Professional Documents
Culture Documents
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© Oxford University Press 1996 Printed in Great Britain
526
Discussing smoking with patients 527
Methods wmcnvENESS
Generation of dimensions of GPs' attitudes towards 1. My ami-smoking advice ii more effective than any other anti-
giving anti-smoking advice smoking education that my patients receive.
The first stage of questionnaire design was the genera- 2. When patients continue to smoke despite repeated advice to (top,
tion of a limited number of dimensions exploring GPs' my anti-smoking advice can still have a worthwhile effect.
attitudes towards giving anti-smoking advice. A 3. My anti-smoking advice is more effective when it u linked to an
literature review revealed only one study dealing with individual1! presenting problem.
GPs' attitudes towards smoking cessation,6 so articles 4. I can be very effective in persuading tome of my patients to stop
concerned with attitudes towards preventive medicine smoking.
were also utilized. Four potentially important dimen-
sions were identified and 13 attitude statements7 ex- 5. My anti-smoking advice is equally effective whether the smoker u
ill with a smoking-related problem or well.
amining GPs' attitudes to these were devised. Figure HME
1 shows the statements relating to each dimension. 6. Discussing smoking with all pretenting smokers is not an
appropriate use of my time.
Generation of attitude statements relating to each 7. Discussing smoking with all presenting smokers is likely to do more
dimension harm than good.
effectiveness was an important constraint to GPs' anti- 9. I don't discuss smoking with all smokers, but prefer to select out
smoking activity.6 An earlier survey,* however, sug- those smokers who I feel will respond to my advice.
gested that the vast majority of GPs felt they were 10. I prefer not to discuss smoking with my patients unless they raise
'probably effective' when giving anti-smoking advice. the subject.
Similarly, an interview study investigating GPs' at- ENTHUSIASM TOWARDS ANTI-SMOKnNfG. A P Y 1 * ^
titudes towards preventive medicine2 concluded that 11. I dislike discussing smoking in my routine consultation.
GPs' generally believed they were effective at pro- 12. Giving anti-smoking advice during routine consultations should
moting life-style change, whereas two others 910 not be part of my job.
reported GPs having concerns about their efficacy. Con-
13. Discussing smoking with my patients can be very rewarding for
sequently, statements 1-5 (Fig. 1) explored a range of me.
GPs' perceived efficacies with smokers. Time con-
FIGURE 1 Questionnaire items relating to each dimension
straints were reported as a problem in many
studies,6-1"10 so statements 6 and 7 (Fig. 1) covered training in how to help patients stop smoking and to
GPs' attitudes towards broaching the topic of smoking provide an estimate of the number of smokers advised
with all presenting smokers. There was evidence that to quit during their last surgery. These data were used
GPs' advice giving is influenced by the clinical situa- to establish construct validity of attitude scores derived
tion,6 with GPs reporting themselves as being more from responses to attitude statements (see Results sec-
likely to give anti-smoking advice to people with symp- tion for full details).
tomatic illness caused by smoking. Accordingly,
Piloting and distribution of questionnaire
statements 8-10 investigated respondents' propensity
Initially the questionnaire was piloted within the
to give anti-smoking advice. Finally, GPs appeared to
Leicester University Department of General Practice.
differ in their orientation towards preventive
This was to check that attitude statements could easily
medicine9 and statements 11-13 dealt with some of
be understood and resulted in minor wording alterations.
the beliefs articulated by them.6*-10
The revised questionnaire was sent to 20 randomly-
To minimize 'acquiescence bias' and 'positive
selected GPs from the Nottinghamshire Family Health
skew',11 attitude statements were placed in a random
Services Authority list. This confirmed that service GPs
order and neutrally worded. Respondents were asked
endorsed a variety of response categories. The final
to choose one response from strongly agree to strongly
survey instrument was posted to all 468 GPs on the
disagree on a six-point Likert-type scale placed
Leicestershire FHSA list.
