Interactive workshops as a dissemination strategy in psychology

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1 Interactive workshops as a dissemination strategy in psychology Kalina Isela Martínez-Martínez, BS, Psych, (1) César Carrascosa-Venegas, MS, Psych, (1) Héctor Ayala-Velázquez, PhD, Psych. (1) Please use Spanish citation: Martínez-Martínez KI, Carrascosa-Venegas C, Ayala-Velázquez H. Una estrategia de diseminación en la psicología: los talleres interactivos. Salud Publica Mex 2003;45:5-12. Abstract Objective. To assess whether interactive workshops are an effective strategy for promoting a psychological intervention model among healthcare providers, to treat problem drinkers. Material and Methods. The study was conducted between the years 1999 and 2000, among 206 healthcare providers at seven Instituto Mexicano del Seguro Social (Mexican Institute of Social Security, IMSS) clinics. Study subjects were selected by hospital executive officers. The study design is a quasi-experimental pre-test/post-test study. Data on providers attitudes, interests, and knowledge were collected using a questionnaire. After that, interactive workshops were conducted, and the same questionnaire was applied again at the end of the workshops. Statistical analysis was carried out using Student s t test for matched samples. Results. Statistically significant differences were found in participants knowledge on alcoholism t (206, 205)= , p= 0.001, as well as in their interest t (206, 205)= , p= Conclusions. Interactive workshops are an effective tool to disseminate the Guided Self-Help Program conducted in IMSS clinics. Healthcare providers can become change-inducing/promoting agents of psychological innovations. Key words: dissemination; interactive workshops; problem drinkers; health personnel; Mexico The dissemination of experimental results is a fundamental component of scientific research. In science in general, but particularly in psychological interventions, present conditions demand sensitivity for researchers in the dissemination of their work. Presently, it has become necessary to ensure the application of results in all scientific disciplines, as well as the techniques and treatments that have been empirically endorsed in psychology. The problem of dissemination in psychology Investigations on psychological interventions have led to great progress in the treatment of a broad spectrum of psychological disorders. These achievements are possible, above all, inasmuch as their intervention techniques are solidly sustained on empirical investigation. However, the use of these This study was made possible thanks to the support received through Project G H, given to the last author by The National Council of Science and Technology (CONACyT). (1) Facultad de Psicología. Universidad Nacional Autónoma de México, México, D.F., México. Received on: January 7, 2002 Accepted on: September 12, 2002 Address reprint requests to: Dr. Héctor Ayala-Velázquez. Facultad de Psicología. Universidad Nacional Autónoma de México. Avenida Universidad No. 3004, Edificio D, Primer piso, Cubículo 17. Colonia Copilco, México, D.F., México. ayavel@servidor.unam.mx 1

2 Martínez-Martínez KI y col. techniques has not turned out as expected, mainly due to a deficient dissemination of findings and techniques of clinical research. A relatively common problem in the field of psychology is that professionals do not use the findings of clinical research; their professional practice is characterized by an eclecticism that is based above all on «trial and error». Barlow 1 points out that this situation must be particularly disturbing for «a discipline whose goal has been to train professionals that could integrate scientific methods with those of clinical practice to produce new knowledge.» The importance of doing research on dissemination The dissemination of findings and techniques in psychological research does not always receive enough attention, above all in terms of identification and promotion of effective means to carry it out. This goal could only be reached through empirical investigation. McCrady 2 sees the dissemination problem as follows: «our research is impeccable; our approach to treatment is creative and effective. Our theory is careful and meticulous. Unfortunately, our work is also invisible.» For this reason, it becomes necessary to find effective ways to disseminate health care procedures to those who are practicing in the field. 3 Persons 4 points out that many effective interventions developed by researchers in psychology are rarely used in clinical practice, for example, in the treatment of alcohol abuse, 5 in the treatment of phobias and panic, 6 in the treatment of patients with psychiatric 7 disorders and in the treatment of childhood problems. 8 The lack of knowledge of techniques and treatments which were empirically obtained points to the existence of a gap between the experimental and applied fields. Thus, it is essential to close the gap, that is, to include health professionals as a complementary part of the research process, 9 and with this, fulfill the objective of dissemination and application of effective techniques and treatments. The nature of the Gap between health researchers and professionals Crosswaitie and Curtice 10 state that research findings in the field of health promotion require greater clarity from the investigators. The authors identified three strategies: 1) defining the dissemination and identifying barriers to effective dissemination (taking Rogers work as a point of reference); 11 2) describing the pertinent audiences in research on health promotion and identifying their needs; 3) indentifying strategies that are adequate to implement the dissemination and promote the use of research results. Particularly, in the context of addictive behaviors, and specifically with respect to excessive alcohol consumption, it becomes necessary to incorporate treatments developed with empirical bases in attention programs, and to evaluate their effectiveness and duration in real settings. The need to develop effective and efficient strategies for the dissemination of innovations in general health care, based on empirical evidence, has taken us to explore the methodological difficulties as well as the sociopolitical ones which prevent their dissemination and evaluation, 12 as well as the obstacles to innovations. 