, and d Research Center, Charles Lemoyne Hospital, Montreal, Canada
Correspondence to Eveline Hudon, Équipe de recherche en soins de première ligne, Cité de la Santé de Laval, 1755, boulevard René Laennec, Laval, Québec H7M 3L9, Canada; E-mail: ferdais.hudon{at}sympatico.ca
Received 9 June 2003; Revised 8 August 2003; Accepted 8 September 2003.
Hudon E, Beaulieu M-D and Roberge D. Integration of the recommendations of the Canadian Task Force on Preventive Health Care: Obstacles perceived by a group of family physicians. Family Practice 2004; 21: 11–17.
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Abstract |
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Background. Surveys conducted in North America and in several European countries show that the preventive activities recommended by some groups of experts are difficult to integrate into medical practice. Interventions to correct this problem have produced mitigated results.
Objectives. Our aim was to gain a better understanding of the obstacles perceived by a group of family physicians concerning the integration of prevention into their routine practices.
Methods. A qualitative design was selected to facilitate the exploration of that topic. Seven focus groups with 35 physicians practising in the Montreal area were conducted. Questions regarding their perception of, and obstacles to, the integration of prevention in their daily work were explored. The text of these interviews was analysed following the content analysis method. Codification of the important themes that were identified was done by two of the researchers.
Results. We met with 35 family physicians in two regions in Montreal, Quebec. The lack of motivation on the part of users and the lack of value placed on continuity of care appear to be the main obstacles in the eyes of the physicians, followed by a lack of financial incentives, work overload, and contradictions among the recommendations. In addition, other obstacles were observed by the researchers: limited intervention strategies on the part of physicians to support behaviour modification among patients, non-recognition of the importance of the organization of practice and inability to acknowledge the obstacles that can be ascribed to their own beliefs.
Conclusion. The family physicians we met identified several barriers to the integration of prevention in their practices. The interventions proposed to date do not address the barriers perceived by the physicians in our study. Continuing medical education activities focus on knowledge, while the difficulties expressed relate more to communication skills coupled with a feeling of powerlessness. The physicians we met with do not seem to consider recall systems and looking at their organization of practice as possible solutions. The physicians seem to ‘cave in’ under the weight of the responsibilities that have been assigned to them in terms of health promotion. There may be room for proposing a more realistic menu. This study identifies a need for much more specific and concrete training on communication and counselling skills.
Keywords. Focus groups, obstacles to prevention, periodic health examination, preventive care, prevention implementation.
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Introduction |
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Studies conducted in most industrialized countries show that the prevention activities that were recommended >15 years ago are far from being integrated into medical practices.1–9 The very principle of the periodic health examination, giving up the annual general medical examination in favour of a specific approach integrated into the general care process, seems difficult to apply.2,4,8,10 The majority of interventions developed to date are based on the assumption that implementation problems are either a matter of knowledge [continuing medical education (CME) activities]11 or they have to do with the organization of practices (recall system, tear sheets providing health information).12,13 These measures have produced mitigated results. Multifaceted interventions have been proposed but are not easily applicable.14
These interventions were developed without the support of richly drawn conceptual frameworks. In fact, very few studies have been conducted in a more fundamental tradition, whose objective is a better understanding of the obstacles to the integration of prevention activities from the physician's viewpoint. Recently, Cabana et al.15–17 described a variety of barriers to guideline adherence: a lack of awareness, lack of familiarity, lack of agreement, lack of self-efficacy, lack of outcome expectancy, the inertia of previous practice, and external barriers. He recommended that we look at these barriers if we want to achieve successful intervention to improve adherence. Grol14,18 insisted on knowing obstacles to change if we want to improve clinical practice, and recommended that the interventions should be related to these barriers identified.
The purpose of this article is to present the obstacles perceived by family physicians in Quebec concerning the integration of prevention into their routine practices. These results are drawn from a study whose goal was to explore the perceptions and expectations of a group of physicians and users with regard to the integration of preventive services in routine medical care.19
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Methods |
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Qualitative methodology proved to be the preferred method for exploring all of the facets of this issue. The focus group method was chosen since it allows for collecting diverse points of view with many participants, in a limited amount of time and at a reasonable cost. Discussion groups also have the advantage of allowing for interactions between individual opinions, richer discussion in terms of information and a better under-standing of the reasons behind these opinions.20–22
At first, two pilot focus groups of family physicians and representatives of the general public allowed us to establish the recruitment strategy, to develop the scenario for the discussions and to estimate how many groups would be needed to obtain saturation in the points of view expressed.
