the College of Family Physicians of Canada was a key component of this study ... The Department of Family and Community Medicine at the Toronto Hospital.
Family Practice © Oxford University Press 2000
Vol. 17, No. 3 Printed in Great Britain
Measuring community-oriented attitudes towards medical practice Ivy F Oandasana, Indraneel Ghoshb, P Niall Byrnec and M Sharon Shafira Oandasan IF, Ghosh I, Byrne PN and Shafir MS. Measuring community-oriented attitudes towards medical practice. Family Practice 2000; 17: 243–247. Background. The measurement of attitude and attitudinal changes regarding communityoriented primary care (COPC) and the community-oriented principles of family medicine from the College of Family Physicians of Canada was a key component of this study involving family medicine residents. The Department of Family and Community Medicine at the Toronto Hospital initiated a new COPC curriculum in July 1997 for its first-year residents which was designed to teach the principles of family medicine which are community oriented. Objective. This study was developed to provide an analysis and summary of the attitude and attitudinal changes of residents exposed to the programme and those of two cohort groups who were not exposed. Methods. A quasi-experimental design was used. A 20-item questionnaire was administered pre- and post-intervention. Qualitative data were also collected from focus group sessions with the residents exposed to the programme. Results. The questionnaire was found to have good reliability, with an alpha coefficient of 0.8. No significant differences were observed between the study and control groups pre- and postintervention. Within the study group, two items from the questionnaire yielded significant differences (P , 0.05). These items dealt with lack of funding and impracticality issues of applying COPC in medical practice. They were also the prevalent themes generated from the focus group session analysis. Conclusions. The qualitative data corroborated the findings of the survey. These findings have helped in the evolution of the curriculum. Longitudinal studies to measure attitudes and the practice of COPC and community-oriented principles of family medicine after residency are recommended. Keywords. Attitudes, community-oriented primary care, evaluation, family medicine, medical education.
With primary health care reform a reality in Canada, The Toronto Hospital Department of Family and Community Medicine developed a curriculum to ensure that its family medicine trainees would develop the knowledge, skills and attitude to practise family medicine in the 21st century. The College of Family Physicians of Canada states that there are four principles upon which all family physicians should model their way of practice, two of which are community oriented3 (Table 1). The Community-Oriented Primary Care (COPC) Curriculum was developed and implemented in July 1997 to address these two principles of family medicine. It was based upon the COPC methodology described by Nutting, which provides an established and validated framework to use in identifying, addressing and
Introduction Medical school and its training programmes have a unique purpose of selecting and educating competent, caring physicians capable of meeting society’s expectations.1 They also have a responsibility to accept some degree of accountability for the health of the community and therefore cannot shy away from the issues related to health care reform.2
Received 7 September 1999; Accepted 21 December 1999. aDepartment of Family and Community Medicine and cFaculty of Medicine, University of Toronto, Ontario and bQueen’s University, Kingston, Ontario, Canada.
243
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Family Practice—an international journal TABLE 1
The four principles of family medicine
The doctor–patient relationship is central to family medicine The family physician is a skilled clinician Family Medicine is community baseda The family physician is a resource to a defined practice populationa a These two principles are community based, and the focus of the new curriculum.