13 The search for these strategies has even taken us to propose the need to learn «a new way of doing business». 14 «Marketing» of the behavioral researcher has been deficient since we «haven t been close to our consumers». Producing treatments that are empirically based has only been part of applied research in psychology. The other part has to do with methods that fulfill the health care expectations. This can be achieved adopting as a value the importance of disseminating psychological interventions in clinical practice, training the graduates in new ways of developing their science, new ways of presenting it to the community and on how to get reciprocal benefits from the association with health professionals. 15 The importance of interactive workshops as a resource for dissemination To solve this problem, the Division of Clinical Psychology of the American Psychological Association 16 recommends effective ways to carry out the dissemination, once effective treatments have been identified for specific disorders, based on current evidence. The Division of Clinical Psychology developed a program with several recommendations: the promotion of skills development for health professionals, the practice of new procedures through continuous education programs (which combine structured didactic learning with supervised clinical work), and activities that may be carried out without a high cost and in little time with numerous audiences, as well as workshops, and 2

3 training in the application of these strategies, followed by supervision of the results of these applications. In the literature of this area, diverse antecedents are mentioned to workshops for dissemination; for example, Rivers, Sarata and Book 17 examined the effects of a workshop on alcoholism with respect to attitudes, satisfaction and levels of execution of the secretarial personnel in institutions dealing with problems related to alcohol consumption. Results showed that the workshop had a positive effect, increasing the secretaries knowledge with respect to problems related to alcohol consumption. Crosswaitie and Curtice 10 acknowledged the practical problems existing in the implementation of dissemination strategies, assuming that, as a basic premise of their project, the research conducted in health services was promoted in terms of the usefulness of the process and the findings for policy designers, health professionals and officials. A fundamental part of the dissemination project was the development of a workshop that would provide an opportunity for researchers and health professionals to interact and debate. Finally, Shanley, Lodge and Mattick, 18 used an informative and interactive workshop with a basic methodology, following the suggestion made by Rogers 11 to the effect that the greatest impact on potential users of research happens when the researchers interact in a sustained way with the users. Altogether, results of these investigations report the effectiveness of dissemination strategies, such as the use of interactive workshops, to fulfill the objective of informing and promoting psychological procedures that are empirically validated. However, and in spite of this evidence of effectiveness, in Mexico research on dissemination, as in many other countries, is virtually nil. Efforts towards dissemination in the different disciplines has gone the usual course and their impact on society has been poor in terms of general health care. These efforts to disseminate have not been adequately systematized. That is, the intervention techniques or procedures have not always been derived in an experimental manner, nor has their efficacy been validated in a rigorous way. One of the dissemination works in our country is called «The Collaborative Project between the Mexican Institute of Social Security (IMSS) and the National Autonomous University of Mexico (UNAM): «Development, Evaluation and Dissemination of a Secondary Prevention Model for Problem Drinkers at IMSS», sponsored by the National Council of Science and Technology (CONACyT). The main objective of the project consists of developing, evaluating and disseminating a short secondary prevention program based on the model called Self-Change for Problem Drinkers 19 in primary health care clinics of the Mexican Institute of Social Security, in the Mexico City metropolitan area and other urban centers throughout the country. Among the diverse dissemination strategies that were applied were the interactive workshops, due to the promissory results obtained, which have been previously mentioned, and in view of the close relationship established between the actors directly involved in the process (health professionals). The purpose of this work was to evaluate the interactive workshops as a dissemination strategy of the «Self- Change Model for Problem Drinkers», among IMSS health professionals. Subjects Material and Methods During the period, 206 subjects were selected by the authorities of the IMSS clinics to participate in the study, according to the interest expressed by the health personnel to know and participate in training on the secondary prevention model for problem drinkers. The summons was carried out by open invitation, without limiting the number of participants, in order to make it reach the greatest possible number of health professionals. Setting The interactive workshops took place in several IMSS clinics at the first level of care, in their meeting rooms, and were assigned by the directors. The states where the interactive workshops were applied were the Federal District, Hidalgo, Queretaro, Morelos and Tlaxcala. Tools I. Questionnaire on attitudes, interests and knowledge. To evaluate the workshop s impact, a tool was developed with three areas: attitudes, knowledge and interests. The internal consistency of the tool was alfa a) Area of attitudes (15 items). This area evaluates the attitudes of health professionals in three dimensions: 3

