Can practitioners' beliefs be changed, and if so, is the change reflected in clinical behaviour?
Campaigns have been carried out aimed at shifting practitioners’ beliefs and increasing guideline adherent practice. A Norwegian campaign aimed at doctors, physiotherapists, and chiropractors carried out between 2002-2005, emphasized optimistic advice to stay active during back pain, and encourage early return to work (Werner et al. 2008). Practitioners’ beliefs were measured in a questionnaire consisting of seven statements. Measures of behaviour included reported use of diagnostic imaging and referral patterns. Responses at baseline and post campaign were obtained only for 25% of those contacted, considerably limiting the value of the findings. The results supported a shift towards consensus with guidelines between 2002 and 2005, but this shift appeared independent of exposure to the campaign. However, despite this general shift and the focused intervention, over 20% of the practitioners failed to endorse an item suggesting that recovery from back pain is enhanced by early return to work. How such beliefs translate into advice to stay off work, and in sick certification for back pain is not known.
In contrast to the findings from the Norwegian campaign, a much more costly and high profile media campaign was carried out in Australia with significant results (Buchbinder et al. 2001). In addition to the general population, a survey of GPs was carried out before and after the campaign. Doctors reported awareness of the campaign (89%) and that it had changed their beliefs about back pain (32%). The survey suggested that doctors in the county in which the campaign was carried out were almost fourfold more likely to endorse the belief that people could return to work with back pain. They also were three times more likely to reject bed rest as treatment. These beliefs were maintained 3 and 4 years post intervention (Buchbinder and Jolly 2005; 2007). Most important, the changes to beliefs in the general population and in general practitioners corresponded to a reduction in claims for back problems.
In another large randomized control trial (RCT) aimed at musculoskeletal practitioners, the trial arm participants (n=876) were sent a printed information pack about guideline recommendations for the management of back pain (Evans et al. 2005). Responses to a vignette of a patient included questions about the practitioners’ recommendations for activity, work, and bed rest, and these were categorized as consistent/inconsistent with guidelines. Practitioners’ beliefs were also measured, using a modified version of the HC-PIRS (Rainville et al. 1995). The results indicated a shift in beliefs, albeit of a small order, indicating a reduction in the belief that back pain should affect daily function. In addition, in the trial arm, reported behaviour became significantly more guideline consistent in reference to advice about staying active and returning to work, suggesting that an educational package can affect both beliefs and clinical behaviour.
As part of two larger RCT’s Vonk and colleagues (2004) describe a small exploratory investigation addressing the relationship between clinicians’ orientation as measured by the PABS-PT and their professional group. The biomedical orientation subscale of the PABS-PT was reduced in those practitioners who received training (1.5 days) to deliver a behavioural graded activity programme. In a larger study of physiotherapy students in Australia exposure to a 16 hour unit of learning on chronic back pain changed some subscale scores on The HC-PAIRS at immediate and one year follow up (Vonk et al. 2004).