TABLE 2
The goals of the COPC curriculum
To understand the role of the family physician as a resource to a practice population and that family medicine is community based To understand the role family physicians have in health promotion and population health To encourage the collaboration between medical professionals, allied health professionals and community workers To understand the barriers preventing health care and improve accessibility To develop an awareness of one’s biases To recognize the applicability of caring for individuals within the context of their families and the community
evaluating community health needs.4 The philosophy of the programme is to create proactive family physicians who are responsive to the needs of individuals and the community. The goals of the curriculum are listed in Table 2. The purpose of this study is to develop a tool to measure attitudes towards community-oriented medical practice and test it on family medicine residents. The study was accomplished using a quasi-experimental design to determine if attitudes towards community-oriented primary care and the community-oriented principles of family medicine underwent significant positive changes as a result of the COPC curriculum. A unique feature of this study was to use a focus group to validate the study’s qualitative findings. The main objective of measuring attitudes is to ensure that learners and future physicians develop the ‘right’ attitudes for their future careers.5
Methods Two tools, one qualitative and one quantitative, were used to measure attitude and attitudinal changes towards COPC and the community-oriented principles of family medicine. The integration of qualitative and quantitative data together provides a synergistic effect in interpreting results.6–8 Attitude questionnaire Design. The questionnaire was an objective tool that collected quantitative data. The self-administered
questionnaire was designed by researchers at the hospital to determine attitudes towards COPC. Originally, it consisted of 26 items; however, after calculating the correlation of each of the items with the overall score, those items whose correlation were ø0.15 were removed. The 20-item questionnaire had an alpha reliability value of 0.8, as calculated by the SPSS package. Items were answered using a Likert scale, and the questionnaire was used at the start of the programme, and then at the completion of their first year. Data were input with low scores corresponding to a more positive (or desirable) attitude towards COPC principles and practice. Participants. The study group comprised first-year Family Medicine residents (R1s) at the hospital. Eleven subjects completed the pre-intervention questionnaire, and 13 completed the post-intervention questionnaire. Two new residents joined the programme later in the year and did not complete the pre-intervention questionnaire. Two control groups were used. One was the second-year Family Medicine residents (C2s) at the same hospital, and the other was the first-year Family Medicine residents at another Ontario University (C1s). Both groups had eight subjects in the pre-intervention questionnaire, but four subsequently were lost to follow-up in the C1 group, and three were lost to follow-up in the C2 group. Data analysis. All statistical analysis was performed by the SPSS package. Due to the small sample size, the Mann–Whitney–Wilcoxon rank sum test was used to analyse the difference between the study group and each control group. To analyse the change within the study group pre- and post-intervention, a paired t-test was used. The data were paired by sample number. In addition, to help to identify specific key issues with regards to attitudinal change, each item was analysed further by a paired t-test. Focus group session Design. The second tool used was focus group sessions with the R1s. The residents were broken up into two smaller groups, and the sessions were facilitated by an independent researcher with whom the residents were not familiar. All participants were assured of confidentiality, and the session was audio-taped with their permission and transcribed. Data analysis. The transcribed notes were distributed to five faculty members from the Department and one medical student involved with the evaluation of the curriculum for independent analysis. Each person analysed the data and generated the major attitudinal themes and issues. Subsequently, all six met to compare and contrast the individual themes and to reach a final list of themes by consensus.
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Measuring community-oriented attitudes towards medical practice
Results and discussion Questionnaire The results of the Mann–Whitney–Wilcoxon rank sum test are summarized in Table 3. There was no significant pre-intervention difference between the study group and either of the control groups. This finding was important as it indicated that at the beginning of their respective years, there was no significantly different attitude between the study group and the control group as measured by the questionnaire. However, the post-intervention results also showed no statistically significant difference. This was unexpected since it indicated that at the end of their respective programmes, the study group had no statistically significant difference in their attitude towards the community-oriented principles of family medicine as compared with either of the control groups. Looking specifically for shifts in attitude within the study group, a paired t-test was performed on the mean scores of all the responses. Data were input with a lower score corresponding to a more positive attitude towards COPC. There was no statistically significant difference in the overall mean scores post-intervention (Table 4); however, the P-value of 0.055 is very close to being statistically significant. Given the small sample size, this result was difficult to ignore. The lower postintervention score indicates a more positive attitude towards COPC principles and practice at the end of the first year of the programme, and was a promising finding. On examining the mean scores of each item, a shift away from the desired attitude was found through a statistically significant higher mean post-intervention score on two items (Nos 8 and 20). The two items read as follows: (8) ‘The role of the physician to a defined population is not usually practical’; and (20) ‘Unless funding formulas change it is unlikely that family physicians will spend time with patients on health promotion and disease prevention’. Both items deal with the issue of practicality and applicability of COPC and, therefore, represent areas of concern within the residents in the study group. TABLE 3