Participants
We aimed to interview 45 physicians, based on an estimated number of participants we would need to reach saturation with our findings. With the collaboration of the Fédération des Médecins Omnipraticiens du Québec, we draw a random sample of 96 family physicians from the region of Montreal, balanced for gender and type of practice (group/solo/community health centre). They were informed by mail. Of these, 72 proved to be eligible. The physicians were not to have a restricted field of practice (e.g. geriatrics, emergency, etc.). Twenty-five of them were available and agreed to participate. We completed the groups with a convenience sample (physicians practising in the same area as the researchers but not known to them personally) of 10 physicians. They were recruited by the researchers, again balancing for gender and type of practice. Seven groups of five physicians each were constituted in such a way as to ensure representation of both men and women and physicians practising in different settings, in particular in CLSCs and in private offices. CME credits were offered. (CLSCs are local community services centres which provide primary medical care and psychosocial services to the population living in a designated geographical territory. The size of the population served by CLSCs in the Montreal ranges from 42 000 to 122 000.)
Interviews
The groups were led by an experienced sociologist. One of the researchers and the research associate were present at the meetings. Many topics were explored: their perception of prevention; their role; obstacles and factors facilitating the integration of prevention, screening tests; and the acceptability of the recommendations of the Canadian Task Force on Preventive Health Care (CTFPHC). An updated version of these recommendations was published in 1994.23 Saturation was reached after seven groups.
Analysis
Three sources of data were used: the transcripts of the group discussions, the observers' and group leader's notes during and after the interviews, and tapes of the discussions among the members of the research team after each group. The rigour of this technique is well recognized.20 The first step in the analysis consisted of reading the interview transcripts in order to identify the different categories that emerged. Individual codings by the researchers, followed by group discussions, were done regularly. A coding grid was developed based on the first two meetings. The coding of the remaining interviews was done by the same person (MDB). Then three of the researchers analysed the material, based on the categories developed. Each researcher worked on a specific section, following the major themes on the analysis grid. The QSR NUD*IST software package was used to facilitate the coding.
Different techniques were used to ensure the internal validity of the different steps in the analysis of the material.24 The first phase of validation of the coding was done with the two principal investigators, another researcher, the group leader and the research associate. By comparing the results of the coding of each one on a sample of the material, we were able to reach a consensus, and thus refine the analysis grid. Once this was done, the two principal investigators and the research associate continued this phase of validation on half of the interviews of the users and the physicians.
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Results |
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Physicians' characteristics
The majority of the physicians who participated in the study were women (57%), between 35 and 44 years old (59%), of French-speaking background, born in Quebec. On average, the physicians who participated in the study had >16 years of experience; they practice mainly in private offices (mainly group practice). One-third of the participants were trained in family medicine and a minority of them were affiliated to a university teaching programme. The differences between the respondents and non-respondents were not statistically significant.
Obstacles
Four categories of obstacles were identified in order of importance: obstacles linked to the users; to the organization of practice; to the CTFPHC recommendations; and to the physicians themselves.
Obstacles linked to the users.
- Lack of motivation. In the physicians' opinions, the major obstacle is a perceived lack of motivation with regard to lifestyle changes. This lack of motivation is seen in the lack of patient compliance with their recommendations, which they find demotivating and sometimes discouraging. While the majority of the physicians considered themselves to be ‘indulgent’ with regard to their patients' lack of motivation, a few of them refuse to promote prevention with those patients who are non-compliant.
- Having a regular physician. It was clear that in the eyes of the physicians we met, continuity of care appears as the main ‘facilitating’ factor to the integration of prevention. However, the physicians have the impression that the users ‘shop’ for information and for physicians. In their opinion, this user behaviour constitutes a major obstacle to the integration of prevention activities in clinical practices. Listening to the discussions, it became clear that the ‘emotional’ and financial investment that prevention requires to get your practice organized is only acceptable if the physician feels that the patient is also ready to ‘invest’ in the therapeutic relationship.
