Family Practice Vol. 21, No. 4, 425-428
Family Practice Vol. 21, No. 4 © Oxford University Press 2004, all rights reserved.
GPs' needs for practice-oriented nutrition education; a Delphi study among Dutch GPs
a Department of General Practice, Maastricht University, PO Box 616, 6200 MD Maastricht and b Skillslab Department, Maastricht University, Maastricht, The Netherlands
E-mail: bas.maiburg{at}hag.unimas.nl
Received 6 June 2003; Revised 9 December 2003; Accepted 10 March 2004.
Maiburg BHJ, Rethans J-JE and van Ree JW. GPs'needs for practice-oriented nutrition education; a Delphi study among Dutch GPs. Family Practice 2004; 21: 425–428.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
Background. Published guidelines and lists of topics in nutrition education for GPs are affected by practical drawbacks, which prevent them from being easily implemented in vocational training curricula.
Objective. Our aim was to draw up a concise priority list of disease-related nutrition topics reflecting the needs among Dutch GPs for nutrition education geared to everyday practice, which can be used to decide on the main topics and educational content of computer-based instruction.
Methods. This was a two-round Delphi study, using pilot-tested questionnaires carried out among 41 GPs who attended a national CME meeting on nutrition in The Netherlands. Sum scores of, and summarized comments on nutrition topics and their frequencies in top-10 lists drawn up by respondents were the main outcome measures.
Results. The response in both Delphi rounds was high (93 and 95%). Analysis of questionnaires in both rounds yielded a priority list of disease-related nutrition topics, with the 14 highest ranking topics identical in both rounds. A fifteenth topic, only found in the second questionnaire, completed the priority list. A group of experts assessed this list as fully acceptable.
Conclusion. It was possible to compile a priority list of disease-related nutrition topics reflecting the needs of GPs for nutrition education. Based on the results of the Delphi study, we generated the following list of five priority topics: weight problems; diabetes mellitus; hypercholesterolaemia; intestinal complaints; and hypertension. This list of five and the summarized comments of respondents will determine the main topics and educational content of a computer-based instruction we are currently developing.
Keywords. Educational objectives and requirements, general practice vocational training, nutrition education, postgraduate.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
The past decade has seen the publication of several guidelines for and lists of topics in nutrition education for GPs or GP trainees, to be implemented in the curriculum of GP vocational training.1–4 These guidelines are affected to a varying degree by practical drawbacks, which means they cannot be easily implemented in current vocational training curricula. Firstly, since there is—within the limited curriculum of GP vocational training—a particular need for a concise list of the main disease-related nutrition topics, the guidelines published so far are too comprehensive.2,5 Secondly, the guidelines seem to be based on the opinions of expert clinicians and expert GPs with a clearly defined field of interest in nutrition, and so probably do not reflect the needs of GPs in everyday practice care.4 Thirdly, from a ‘national appropriateness’ point of view, several publications do not refer to the Dutch situation, making them less useful for Dutch GPs.1
In The Netherlands, the need for postgraduate nutrition education has re-emerged after recent research showed that patients' questions on nutrition and food tend to be addressed preferentially to GPs, who are seen by patients as the major and most reliable source of nutrition guidance.6 At the same time, however, it has been found that GPs, as well as GP trainees, feel impeded by a lack of training and education in nutrition.7,8 GP trainees have also indicated the necessity of introducing disease-related nutrition topics in the vocational training curriculum.8
To overcome the above practical limitations of published guidelines, a project was initiated whose main goal was the compilation of a concise priority list of disease-related nutrition topics, reflecting the needs of Dutch GPs for nutrition education geared to everyday practice. It was believed that such a practice-oriented list would prove to be a useful starting point for implementing nutrition topics in vocational training curricula and for deciding on the educational content of a computer-based instruction on nutrition currently under development at the Department of GP Vocational Training of Maastricht University.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Since we wanted to prepare a consensus list of the most important nutrition-related topics in general practice and find any disease-related nutrition topics that had so far been overlooked, a Delphi study among Dutch GPs seemed the preferred method.9 The Delphi method is generally accepted as a powerful means of reaching consensus and generating ideas among respondents. Briefly, the method involves sending a questionnaire to the respondents and analysing their response. This is then used to develop a new questionnaire and the cycle is repeated. Three methodological aspects are important in a Delphi study. First, respondents are not aware of the identity of the other respondents, to ensure that their responses are independent. Secondly, participants respond individually to avoid group domination by certain individuals. Thirdly, mathematical voting procedures are used which permit the ranking of items. A two-round procedure was considered sufficient, since a comprehensive list of disease-related nutrition topics was already available.10 Our main Delphi question was: which disease-related nutrition topics are needed for a practice-oriented nutrition education for GPs? The procedure was carried out in the period from June to September, 1998.
