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Advancing Evidence-Based Practice in Primary Care Physiotherapy

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Advancing Evidence-Based Practice in Primary Care Physiotherapy Linköping University Medical Dissertation No. 1486 Advancing evidence-based practice in primary care physiotherapy Guideline implementation, clinical practice, and patient preferences Susanne Bernhardsson Division of Physiotherapy Department of Medical and Health Sciences Linköping University, Sweden Linköping 2015 Susanne Bernhardsson, 2015 Cover art: “Not black or white”, © Lucas McNabb, 2015 Published articles have been reprinted with the permission of the respective copyright holder. Papers I and II have been reprinted from Phys Ther. 2013;93:819–32 and Phys Ther. 2014;94:343–354 with permission of the American Physical Therapy Association. ©2013 and ©2014, respectively, of the American Physical Therapy Association. Paper IV has been reprinted from J Eval Clin Pract. 2015; Epub 2015 May 19, with permission of John Wiley & Sons, Ltd. ©2014 John Wiley & Sons, Ltd. Copyright for Paper III is held by the authors. Printed in Sweden by LiU-Tryck, Linköping, Sweden, 2015 ISBN: 978-91-7685-935-3 ISSN: 0345-0082 Knowing is not enough; we must apply. Willing is not enough; we must do. —Johann Wolfgang von Goethe, 1749-1832 Contents TABLE OF CONTENTS ABSTRACT ................................................................................................................................i LIST OF PUBLICATIONS .................................................................................................... iii ABBREVIATIONS ................................................................................................................. iv TERMS AND CONCEPTS .................................................................................................... v INTRODUCTION .................................................................................................................... 1 BACKGROUND ...................................................................................................................... 3 Evidence-based practice .................................................................................................. 3 What is evidence? ........................................................................................................ 3 Origins and evolution of evidence-based practice ........................................................ 4 Criticism of evidence-based practice ............................................................................ 6 Physiotherapy practice .................................................................................................... 7 Knowledge bases in physiotherapy ............................................................................... 8 Challenges in applying evidence-based practice in physiotherapy .............................. 8 Primary care physiotherapy in Sweden ....................................................................... 9 Growth in physiotherapy research ............................................................................. 10 Clinical practice guidelines .......................................................................................... 11 Guidelines in practice ................................................................................................ 12 Guideline development in Sweden ............................................................................. 12 Implementation science ................................................................................................ 13 Implementation theories, models and frameworks ..................................................... 14 Implementation strategies .......................................................................................... 16 Guideline implementation .......................................................................................... 20 Previous research on guideline implementation in physiotherapy ............................ 20 Patient preferences......................................................................................................... 21 THEORETICAL APPROACHES ......................................................................................... 23 Behaviour change theories ........................................................................................... 23 Grol and Wensing’s implementation of change model............................................ 24 Rogers’ theory of diffusion of innovations ................................................................ 26 RATIONALE FOR THE THESIS ......................................................................................... 27 AIMS........................................................................................................................................ 28 Overall aim ..................................................................................................................... 28 Contents Specific aims ................................................................................................................... 28 METHODS.............................................................................................................................. 29 Epistemological perspectives ....................................................................................... 29 Study designs ................................................................................................................. 30 Procedures ...................................................................................................................... 32 Guideline development ............................................................................................... 32 Questionnaire development (Study A) ...................................................................... 33 Development of the implementation strategy (Studies B-C) ..................................... 34 Implementation intervention (Study C) .................................................................... 35 Setting and participants ................................................................................................ 35 Setting ........................................................................................................................ 35 Participants ................................................................................................................ 36 Inclusion criteria ........................................................................................................ 37 Data collection and outcomes measured .................................................................... 37 Studies A-C ................................................................................................................ 37 Study D ...................................................................................................................... 38 Data analysis ................................................................................................................... 39 Statistical analyses ..................................................................................................... 39 Content analysis ........................................................................................................ 40 Ethical considerations ................................................................................................... 42 RESULTS ................................................................................................................................. 43 Summary of findings from the quantitative studies ..................................................... 43 The questionnaire (Study A) ........................................................................................ 44 Determinants of guideline use (Study B/Paper II) ....................................................... 44 Prerequisites for guideline use ................................................................................... 44 Associations to demographic variables ...................................................................... 45 Barriers for guideline use ........................................................................................... 45 Guideline use .............................................................................................................. 46 Factors associated with frequent guideline use .......................................................... 46 Effects of the guideline implementation (Study C) ......................................................... 47 Primary outcomes ...................................................................................................... 47 Secondary outcomes ................................................................................................... 47 Clinical practice (Study B/Paper IV) ........................................................................... 48 Patient preferences for physiotherapy (Study D) ......................................................... 49 DISCUSSION OF RESULTS ................................................................................................. 51 Research evidence .......................................................................................................... 51 Determinants of guideline use ................................................................................... 51 Contents Effects of the implementation in relation to other studies ......................................... 54 Factors influencing the implementation outcome ...................................................... 55 Clinical
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