- Expectations. The majority of the physicians were disappointed to see that the patients place greater importance on tests than on the interview and the physical examination and that they want a quick fix rather than advice. The physicians find it difficult to ‘refuse’ a screening test when a patient requests it out of fear of damaging the relationship that they are trying to establish. The test becomes a ‘negotiating’ tool. Moreover, the physician feels a responsibility not to miss an opportunity to detect a disease.
"For a patient, prevention can be simply a matter of saying: doctor, do you want to give me a whole packet of papers to go take some tests?"
What has happened is that this is what the general public thinks of as prevention. It has nothing to do with talking to the doctor, discussing the patient's problem; it is not even about having a physical examination."Now patients come in with their shopping list and they want to go for an abdominal scan, a brain X-ray ... for them, that's what prevention means." "Patients are no longer even capable of describing their own symptoms to us. But they know the names of diseases, types of X-rays, medications."
- Patient's characteristics. Finally, some obstacles appear to be linked to types of patients. The physicians feel powerless in the face of certain situations such as poverty, unemployment, violence and alcoholism. They perceive the patients who come from underprivileged environments, men and adolescents, as being less interested in prevention.
Obstacles linked to the health care system and to practice organization.
- Lack of time. Time management poses a problem for the majority of the physicians. Many of them brought up the issue of the increase in their workload, especially since the implementation in the province of the shift towards ambulatory care and the retirement of a large number of their colleagues.
The physicians feel that they are caught in the vicious circle of rapid medicine, where both the doctors and users blame each other for not taking responsibility for prevention. Physicians working in the CLSCs complained that they no longer have time to carry out preventive measures."When a person comes in with a problem, I will do prevention in relation to this problem, and that's all. I don't have the time to work on prevention for all the other problems. If I have asthma to deal with and I have to provide information, I've only scratched the surface in terms of prevention. I've just spent 10 or 15 minutes, just for the asthma, just to put them on a new track. But I won't mention cholesterol; I won't ask if she's had a PAP smear or a mammogram if she's 40... I won't check into that. I just move on to the next patient."
- Reason for encounter. The settings of emergency care or walk-in clinics, which are very prevalent in North America, are ill suited to prevention, hence the difficulty in taking advantage of each encounter with a patient to integrate prevention, as the CTFPHC proposes. In spite of everything, some physicians use walk-in clinics to integrate preventive interventions related to the reason for the consultation: screening for sexually transmitted diseases (STDs), anti-smoking counselling, screening for hypertension. It allows for detecting patients who are at greater risk and offering to see them again with an appointment at a later time.
- Remuneration and access to resources. Remuneration appears to be a major obstacle, closely linked to the time factor. As one physician put it so aptly: "for us, time is money. We have to run our offices like businesses." According to many physicians, decisions regarding billing lack coherence since prevention activities are not included in their professional honoraria.
Lastly, the physicians feel that they lack tools (information leaflets or tear sheets) and resources (dietician, anti-smoking clinic, etc.), particularly when they are practising in private offices. Very few used reminder systems. Most questioned their use for economical or ‘ethical’ reasons (i.e. they saw reminder systems as a breach in patient's autonomy).
Obstacles linked to the guidelines. The physicians expressed several types of difficulties in the application of the CTFPHC recommendations that, in many instances, they consider not applicable in their routine practice.
The sequence of interventions to propose is complicated; for the doctors, this means that they run the risk of losing track of patients.
"There is something that doesn't ring true. You tell them every 3 years, but on the other hand for certain things, you say an annual examination for the breasts, counselling for other things, for STDs, and all those other topics. But if it's not for her PAP smear, she will not come in for the rest; she will not come just for information or just for a breast examination like that."
In addition, the physicians are particularly uncomfortable with the idea of explaining to a patient that they are discontinuing certain tests because of the patient's age (e.g. too old to check cholesterol, prostate-specific antigen, etc.). Lastly, some of the recommendations appear to contradict those made by other groups of experts.