A panel of 
30 GP respondents was considered sufficient for our objective, i.e. generating topics for nutrition education. GPs were recruited by telephone from the list of participants to a national refresher course on nutrition.11 Since such nutrition courses are organized very rarely, the GPs were expected, from their attendance at this course, to be at least interested in the subject of nutrition in general, without being experts on a specific nutrition topic.
In the first Delphi round, respondents received a pilot-tested questionnaire comprising 77 nutrition topics. These topics were derived from a comprehensive list of disease-related nutrition topics in general practice compiled by the Dutch Nutrition Foundation3 which, in turn, was based on the guidelines of the Dutch College of General Practitioners.12 The description of some topics was slightly modified to obtain a consistent list of diseases and complaints. Respondents were asked to comment on all items in terms of acquaintance, importance and clarity, and to select the 10 most important topics (top-10) for GP nutrition education. Although a comprehensive list of disease-related nutrition topics was used, respondents were invited to add their own topics. Participants in the study were twice reminded by telephone to complete the questionnaire. The questionnaires returned were analysed by summarizing the comments on each item and scoring the topics selected by respondents (by awarding 10 points to the top item in each top-10, nine points to the second item, and so on to 1 point for the tenth item). The frequency with which each topic occurred in the respondents' top-10 lists was also assessed.
On the basis of the findings, a 39-item list was compiled for the second Delphi round. Thirty-five items were retained from the first questionnaire by deleting those items that had been mentioned fewer than three times in the top-10 lists. Comments on all items to be deleted were analysed by the researcher before removal for any important observations which would justify retaining the items. Four new items mentioned by respondents were added. The second round questionnaire was constructed by listing the 39 items, their scores and summarized comments from the first Delphi round. Respondents were again asked to comment on all items and to select their final top-10. If necessary, they were twice reminded by telephone to complete the questionnaire. The analysis of the second questionnaire was identical to that of the first. The 39 disease-related nutrition items were ranked by their sumscores and by the percentage of respondents who had mentioned each item.
The findings of the second Delphi round were finally presented to a small panel of experts including an experienced GP, a professor of general practice and a professor of clinical nutrition. They were asked to evaluate the face validity of the ranking of the topics in the list generated from the analysis of the second Delphi questionnaire.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Respondents
Fifty GPs who had attended a continuing medical education (CME) meeting on nutrition were eligible for inclusion in the study. Of these GPs, 41 agreed to participate in the Delphi study. Four GPs were unable to participate because of holidays during the study period or lack of experience in general practice. Only five GPs refused to take part. Among the 41 GPs thus recruited, seven were women. About half of the 41 GPs (n = 21) worked in an urban setting, the other half in a more rural setting.
First Delphi round
Of the 41 respondents, 38 (93%) returned the first questionnaire on time. These 38 GPs were to represent the panel of respondents for the second Delphi round. Table 1 shows the 14 highest ranking items from the first questionnaire, together with their frequency of occurrence in the top-10 lists sent in by respondents (displayed as the percentage of respondents who mentioned the item). The ‘syndrome X’ item was not included in the list of items in the first questionnaire, but was mentioned by several respondents who felt it had to be added in the second questionnaire.
|
Second Delphi round
The response to the second questionnaire was 95% (36 of 38 respondents). The 15 items shown in Table 1 represent the 15 highest ranking items from this 39-item questionnaire. These are shown together with their sumscores and the percentage of respondents who mentioned each item in their top-10 list. Irrespective of the way items were ranked (by sumscore, percentage of respondents or both sumscore and percentage), the same cluster of 15 highest ranking items emerged.
