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General practitioners' attitudes towards research in primary care: qualitative results of a cross sectional study
© Rosemann and Szecsenyi; licensee BioMed Central Ltd. 2004
Received: 30 June 2004
Accepted: 21 December 2004
Published: 21 December 2004
Research in General Practice requires the participation of General practitioners (GPs). In Germany there is little tradition of research in this field, and GPs are not used to be participants in research. Little is known about German GPs attitudes towards research. Therefore the aim of our study was to assess the willingness of German General Practitioners to participate in primary care research and their attitude towards research in general practice. The results should enable a more successful approach to GPs in further studies.
Cross sectional study using semi-structured interviews with a random sample of 76 General Practitioners who participate in the teaching of medical students at the University of Heidelberg.
Despite little experience, over 85 % of GPs appreciated research in their field. Important reasons for scepticism about research were the gap between theoretical research and practical work of GPs and the domination of research by specialists. Main barriers for participation are clinical workload, administrative overload and the newly introduced Disease Management Programs. The highest motivation for GPs to participate in research emanates from the will to substantiate their quality of care with solid research data.
Financial incentives and personal support e.g. with study nurses are certainly necessary to establish a research culture and to overcome main barriers against participation. The most successful approach to motivate GPs to participate is to convince them that research documents their quality of care. This data may reflect the facts on which the financial resources are provided in the future health care system.
Compared to other European countries, Germany still has little of a research tradition in general practice. Increasingly policy-makers have realized that the continuity and the efficacy of the healthcare system have to be improved. For this a well-developed primary medical care system is needed. In recent years a number of new chairs of general practice have been established and a national funding programme was created in order to promote General Practice as an academic discipline in Germany. The University of Heidelberg, which is the oldest university in Germany, is among the beneficiaries of these developments. Despite of a well established network of teaching practices, the research group for general practice and health services research was only created in 2002 . This group faces the challenge to perform studies with general practitioners who have little experience with participation in scientific research. It is known, that by specifically addressing strategies significant improvements in participation rates can be achieved . The aim of the study was to investigate the willingness of GPs to participate in research and to learn about their attitude towards research in their field in general. These data should help to create successful approaches for further projects.
We performed a cross sectional observational study collecting qualitative data. The Ethical Commission of the University of Heidelberg approved the study.
A random sample of 76 GPs in the area of Heidelberg was approached for the study. The GPs were selected by choosing every third of an alphabetical list of 250 practices. These GPs were associated with the university by frequently teaching students in their practices. Due to old data, in six cases the GPs did not practice any more. So finally 76 GPs were included. All of the selected GPs were in practice for more than five years. Former studies indicated that relevance of the topic has a positive predictive value for the recruitment rate. Therefore we selected a topic with a high clinical relevance in daily practice: osteoarthritis [3, 4]. Based on this information we performed a fictitious study, aiming at improving the quality of care of patients with osteoarthritis. The GPs received an official letter from the Department of General Practice and Health Services Research. This letter contained detailed information about the relevance of the topic, the aim of the study and the possible benefit for GPs, their teams and their patients. They were also informed about the time requirement for the study, which was estimated to be 30 minutes. The allowance for participating was fixed to 50 Euro to exclude financial reasons for consent. The letter concluded with the request to fax an agreement form back to the university.
No letters were returned to the university because of wrong addresses. A reminder or anything similar did not follow the first letter. One week after the letter, every GP was called by the principal investigator and was asked – after giving him again information on the study – if she or he wanted to participate. This approach was chosen to get qualitative information of all approached GPs about their willingness to participate and their opinion in general. This way of data collecting has already been used in this field of research and enables not only a high rate of data response, it is also a feasible way of collecting qualitative data . If the GP decided not to participate, her or his reason to do so were recorded without further discussion. Every GP, whether he denied or agreed to participate was asked about his opinions concerning research in general practice in general and the relevance of the research topic to him or her. The GPs who agreed to participate where asked to fax the sheet of agreement.