"The group recommends stopping mammograms at age 70. But the 73-year-old woman who I've been seeing for the past 8 years and for whom I have prescribed mammograms every 2 years, all of a sudden, I tell her that I don't need to do a gynaecological examination, PAP smear or mammogram. It's as if I am telling her: 'you don't have enough years left to live for it to be worth the trouble anymore'."
Obstacles linked to physicians. Very few physicians identified obstacles that can be traced to themselves, apart from the lack of time available. Lack of training (in nutrition and in counselling techniques) is the obstacle mentioned most frequently, even by those who had completed a residency in family medicine.
We were surprised to find that many physicians reduce ‘counselling’ to the transmission of information, and they expect that this should be enough to trigger a change in behaviour.
"And then there's lung cancer. You recite the entire litany of warnings imaginable to patients to try and convince them to stop smoking, to change their lifestyle. Yes you can anticipate that the message will not get through every time. But it seems to me that it is often the case that it doesn't get through."
Specialists are sometimes identified as obstacles to prevention because they convey messages that contradict the CTFPHC recommendations and they recommend to patients to have screening tests or to ask their family physician for certain tests.
Few physicians spoke about their personal beliefs as obstacles to the application of the recommendations. Some, however, recognized that their own beliefs could influence their practice, for example the fact that they would want certain tests for themselves.
Table 1 summarizes the main obstacles expressed, as well as those that we perceived as researchers.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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This study demonstrates that the family physicians we met identify many major obstacles to the integration of prevention in their practice. It should be noted that the interventions proposed up to now do not address the barriers perceived by the physicians in our study. Existing CME activities focus on knowledge, while the difficulties raised have to do much more with communication skills and with a feeling of powerlessness. These could be the baseline barriers Cabana15–17 was referring to when he suggested that: "the effectiveness of interventions to improve adherence is dependent not only on the intervention itself but also on the existence and intensity of baseline barriers."
The physicians whom we met do not place a great deal of importance on recall systems and on the organization of their practice, in spite of the demonstrated effectiveness of these interventions.12,25 They do not want to accept this responsibility, unless they are provided with financial incentives, which do not currently exist in Quebec and Canada. Some participants even question the ethical nature of recall systems.
Our observations suggest that the contradictory recommendations among different groups of experts have a negative impact on the integration of prevention and that there should be emphasis placed on reaching consensus in the formulation of recommendations.
Lastly, we believe that there must be particular concern for the difficulties experienced by physicians to reach more vulnerable populations, i.e. those who are particularly at risk in terms of their health. The physicians view these patients as being uninterested and they appeared to us to be not inclined to get past the perceived obstacles, particularly for their underprivileged, vulnerable patients, from different cultural backgrounds. The physicians appear to be naturally drawn towards those patients who are most similar to themselves, which reinforces the adage: "It's better to be rich and healthy than poor and sick."
We are aware that our study was done in a North American context; more specifically, a fee for services system without registered patient lists. Certain barriers are specific to certain countries, and others are similar everywhere. For example, continuity of care, financial support to prevention, capitation and patient lists (e.g. in the UK and The Netherlands) might affect the physician's responses toward prevention and their perceptions of barriers. However, physicians with a salary, in our study, did not seem to do carry out more preventive measures in their practice because of the workload. Cultural differences with patients play a role. It has been shown that North American patients have high expectancies regarding blood tests for example.26
On the other hand, some similarities can be found in both continents. The patients' motivation to carry out preventive measures, difficult clientele (e.g. poor people or the elderly), the physician's workload, unclear recommendations and physician's lack of insight regarding patients risk behaviours and their own personal attitudes and beliefs are likely to be universal.27 Grol identified many obstacles to implement practice change, e.g. beliefs that the practice change will make a difference, not knowing well the instructions for how to do them and a lack of collaboration between different groups of care providers. He suggested that well-designed strategies, with a combination of different interventions, are necessary to be effective.18,27–29 However, since prevention is not perceived by family physicians as the first priority in their daily work, strategies suggested will have to be simple, very practical and approved by different groups of experts and care providers. Studies similar to this one should be repeated in European countries with a different context to observe the influence of this context on barriers. We have already replicated our study in rural area in Quebec to see if physicians have the same struggles (to be published).
The analysis of the socio-demographic characteristics of the respondents enables us to see the resemblance of our groups to the population of family physicians in the region we studied. We would like to point out that, while we attracted participants who, by definition, had ‘bought into’ prevention already, several physicians expressed opinions that challenged the proposed standards.