It should be noted that these 15 items correspond exactly to those found in the first Delphi round, except of course for ‘syndrome X’. Furthermore, these 15 items (from the total of 39) represent 88% of all scores given to the items selected in the respondents' top-10 lists.
The comments on the topics in both questionnaires could be assigned to the following five categories: social importance; incidence/prevalence; influence of nutritional change; co-operation with dieticians; and item overlap. Respondents suggested combining the items ‘irritable bowel syndrome’ and ‘chronic constipation/haemorrhoids/anal fissure’ into one item: ‘intestinal complaints’.
Meeting of experts
The participants of the meeting of experts qualified the ranking of the nutrition-related topics that had emerged from the Delphi study as fully acceptable. They assessed the list of the 15 highest ranking nutrition-related topics as highly relevant to GPs in everyday care. They proposed the introduction of the item ‘weight problems’ to replace the items ‘obesity’ and ‘eating disorders/loss of weight/overweight’.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
The objective of this study was to develop a concise priority list of disease-related nutrition topics reflecting the needs of GPs for nutrition education geared to everyday practice. After the proposals made by respondents and experts for the integration of items had been implemented, we were able to compile a concise list of disease-related nutrition topics. It includes the following top-5 of the most important nutrition-related topics in general practice: weight problems; diabetes mellitus; hypercholesterolaemia; intestinal complaints; and hypertension. Although these topics can also be found in existing comprehensive guidelines for nutrition education,1,2 the added advantage of the new list is the ranking of topics. The selection differs from the content of a previously developed Dutch nutrition course.4
From the point of view of nutrition education, it is interesting that this top-5 covers the main categories of nutrients and energy equilibrium (carbohydrates in diabetes mellitus; fats in diabetes mellitus and hypercholesterolaemia; fibre in intestinal complaints and diabetes mellitus; minerals in hypertension; and energy in weight problems). Together with the summarized comments made by the respondents in our Delphi study, the top-5 list will be used as a basis for the content of a computer-based instruction on nutrition currently under development at Maastricht University.
We feel that the high participation rate among the GPs invited for this Delphi study and the high response rate in both rounds reflect the interest in and attention to nutritional matters among the participants. In our view, this kind of general interest and attention justifies giving serious consideration to the topics in the Delphi questionnaire. If we had opted for nutrition experts as respondents, this would not only have been difficult to achieve, because such experts are scarce among GPs, but would also entail the danger of focusing attention on their expert subjects. On the other hand, inviting interested GPs to participate, as we did, may have led to an underestimation of the importance of certain nutrition topics due to a lack of knowledge about nutrition among these GPs.13
We acknowledge that the selected GPs potentially were biased in their selection of a top-10 of topics by their attendance at the CME meeting on nutrition. For example, the high ranking of the item ‘infant food allergy’ in the first Delphi round could be attributed to this topic being one of the subjects at the CME meeting. In view of its score in the second Delphi round, any such effect seems to have waned over time, although it should be noted that respondents in this round were presented with a reduced pool of items from which they could select their final top-10. Nevertheless, GPs who have little interest in nutrition or who have not recently attended a nutrition course may well have given a different response to the ranking of nutrition topics.
The lists of highest ranking items emerging from the two Delphi rounds included exactly the same disease-related nutrition topics. Since these items also represented 90% of all scores, it may be concluded that there was a very high level of consistency in the respondents' choice of items: as a group, they selected only a limited number of items for their top-10 lists. We therefore consider the results of this Delphi study to be reliable.