4 Martínez-Martínez KI y col. II. i) Evaluation of the problem drinker and his/her characteristics (three items). ii) Role of the health professional in the treatment of problem drinkers (seven items). iii) Evaluation of empirical evidence of the effectiveness of different treatments for problematic alcohol consumption (five items). However, results are not reported in the area of attitudes since this is not the objective. b) Area of Knowledge (eight items). Questions were formulated to evaluate information with respect to the Self-Change Program for Problem Drinkers. The tool evaluates knowledge about the program in three dimensions: i) Goal of the treatment (moderation or abstinence). ii) The role of relapses in the treatment process. iii) The importance of evaluating the consumption pattern (quantity, frequency and consumption situations). c) Area of interest: This area has nine items to identify the health professional s interest in the following dimensions: i) interest in knowing about successful treatments for problems derived from alcohol abuse, ii) interest in training in the Self-Change Program for Problem Drinkers, iii) interest in identifying, referring and treating this problem within the proposed model (Self-Change for Problem Drinkers). Tool for Satisfaction (nine items). This tool was developed to evaluate the satisfaction of participants in the interactive workshop, with respect to general characteristics of the workshop (duration and topics presented) and didactic techniques (reading, role playing, brainstorming). This was evaluated with a Likert scale going from «very satisfactory» to «not satisfactory at all». Type of study The type of study was quasi-experimental, with a pre-test/post-test design. Procedure According to the Rogers model, 11 where the idea is set forth that dissemination refers to the transfer of innovation from the resource system to the user system, a first step of this investigation was to carry out the interactive workshops at health centers. The interactive workshops had an approximate duration of five hours and took place in one work session. The workshops had three parts. During the first one, the following activities took place: a) besides the usual presentations, the first application of the tool on attitudes, interests and knowledge was done; b) then, the problem of excessive alcohol consumption in Mexico was discussed, as well as the role to be played by health professionals, besides the health policies with respect to prevention and treatment of excessive alcohol consumption. In the second part, contrasting concepts were analyzed and discussed, such as «alcoholic» versus «problem drinker» and «progressive and mortal disease» versus «learned and modifyable behavior». This discussion was supported by vignettes that illustrated the cases. The main bases of the Self- Change for Problem Drinkers model were presented. The third part included role playing between one of the participants and one of the moderators, in order to illustrate the adequate identification and referral of a problem drinker. At the end of the workshop, we went on to the second application of the questionnaire on attitudes, interests and knowledge. Besides, we included an evaluation of the participants satisfaction with the coordination of the interactive workshop and its didactic techniques. The tool s area of knowledge was as follows: each item had five options for the response, which went from «Totally disagree» to «Totally agree». Items 2, 5 and 6 were given a point if the health professional answered «Agree», and two points if he/she answered «Totally agree». Items 1, 3, 4, 7 and 8 got a point if the answer was «Disagree», and two points if the answer was «Totally disagree». In the area of interests, a point was given to the items if the answer was «Agree», and two points were given if the answer was «Totally agree». Results Of the total number of participants in the interactive workshops, 30% were men and 70% were women. The average age was 38 years, in a range from 23 to 69 years. The specialty of participants was nursing, 13.1%; social work, 12.6%; family doctor, 52.8%; medical assistant, 8.8%; public health, 6.8%, and psychology 5.9%. The results of the interactive workshop are presented in the following order: first, results from the area of knowledge and interests are described, where a statistical analysis of t tests of paired samples, before and after the interactive workshop, was carried out. As a second point, results are 4

