Variations in general practitioners’ views of asthma management in four European countries

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Abstract

The aim was to identify differences and similarities in views regarding asthma management among general practitioners in four European countries (Germany, Netherlands, Norway and Sweden), and to explore reasons for sub-optimal performance. The results are to be used for the development and tailoring of educational interventions. Semi-structured interviews with 20 GPs in each country were conducted and analysed using a phenomenographic approach. The domains of (i) general view of asthma, (ii) the doctor–patient relationship in managing asthma, and (iii) overall management of asthma (treatment goals and evaluation of results) were approached during the interviews. There were different ways of experiencing phenomena related to asthma management both within and between the four countries. Three general views on asthma were found where different perspectives were emphasised: a medical, a ‘global’ (including community health, social and environmental aspects) and a patient's perspective. Within the medical perspective, only a few German doctors emphasised a psychological aetiology of asthma. The views on the doctor–patient relationship described as ‘authoritarian’, ‘teaching’ or ‘empowering’ occurred similarly in all countries. The majority of the doctors showed confidence in the effectiveness of the pharmaceutical treatment of asthma, some doctors were concerned about limitations, but only in Germany a few doctors were explicitly critical of the values of conventional pharmaceutical treatment. The main treatment goals were either conceived as getting the patient symptom-free (Netherlands, Norway, and Germany) or to control the inflammatory process (Sweden). Several German and some Norwegian doctors expressed the view that patients had to accept the disease and learn how to manage it, while a few German doctors aimed at alternative treatments of asthma. The existence of qualitatively different ways of experiencing asthma management, both in and between countries, calls for consideration when trying to implement general evidence-based treatment guidelines. A variation of approaches in continuing medical education for GPs is needed to address such existing beliefs and conceptions that could sometimes be opposed to the content of educational messages.

Introduction

Looking at different guidelines it seems there is not much controversy on the basic principles of asthma treatment (National Heart Lung and Blood Institute, 1992; Medical Products Agency, 1993; Vennerod, 1994; Kristufek & Hruskovic, 1996; Geijer, van Schayck, & van Weel, 1997; Nicklas, 1997). In practice, however, quite some variation and sub-optimal management has been observed when comparing knowledge and attitudes with prescribing in five European countries (Lagerløv et al., 2000). The appropriateness of actual asthma management has been challenged repeatedly in the last years (Lang, Sherman, & Polansky, 1997; Legorreta et al., 1998; Smeele et al., 1998; Kljakovic & Mahadevan, 1998; Gourgoulianis, Hamos, Christou, Rizopoulou, & Efthimiou, 1998; Roghmann & Sexton, 1999). Various barriers exist for a successful integration of evidence-based medicine into clinical practice (Grol, 1992; Davis & Taylor Vaisey, 1997; Haynes & Haines, 1998). Some of these barriers relate to attitudes and beliefs held by patients (Green & Britton, 1998), while others relate to the doctors’ attitudes, views, and knowledge (Grol, 1992; Doerschug, Peterson, Dayton, & Kline, 1999). To understand the foundations of such barriers qualitative research is needed (Dahlgren & Pramling, 1985; Green & Britten, 1998). Seemingly inappropriate behaviour may be understood better if the related conceptions or ways of experiencing the situation are illuminated (Schön, 1987; Marton, Hounsel, & Entwistle, 1984). Knowledge on the doctors’ ways of experiencing their own clinical practice and relationship with patients can be used to develop tailored interventions for improving clinical performance (Wahlström, Dahlgren, Tomson, Diwan, & Beerman, 1997; Fishbein, 1976).

When this study was planned, little was known of how doctors look upon and relate to asthma management (Bauman, McKenzie, Young, & Yoon, 1990). Since then several studies focusing on doctors’ attitudes and views regarding asthma management have been conducted in the USA, Canada and Australia, but most were quantitative studies based on mailed questionnaires (Grant, Moy, Turner-Roan, Daugherty, & Weiss, 1999; Moy, Grant, Turner-Roan, Li, & Weiss, 1999; Cicutto, Llewellyn-Thomas, & Geerts, 1999; Coates et al., 1994). A few qualitative studies have been reported from Great Britain (St Claire, Watkins, & Billinghurst, 1996), Belgium (Van Ganse et al., 1997), and Netherlands (Jans, Schellevis, van Hensbergen, Dukkers van Emden, & van Eijk, 1998). Notable findings are that treatment outcomes are not sufficiently monitored by doctors, that the use of peak-flow meters is not fully accepted, and that some doctors are reluctant to educate their patients. In one of the studies, some doctors questioned the prolonged prescription of inhaled corticosteroids for patients with mild asthma (Jans et al., 1998). These findings confirm that concordance with current guideline recommendations is sub-optimal, but the underlying reasons have not been thoroughly investigated. One may expect that views from doctors in one country can not directly be generalised across countries (Kahan, Weingarten, & Appelbaum, 1996).

In the joint Drug Education Project (DEP), general practitioners’ views and conceptions on asthma management were studied in four European countries. Semi-structured interviews were conducted with a sample of general practitioners (GPs) in each of the four countries, i.e. Germany, Netherlands, Norway, and Sweden. Some of the findings, based on national data, have already been reported elsewhere (Lagerløv, Leseth, & Matheson, 1998; Stålsby Lundborg, Wahlström, & Dall’Alba, 1999; Veninga, Denig, Heyink, & Haaijer-Ruskamp, 1998). These national analyses did not cover all aspects of asthma management, making direct comparison of the results problematic. Therefore, an additional international study was conducted using the original data collected in each country.

The aim of the international study presented here was to identify the differences and similarities in views regarding the management of asthma among GPs working in different countries, and to explore reasons for sub-optimal performance. The results are to be used for the development and tailoring of educational programmes to improve drug treatment and overall management of asthma.

Section snippets

Methods

The study has been conducted using the phenomenographic approach, which is a descriptive, empirical and content-oriented line of qualitative research (Sandberg (1981), Marton (1988)), exploring views of phenomena in the world as they are conceived. The focus is on the experienced reality. The approach aims at preserving the experiential content of verbal expressions, minimising interpretation and avoiding application of predetermined categories of description. In phenomenographic analysis

Results

The results are presented under the headings of each of the defined domains.

Discussion

In this study in four European countries we have found both similarities and differences regarding general practitioners’ ways of experiencing asthma as a disease, their views on the doctor–patient relationship, and their views and attitudes regarding the management of asthma. Some remarkably different conceptions and views were observed between countries, but also within a single country, different views were fairly common. This has consequences for medical practice and educational activities.

Acknowledgements

We want to thank all the participating doctors for sharing their experiences and views on asthma management. We also want to express our appreciation of the contributions from researchers outside the DEP group working with the respective national materials in Netherlands: J. Heyink, in Sweden: G. Dall’Alba, in Norway: A. Leseth, and in Germany: I. Hinrichs and M. Schroeter. The project was financially supported by EU BIOMED I Programme (contract BMH1-CT93-1377). Specific parts of the project

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    DEP (Drug Education Project) group include F.M. Haaijer-Ruskamp (international co-ordinator), P. Denig, and C.C.M. Veninga (Netherlands); V. Diwan, G. Tomson, R. Wahlström, T. Oke, and C. Stålsby Lundborg (Sweden); M. Andrew, I. Matheson (deceased), M. Loeb, and P. Lagerlov (Norway); M.M. Kochen, and E. Hummers-Pradier (Germany).

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