We also consider the results to be representative of the total group of 41 participants in the Delphi study, in view of the high response rate in both rounds. As mentioned in the Methods section, the size of this panel of respondents in a Delphi study ensured that it was a powerful instrument for generating the nutrition topics we were looking for. Nevertheless, it is not possible to generalize the results of the present study to the total population of GPs. Although the sex ratio among respondents corresponds closely to the national figures14 and the participating GPs were well distributed over urban and rural settings, the group of GPs included was recruited from among the limited number of GPs who attended the national CME meeting on nutrition. However, we feel that the results of the present study are likely to represent the opinion of those GPs who are interested in the subject of nutrition.
In conclusion, we were able to compile the intended concise list of disease-related nutrition topics using the Delphi method. Because the list is prioritized, it provides a useful indication of the topics that should be implemented successively in GP training curricula.
|
Acknowledgments |
|---|
We would like to thank all 41 GPs for their contribution to this study.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
1 The Group on Nutrition, Society of Teachers of Family Medicine. Physician's Curriculum in Clinical Nutrition: Primary Care, 2nd edn. 2001. http://www.stfm.org/pdfs/GrouponNutrition.pdf [accessed 18 February 2003].
2 American Academy of Family Physicians. Nutrition. Recommended Curriculum Guidelines for Family Practice Residents. June 2000. http://www.aafp.org/x16543.xml [accessed 19 February 2003].
3 Dutch Nutrition Foundation. Huisarts en voeding [General practitioner and nutrition]. The Hague: Dutch Nutrition Foundation; 1997.
4 Buijs G, Almekinders F, Stasse-Wolthuis M, Schadé E, Schretlen E, Steenmetz Y. Onderwijsprogramma Voeding [Nutrition course] Utrecht: Department of General Practice, University of Utrecht; 1988.
5 Mularski RA. Essentials of nutrition education in medical schools: a national consensus. Am J Clin Nutr 1997; 65: 1559–1561.
6 Hiddink GJ, Hautvast JG, van Woerkum CM, Fieren CJ, van't Hof MA. Consumers' expectations about nutrition guidance: the importance of primary care physicians. Am J Clin Nutr 1997; 65: 1974s–1979s.
7 Hiddink GJ, Hautvast JG, van Woerkum CM, Fieren CJ, van't Hof MA. Nutrition guidance by primary-care physicians: LISREL analysis improves understanding. Prev Med 1997; 26: 29–36.[CrossRef][Web of Science][Medline]
8 Maiburg HJS, Hiddink GJ, van't Hof MA, Rethans JJ, van Ree JW. The NECTAR-Study: development of nutrition modules for general practice vocational training; determinants of nutrition guidance practices of GP-trainees. Eur J Clin Nutr 1999; 53 (Suppl 2): S83–S88.
9 Dunn WR, Hamilton DD, Harden RM. Techniques of identifying competencies needed of doctors. Med Teach 1985; 7: 15–25.[Web of Science][Medline]
10 Delbecq AL, van de Ven AH, Gustafson DH. Group Techniques for Program Planning. A Guide to Nominal Group and Delphi Processes. Glenview: Scott, Foresman Co.; 1975: 83–107.
11 Büller HA, Mathus-Vliegen EMH, van Staveren WA. Voedingsproblematiek per levensfase [Nutrition problems related to different stages of life]. Amersfoort: Benecke Consultants; 1997.
12 Thomas S, Geijer RMM, van der Laan JR, Wiersma T. NHG-Standaarden voor de huisarts [Practice Guidelines for the General Practitioner]. Utrecht: Wetenschappelijke uitgeverij Bunge; 1996.
13 Cornel M. Detection of Problem Drinkers in General Practice. Maastricht: Maastricht University; 1994.
14 Hingstman L. Cijfers uit de registratie van huisartsen [Figures from GP registration]. Utrecht: Netherlands Institute of Health Services Research; 1998.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  S M E van Dillen and G J Hiddink A comparison of Dutch family doctors' and patients' perspectives on nutrition communication Fam. Pract., December 1, 2008; 25(suppl_1): i87 - i92. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||