A variety of interventions are needed to progress from awareness, to agreement, to adoption, to adherence with evidence-based practices, where interventions should push in three directions (see Table 1):

• To facilitate change by increasing knowledge or skills,
• To enable change by promoting conducive conditions in the practice and elsewhere, and
• To reinforce the change, once it is made¹.

 

Table 1: Pathman-PRECEED model for knowledge translation1

Perspective of target (policy maker, consumer, or clinician)
Intervention*	Awareness	Agreement	Adoption	Adherence
Facilitating	Distribution of printed information; journals; media campaigns; lectures; rounds; academic detailing
Enabling		Opinion leaders; small group sessions for clinicians	Small group sessions for clinicians; patient education routines; clinical flowcharts or algorithms; academic detailing
Reinforcing			Small group sessions for audit and feedback	Reminders (professional and patient), multiple interventions
* Perspective of healthcare or educational system

Methods to overcome barriers/obstacles and increase professional adherence

It is important to also include some interventions that will help you to overcome barriers/obstacles and increase professional adherence. You have already done an evaluation with your focus groups and understand what barriers/obstacles exist in your environment. Different methods can be used to overcome them and increase health care professionals' adherence to clinical practice guidelines.

These methods include:

• educational materials
• conferences
• local opinion leaders and consensus-building processes
• outreach visits
• patient-mediated interventions
• audits and feedback
• reminders
• marketing
• multifaceted interventions²

 

PLEASE NOTE THAT NOT ALL THESE INTERVENTIONS ARE EQUALLY EFFECTIVE IN OVERCOMING BARRIERS/OBSTACLES Davis3 noted that didactic lecture-based CME are weaker interventions when it comes to changing care provider performance, while audit and feedback is a moderately effective intervention and multifaceted interventions and reminders are the most likely to be successful, particularly when they target awareness and behaviour.

 

[1] Davis D, Evans M, Jadad A et al. The case for knowledge translation: shortening the journey from evidence to effect. BMJ 2003; 327(7405):33-35.

[2] Oxman AD, Thomson MA, Davis DA et al. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ 1995; 153(10):1423-1431.

[3] Davis DA, Taylor-Vaisey A. Translating guidelines into practice. A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. CMAJ 1997; 157(4):408-416.

 

By identifying obstacles to adherence, and including healthcare professional perspectives on potential barriers and their solutions to bridge the gaps in care, a more successful intervention can be achieved.