We took great care in ensuring that our observations were reliable, by applying the precepts of qualitative research. In spite of this, there are certain limits inherent in the group discussion technique. It produces a more superficial investigation of opinions than individual interviews. It is also more sensitive to the group dynamics, which create a phenomenon knows as ‘group censure’, i.e. some people can choose not to share or express their opinion because they may view it as being unacceptable for the group as a whole.20,21,30 We systematically went round the table at different points during the interviews, to make sure that each participant had a chance to speak. There did not seem to be a strong group effect among the physicians, who are probably more accustomed to expressing diverging viewpoints.
What are the potential consequences of these results? In our opinion, qualitative studies are needed to understand better the apparent reluctance of physicians to act as managers of their practices and the difficulties that they experience with vulnerable patient populations. Our study also identifies a need for concrete training on communication skills, focusing on a better comprehension of the complexity of behaviour changes, particularly in the area of lifestyle.
The physicians seem to ‘cave in’ under the weight of the responsibilities that are assigned to them in terms of health promotion. There may be room to propose a menu that is easier to digest and more realistic. In Canada and Quebec, we must consider modes of remuneration that are better adapted to the delivery of preventive services and agree to equip physicians properly to follow their patients more adequately, as has been done in many European countries such as the UK and The Netherlands.
All of the players involved in the distribution of services should be concerned with the observations that we have made about the importance of continuity of care, which can contribute to reinforcing preventive interventions by offering a variety of opportunities for doctor–patient encounters. Continuity of care also allows for seizing the right moment for the patient to gain a new awareness.
This study shed new light on understanding the difficulties family physicians face in trying to implement preventive guidelines in their practices. Knowledge transfer and practice organization—two areas of intense interventions in the last 15 years—do not appear to be major barriers. Barriers related to training issues and health care policies (continuity of care; remuneration) play an important role. It would be interesting to replicate such a study in a variety of health care settings. We have already repeated this study in two rural areas in Quebec (to be published).
In conclusion, in a Canadian context of lack of physicians, family physicians will have to question their way of carrying out prevention activities during their clinical activities. If not, the burden of the clinic will force them to give up certain prevention interventions. Guidelines, although perceived as helpful, will have to be realistic and congruent if they are to be integrated by physicians.
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Acknowledgments |
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The authors would like to thank Danièle Forté, Judith Paré and Cécile Pineault for their invaluable support throughout the research project and the writing of this article. They would also like to express their appreciation to the physicians who generously agreed to give their time to help us in this study. This research was funded by the Medical Research Council of Canada.
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1 Santé Québec. Et la santé, ça va? Québec: Les Publications du Québec; 1988.
2 Battista RN. Adult cancer prevention in primary care: patterns of practice in Quebec. Am J Public Health 1983; 73: 1036–1039.
3 Battista RN, Palmer CS, Marchand BM, Spitzer WO. Patterns of preventive practice in New Brunswick. Can Med Assoc J 1985; 132: 1013–1015.[Abstract]
4 Battista RN, Spitzer WO. Adult cancer prevention in primary care: contrasts among primary care practice settings in Quebec. Am J Public Health 1983; 73: 1040–1041.
5 Borgiel AE, Williams JI, Bass MJ et al. Quality of care in family practice: does residency training make a difference? Can Med Assoc J 1989; 140: 1035–1043.[Abstract]
6 Abelson J, Lomas J. Do health services organizations and community health centres have higher disease prevention and health promotion levels than fee-for-service practices? Can Med Assoc J 1990; 142: 575–581.[Abstract]
7 Bass MJ, Elford RW. Preventive practices patterns of canadian primary care physicians. In: Battista RN, Lawrence RS (eds). Implementing Preventive Services. New York: Oxford University Press; 1988: 17–23.