Focus group The focus group discussion yielded five major themes: (i) an interesting, enjoyable and eye-opening experience; (ii) the applicability of COPC in future practices is not practical; (iii) COPC is best learned ‘hands-on’ in the community; (iv) poor scheduling of COPC projects led to conflicting priorities; and (v) the structure of the COPC programme is too formal. The first two of these five themes corroborate the findings of the quantitative data. The study group found the community interaction to be a positive experience, as identified by the shift in overall attitude measured by the questionnaire. The specific findings of items 8 and 20 were also supported, as many residents in the study group expressed concern with the practicality of COPC application due to present fiscal restraints. These findings were crucial as they addressed the validity of the questionnaire and the inferences made from it. The other themes generated identified the need for more experiential ‘hands-on’ learning and the time demands of the current curriculum. These features were important findings as they provided valuable information regarding evaluation of the programme and were recognized as key features for reform for the following year Limitations The sample sizes in the study and control groups were small and compounded by the loss to follow-up in both control groups. However, the inferences made from the survey were supported by the focus group findings. It is difficult to measure a variable such as attitude change over a short time period. A long-term evaluation of the programme with a longitudinal trend design study would be useful in measuring change. Attitudinal measurements may not be reported accurately with a standardized objective procedure. Individuals may answer a survey in a manner they feel is more desirable, but may not reflect what they actually do in their future practices. Once again, a longitudinal study may address this issue by looking at outcomes such as community-oriented activities in practice. However, “as residency programs adapt to the need to promote primary care, the importance of
Mann–Whitney–Wilcoxon rank sum test: attitude surveys pre- and post-intervention
Pre-intervention
Variable
No. of cases
U of T R1
11
U of T R2
8
U of T R1
11
Post-intervention
P-value (corrected for ties)
No. of cases 13
0.0895
0.2569 4 13
0.6191 Queens R1
8
P-value (corrected for ties)
0.4014 5
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Family Practice—an international journal TABLE 4
Item no.
Paired samples t-test for the attitude survey pre- and post-interventiona
No. of pairs
Pre-intervention mean
Post-intervention mean
SD
Two-tailed P-value
1
11
1.6364
2.0909
1.036
0.176
2
11
1.6364
1.7273
0.701
0.676
3
11
3.7273
3.7273
1.265
1
4
11
3.2727
3.8182
0.934
0.082
6
11
3.2727
3.5455
1.737
0.614
8
11
2.1818
2.8182
0.924
0.046
9
11
1.2727
1.4545
0.405
0.167
11
11
3.5455
3.5455
0.775
1
12
11
3.0909
2.5455
0.82
0.052
13
11
2.8182
3
0.874
0.506
14
11
2
1.9097
0.539
0.588
16
10
1.6
1.6
0.667
1
17
11
3.2727
3.1818
1.044
0.779
18
10
1.6
1.5
0.738
0.678
20
9
3
3.6667
0.866
0.05
21
11
2.0909
2.2727
0.603
0.341
22
11
2
2.7879
1.489
0.136
23
10
2.6
2.5
0.994
0.758
25
11
2.0909
2.1818
0.831
0.724
26
11
2.6364
2.3636
0.905
0.341
Average
11
3.5246
3.3906
0.205
0.055
a
Items 5, 7, 10, 15, 19 and 24 were omitted from the data analysis (see Methods).
quantitating qualitative issues increases”.9 The need to measure and document changes in significant variables is essential in guiding programme developers to modify and improve the existing programme. The need for qualitative data in programme evaluation and in driving curricular change is well documented.10,11 Thus quantitative data supported by qualitative data provide powerful information.
of using both qualitative and quantitative data in the evaluation of a residency medical training programme were also realized. It is hypothesized that if the community dimensions of clinical practice are emphasized within medical training, more community-responsive physicians will be developed and prepared to work in a health care system which demands increasing active community participation.12
Conclusions The survey did not reveal any difference in attitudinal change between the study group exposed to the new COPC programme and either of the two control groups. Examining the study group on its own revealed a shift towards a more positive attitude towards COPC at the end of the pilot year, although the result was not statistically significant. This was corroborated further by qualitative data where the residents confirmed the positive experience of working in the community. The questionnaire and focus group also identified that the practicality of applying COPC in present practice was of concern to residents in the study group. The advantages
Acknowledgement The writers would like to acknowledge the support of the Educating Future Physicians of Ontario Project for the research conducted in this study.
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