alongside each statement. The scale had no neutral
point, forcing respondents to make a tentative choice
for each item. Points were awarded to responses to Results
statements on the scale of 1-6 with 1 representing a Of the 468 questionnaires sent 327 (69.9%) were re-
strongly negative attitude towards giving anti-smoking turned after two reminders. Details of differences be-
advice and 6 strongly positive (see Appendix for fuller tween respondents and non-respondents are described
explanation). elsewhere. 12 Briefly, GPs holding the MRCGP
qualification, younger GPs and women were more likely
Data requested to provide construct validity checks to respond. Of the 325 respondents who replied to the
Respondents were asked whether they had received any question about anti-smoking training, 111 (34.2%)
528 Family Practice—an international journal
answered positively. Three hundred and seven GPs gave TABLE 1 The seven enthusiasm statements showing mean scores,
an estimate of the number of smokers advised to quit standard deviations (SD) and factor loading values
during their last surgery and 288 (88.6%) reported this
surgery as being typical of their usual practice. Details Attitude statement Mean score (SD) Factor loading
of responses to attitude statements have been reported value
already.12
Discussing smoking with
Factor analysis of attitude statement responses all smokers not an ap-
A principal components analysis (PCA)13 was run on propriate use of time 3.87 (1.51) 0.652
attitude statement responses to indicate which statements Prefer not to discuss
could be grouped together on subscales. This initially smoking unless patient is
suggested that a three factor structure could best rep- ill with a smoking-
resent the data. The third factor extracted, however, relatcd problem 4.50 (1.13) 0.710
explained only 10% of the variance and had only one Dislike discussing smok-
statement (statement number 5, Fig. 1) loaded strongly ing in routine con-
sultations 4.64 (1.08) 0.742
on it. This statement had factor loadings of below 0.36
Giving anti-smoking ad-
on both other factors. Consequently, this item was dis-
Score No. of respondents Range of Median score Interquartile 10th percentile 90th percentile
for whom score possible scores range (25-75%)
calculated
A further test of construct validity was a comparison with patients. The concept of utilizing this type of in-
of the attitude scores of GPs who reported having strument to sample GPs with diverse attitudes for
received anti-smoking training with those of GPs who qualitative studies is important. For example, standard
did not. GPs who reported having received anti-smoking instruments like the depression attitude questionnaire,
training had significantly higher perceived efficacy which differentiates between psychiatrists' and GPs'
scores [median = 22 (range 15-28) based on 104 GPs attitudes towards depression,13 could be used in a
References 13
Kerr M, Bli^ard R, Mann A. General practitioners and
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psychiatrists: comparison of attitudes to depression using the
Mays N, Pope C. Rigour and qualitative research. Br Med J depression attitude questionnaire. BrJ Gen Pract 1995; 45:
1995; 311: 109-112. 89-92.
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Tapper-Jones L, Smail SA, Pill R, Davis RH. Doctors' at- 16
Mahoney CA, Thombs DC, Howe LZ. The art and science of
titudes toward patient education in the primary care consulta- scale development in health education research. Health Educ
tion. Health Educ J 1990; 49: 47-50. Res: Theory and Pract 1995; l(h 1-10.
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Williams SJ, Calnan M. Perspectives on prevention: the views
of General Practitioners. Sodol Heahh Illness 1994; 16:
373-393.
4
Skelton AM, Murphy EM, Murphy RJC, O'Dowd TCO. Appendix
General Practitioner perceptions of low back pain. Fam Pract
1995; 12: 44-48. Attitude statement scoring
3
Beasdow R, Cheung K, Styles W McN. Factors influencing Below are two examples of questions with scoring
the career choices of general practitioner trainees in North explained:
West Thames Regional Health Authority. Br J Gen Pract
1993; 43: 449-452. Key
6
Lennox AS, Taylor R. Smoking cessation activity within SA = strongly agree; A = agree; TTA = tend to agree;
primary health care in Scotland: present constraints and their TTD = tend to disagree; D = disagree; SD =
implications. Health Educ J 1995; 53: 4860. strongly disagree