8 Smith HE, Herbert CP. Preventive practice among primary care physicians in British Columbia: relation to recommendations of the Canadian Task Force on the periodic health examination. Can Med Assoc J 1993; 149: 1795–1800.[Abstract]
9 Stange KC, Fedirko T, Zyzanski SJ, Jaén CR. How do family physicians prioritize delivery of multiple preventive services? J Fam Pract 1994; 38: 231–237.[Web of Science][Medline]
10 Beaulieu MD, Hudon E, Roberge D, Pineault R, Forté D, Légaré J. Practice guidelines on clinical prevention: do patients, physicians and experts share common ground? Can Med Assoc J 1999; 161: 519–523.
11 Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies. J Am Med Assoc 1995; 274: 700–705.
12 Grimshaw JM, Russel IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluation. Lancet 1993; 342: 1317–1322.[CrossRef][Web of Science][Medline]
13 Buntinx F, Winkens R, Grol R, Knottnerus JA. Influencing diagnostic and preventive performance in ambulatory care by feedback and reminders. A review. Fam Pract 1993; 10: 219–228.
14 Hulscher ME, Wensing M, van Der Weijden T, Grol R. Interventions to implement prevention in primary care. Cochrane Database Syst Rev 2001; CD000362.
15 Cabana MD, Ebel BE, Cooper-Patrick L, Powe NR, Rubin HR, Rand C. Barriers pediatricians face when using asthma practice guidelines. Arch Pediatr Adolesc Med 2000; 154: 685–693.
16 Cabana MD, Medzihradsky OF, Rubin HR, Freed GL. Applying clinical guidelines to pediatric practice. Pediatr Ann 2001; 30: 274–282.[Web of Science][Medline]
17 Cabana MD, Rand CS, Becher OJ, Rubin HR. Reasons for pediatrician nonadherence to asthma guidelines. Arch Pediatr Adolesc Med 2001; 155: 1057–1062.
18 Grol R. Personal paper. Beliefs and evidence in changing clinical practice. Br Med J 1997; 315: 418–421.
19 Beaulieu M D, Hudon E, Roberge D, Forté D, Légaré J. Intégration des activités de prévention aux pratiques médicales: sommes-nous tous sur la même longueur d'ondes? Rapport d'une étude exploratoire sur les perceptions des usagers et des médecins relativement aux recommandations du Groupe d'étude sur l'examen médical périodique. Monréal: Groupe de recherche interdisciplinaire en santé; 1998.
20 Krueger RA. Focus Groups. A Practical Guide for Applied Research, 2nd edn. London: Sage Publications; 1994.
21 Morgan DL. Focus Groups as Qualitative Research. London: Sage Publications; 1988.
22 Geller G, Holtzman NA. A qualitative assessment of primary care physicians’ perceptions about the ethical and social implications of offering genetic testing. Qual Health Res 1995; 5: 97–116.
23 Groupe de travail canadien sur l'examen médical périodique. Guide Canadien des Soins de Santé Préventifs Cliniques. Ottawa: Groupe Communication Canada; 1994.
24 Altheide DL, Johnson JM. Criteria for assessing interpretative validity in qualitative research. In: Denzin NK, Lincoln YS (eds). Handbook of Qualitative Research. London: Sage Publications; 1994: 485–499.
25 McVea K, Crabtree BF, Medder JD et al. An ounce of prevention? Evaluation of the ‘Put Prevention into Practice’ program. J Fam Pract 1996; 43: 361–369.[Web of Science][Medline]
26 Battista RN, Beaulieu MD, Feightner JW, Mann KV, Owen G. The periodic health examination: 3. An evolving concept. Can Med Assoc J 1984; 130: 1288–1292.[Medline]
27 Grol R, Wensing M. Implementation of quality assurance and medical audit: general practitioners’ perceived obstacles and requirements. Br J Gen Pract 1995; 45: 548–552.[Web of Science][Medline]
28 Schers H, Wensing M, Huijsmans Z, van Tulder M, Grol R. Implementation barriers for general practice guidelines on low back pain: a qualitative study. Spine 2001; 26: E348–E353.[CrossRef][Medline]
29 Geboers H, Mokkink H, van Montfort P, van den Hoogen H, van den Bosch W, Grol R. Continuous quality improvement in small general medical practices: the attitudes of general practitioners and other practice staff. Int J Qual Health Care 2001; 13: 391–397.
30 Carey MA, Smith MW. Capturing the group effect in focus groups: a special concern in analysis. Qual Health Res 1994; 4: 123–127.
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