EMPIRICAL ARTICLE
Using a Knowledge Transfer Framework to Identify Factors Facilitating Implementation of Family-Based Treatment Jennifer Couturier, MD1,2,3* Melissa Kimber, MSW3 Susan Jack, PhD3,4 Alison Niccols, PhD1 Sherry Van Blyderveen, PhD1,2 Gail McVey, PhD5
ABSTRACT Objective: To conduct a qualitative study to identify factors that would facilitate the transfer of the research evidence on Family-Based Treatment (FBT) into clinical practice. Method: Fundamental qualitative description guided sampling, data collection, and analytic decisions for this study. Forty therapists who treat children and adolescents under the age of 18 with Anorexia Nervosa (AN) and belong to Ontario’s provincial network of specialized eating disorder services completed an in-depth interview focusing on elements proposed by the Lavis knowledge transfer framework. An experienced coder conducted content analysis, with 20% of the interviews double-coded for reliability purposes. Results: Participants requested training in the FBT model, including the provision of research evidence (i.e., journal articles), as well as the specific tenets of the model according to the FBT manual. The suggested audience for implementation included not only therapists themselves, but administrators, physicians, and community
Introduction A gap often exists between evidence-based interventions and their uptake in clinical practice, leadAccepted 20 October 2013 Supported by Hamilton Academic Health Sciences Organization Alternate Funding Plan Innovation Fund. *Correspondence to: Jennifer Couturier, Department of Psychiatry and Behavioural Neurosciences, Pediatric Eating Disorders Program, McMaster Children’s Hospital, McMaster University, McMaster University Health Sciences Centre, Room 3H8G, 1280 Main St. West, Hamilton, Ontario, Canada, L8S 4L8. E-mail:
[email protected] 1 Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada 2 Department of Pediatrics, McMaster University, Hamilton, Canada 3 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada 4 School of Nursing, McMaster University, Hamilton, Canada 5 Dalla Lana School of Public Health, University of Toronto, Toronto, Canada Published online 00 Month 2013 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/eat.22225 C 2013 Wiley Periodicals, Inc. V
International Journal of Eating Disorders 00:00 00–00 2013
members. The development of best practice guidelines was also supported. Local FBT experts were suggested as credible messengers. Infrastructure relating to financial support and time away from clinical duties were reported to be essential for training. Ongoing supervision and mentorship were reported to be important elements of implementation and evaluation processes. Discussion: Suggestions for moving FBT into practice were consistent with previous research, however, the importance of obtaining the evidence in the form of primary research articles and obtaining team buy-in were remarkable. Developing context-specific training programs and administrative processes for the implementation of FBT are warranted. C 2013 Wiley Periodicals, Inc. V Keywords: knowledge transfer; implementation; family-based treatment; Anorexia Nervosa; adolescents (Int J Eat Disord 2013; 00:000–000)
ing to the under-use of effective treatments, misuse of treatments, and suboptimal health outcomes for patients. This is particularly true with respect to the treatment of eating disorders.1 Fortunately, family-based approaches where parents are actively addressing eating disorder symptoms are gaining an evidence base and are currently recommended by the American Psychiatric Association2 as the first-line of treatment for children and adolescents diagnosed with Anorexia Nervosa (AN). This type of therapy places parents in charge of the refeeding process at the beginning of treatment. Despite the fact that family approaches have been shown to have better outcomes than individual approaches,3 are cost effective and may reduce reliance on hospitalization,4 there appears to be sub-optimal application of this model in practice.5 This situation is problematic when one considers that family therapy has been shown to be superior in producing a more rapid recovery in patients 1
COUTURIER ET AL.
diagnosed with AN,6,7 as well as in maintaining remission of AN symptoms at 6- to 12-month follow-up compared with individually based treatments,3 confirmed in a recent meta-analysis.8 Organizational culture and climate supportive of practice change, as well as individual practitioner readiness to change, are factors that impact the effective implementation of change initiatives.9,10 Furthermore, leadership buy-in throughout the implementation of any new practice has been shown to be imperative.11,12 Similarly, it has been shown that therapists working in the mental health field are more likely to adopt a particular EvidenceBased Treatment (EBT) if the evidence to support its use is generated by colleagues close to that individual, and if there is minimal divergence between the old and the newly proposed model.13–15 Although barriers to the use of manualized Family-Based Treatment (FBT)16 have been studied and described elsewhere by our research group,5 such information does not comprehensively address the best strategies for FBT uptake within this specialized mental health field. A greater understanding of the factors that facilitate the adoption of cost-effective, outpatient, evidencebased treatments, is needed. Lavis et al.17 have suggested five elements of knowledge transfer that support the effective transmission of knowledge into clinical practice. These five elements are: (1) identifying what specific knowledge needs to be transferred (“the message”), (2) identifying whom the knowledge should be transferred to (“the audience”), (3) assessing by whom should the knowledge be transferred (“the messenger”), (4) exploring how the knowledge will be transferred (“knowledge transfer strategies and infrastructure”), and finally (5) determining the effect of the knowledge transfer process (“evaluation”). In this study, our main objective was to examine all five of the knowledge transfer questions within the framework developed by Lavis et al.,17 in order to identify factors to increase the uptake of FBT within a well-developed network of eating disorder professionals in Ontario, Canada.
Method Design The principles of fundamental qualitative description18 guided sampling, data collection, and analytic decisions in this study. This qualitative approach is appropriate for identifying the fundamental structures of a phenomenon, including an exploration of experiences and perceptions, and then providing a comprehensive
2
summary of events. A qualitative approach was chosen for this study in order to obtain a rich understanding of therapists’ perceptions on implementing FBT, a highly complex process. This study was reviewed and approved by the Hamilton Health Sciences/McMaster Faculty of Health Sciences Research Ethics Board. Sample In Ontario, Canada, a well-established provincial network of clinicians treating eating disorders exists that is coordinated by the Ontario Community Outreach Program for Eating Disorders (OCOPED).19 Membership in the network includes a diverse group of clinicians within rural, urban, suburban, academic, and nonacademic settings. Any adolescent with AN in Ontario would have a high probability of being treated by a member of the network given the referral pathways in place. For this reason, these therapists were sampled rather than private practitioners, as members of the network would be most able to speak to the experience of treating young people with AN. Given the diversity in the provincial network membership, we estimated that a sample of 40 therapists would lead to data saturation. Each organization listed on the OCOPED’s training website was contacted through their central contact person via e-mail asking the contact person to forward an email inviting participation from those therapists providing psychotherapeutic intervention for children and adolescents diagnosed with AN within their organization. Study inclusion criteria were: (1) ability to understand and speak English, and (2) being a provider of psychotherapeutic interventions to children and adolescents (