We were mainly focused on qualitative information. Therefore the statements of the GPs were grouped and coded by two separate researchers and then discussed in order to agree on the selected categorisation according to the guidelines for qualitative researchers .
A total of 18 GPs (23.8%) of the approached GPs was female, 58 GPs (72.2 %) were male. Only two GPs faxed their agreement-sheet within the first week, before they were phoned and interviewed by the principal investigator. During the telephone calls 25 GPs (32.8 %) agreed to participate and promised to fax the sheet. Out of this group 5 GPs (18.5%) sent their fax during the subsequent two weeks. A total of 8 (10.5 %) faxes were returned. Five female (27.7 %) and 22 male GPs agreed (37.9 %) to participate. A total of 27 GPs agreed to participate ultimately.
Reasons mentioned by GPs for non-participation in research
Overwork in practice
Already too much paperwork / bureaucracy
The results might not be implemented in practice because of financial constrains
Overload because of "disease management program"
No belief in results because of the degenerative progress of the illness
Personal time exposure for courses, etc.
Adherence to an other study at the same time
To less connection between (theoretical) university research and practical work as a GP
No problem in treating arthritis patients
Feeling of being monitored
Only the researcher takes benefit out of this research
GPs' attitudes regarding research in General Practice in general
Reasonable and eligible
Makes sense because it improves the reputation of GPs
Not sure if it makes sense ("I am not convinced"), no further explanation
University research and daily work in family medicine have only little in common
Makes no sense because research is dominated by specialists
Does not lead to results (without more explanation)
Better more money for the GPs then for research
Feeling of being monitored
There were three main conclusions that can be drawn out of our interview results. Firstly, the research topic improving the quality of care for patients suffering from osteoarthritis was considered as highly relevant by the interviewed GPs. This is concordant to our assumptions based on epidemiological data, which led to the fictitious research topic. The same reasoning causes GPs to seek support in the daily treatment of patients with osteoarthritis. Consequently this will be subject of future research projects.
Secondly, most of the GPs appreciate research in general practice, but a few were very sceptical. German GPs still don't realise it as a professional obligation as their colleagues in countries like e.g. the Netherlands or the United Kingdom, with a much longer tradition in research, do .
The third main result of our survey has not yet been shown in former studies. It is the fact that the willingness for participating in research emanates mainly out of the motivation to improve the reputation of family medicine in general by documenting the high quality of care with data attained in solid surveys. This may reflect the increasing self-confidence of German GPs, which are about to expend the influence in the health care system, and their awareness that an own research culture helps to enhance this. Facing decreasing financial resources in the Health care system, GPs may also be aware that a solid database documenting the quality of care will get more important for the distribution of financial resources in the near future.
The revealed barriers against participating in studies mentioned in our telephone survey are in line with results from previous studies in other countries . According to those former results, relevance of the research topic, reimbursement and compatibility with routine general practice work are important factors. Ideally the GPs are embedded in an existing research culture [7, 9, 10]. Study nurses or mentors could be an important factor to enhance GPs' preparedness to participate in General Practice research because they reduce the administrative workload for GPs and enhance the motivation to participate in research [8, 10, 11]. Furthermore financial incentives for participation are essential because of time constraints and overwhelming administrative work that compete with research and represent important barriers [8, 11]. An unexpected quantitative result of this study was that being involved with the training of medical students and being linked with the University is not reflected per se in a higher motivation in participating in research. Participating rates of about 30 % are usually achieved in random postal mailings to GPs without academic affiliation [5, 9, 13, 14]. Previous studies have shown that involvement in student teaching represents a positive predictive factor for participation in research, so we assumed to achieve a much higher participation rate. It appears that a well-established teaching network does not necessarily yield much benefit for research purposes .
Agreement for participation related to sex
Agreement after letter
Agreement during telephone call
2 (2.6 %)
25 (32.8 %)
27 (35.5 %)
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