5 reported of the satisfaction questionnaire for the participants of the interactive workshop. In the area of knowledge, the result obtained from the t test of samples paired between the applications, before and after finishing the interactive workshop, showed a significant statistical difference t (206, 205)= , p=0.001; the pre mean was and that for the post was This means there was an increase of in the area of knowledge by the end of the interactive workshop. An analysis of the items in the area of knowledge was performed, to identify which ones showed significant differences before and after the interactive workshop (table 1). Table I shows that items 1,2,3,5,6, and 8 had significant differences before and after the interactive workshop. For example, item 1 had a mean, prior to the workshop, of 0.98, and after the workshop the mean was This means there was an increase in knowledge of the workshop participants with respect to the main characteristics of the brief intervention program for problem drinkers. In this case, the goal could be, besides abstinence, moderation. Interests With respect to the area referring to the interest reported by health personnel in participating in the identification, referral and treatment of problem drinkers, the result obtained from the t test of samples paired between the applications done before and after the interactive workshop, show a significant statistical difference t (206, 205)=-2.3l8, p=0.021; the mean for the pre test was and for the post test it was Table II shows that items 3, 5 and 7 had statistically significant changes; these items refer to the interest that health personnel manifest in obtaining information and teaching their patients moderation in their alcohol consumption, as well as the use of a consumption pattern in diagnosis. Satisfaction One of the fundamental elements of the interactive workshop was the evaluation of the satisfaction of workshop participants with respect to its general characteristics (duration and topics), and its didactic techniques (reading, role playing, brainstorming). In general terms, 79% of participants said they feel satisfied and very satisfied with the workshop s general characteristics and its didactic techniques; 12% said they felt moderately satisfied and only 9% reported feeling slightly satisfied. Discussion Results of the evaluation of the interactive workshop are divided into two areas: 1) knowledge of health professionals with respect to the Self-Change Model for Problem Drinkers, and 2) the interest reported by health professionals in participating in the identification, referral and treatment of problem drinkers through the proposed intervention model, and their satisfaction with the workshop they attended. a) The interactive workshop showed statistically significant changes in the participants «knowledge» about the characteristics of the brief interventions for problem drinkers. This was specifically related to: 1) the consumption Table I COMPARISON BETWEEN ITEM RESULTS IN THE AREA OF KNOWLEDGE APPLIED TO HEALTH PERSONNEL OF SEVEN CLINICS OF THE MEXICAN INSTITUTE OF SOCIAL SECURITY. MEXICO, Pre Post Item Mean SD Mean SD t p 1. For people who consume alcohol in excess, the only alternative is abstinence* There are people who are not able to control their alcohol intake* Problem drinkers consume alcohol in excess in any situation* The problem of alcohol consumption is a progressive and incurable disease Self-selection of goals is a characteristic of the treatment of problem drinkers* Brief therapies are characterized by their low cost and short duration* In Mexico, death rates by cirrhosis are among the lowest in the world Loss of jobs and family, cirrhosis, severe alcohol dependency, are characteristics of a problem drinker* * (<0.05) 5

6 Martínez-Martínez KI y col. Table II COMPARISON OF RESULTS OF THE ITEMS IN THE AREA OF INTEREST, APPLIED TO HEALTH PERSONNEL OF SEVEN CLINICS OF THE MEXICAN INSTITUTE OF SOCIAL SECURITY. MEXICO, Pre Post Item Mean SD Mean SD t p 1. Identifying people who have problems with alcohol consumption is useful to provide adequate treatment Teaching people who have problems with alcohol consumption how to moderate this consumption, is important in my clinical practice I am interested in obtaining information about different treatments for people who have problems with their alcohol consumption* I use the collected information to identify patients who have problems with their consumption of alcohol I use the alcohol consumption pattern as a tool regularly in diagnosis* I refer my patients who have problems with alcohol consumption to treatment to change their consumption I am interested in teaching my patients who have problems with their consumption of alcohol, how to moderate their consumption* I am interested in collaborating with other professionals in the treatment of people who have problems with their alcohol consumption I am willing to invest time and effort in learning how to identify, refer and treat people who have problems with their alcohol consumption * (> 0.05) goal. Health professionals participating in the interactive workshop reported that within the treatment for problem drinkers, a possible alternative is moderation and not only abstinence, being this one characteristic of brief interventions with problem drinkers, 20 2) the possibility that the problem drinker may choose his/her consumption goal. That is, to promote responsibility with respect to consumption behavior, making the individual an active agent in the learning process, and thus in the behavioral change; goals represent a norm or internal model used by people to evaluate their own performance; Miller and Collaborators 5 suggest that when the clients are involved in the decision-making process, they commit and reach their goal better than when these are assigned by others. In the long term, a self-selected goal strengthens trust and helps maintain the behavioral change, and 3) the characteristics of problem drinkers and the differences between this concept and that of alcoholism. That is, we explained that problem drinkers do not have severe dependency nor withdrawal symptoms; their problematic consumption goes back less than ten years average and in most cases, they have not searched for treatment; usually, their social and family networks are intact; there are few consequences due to their drinking. They also have a greater economic and work stability, compared to those who have severe dependency. 21 b) With respect to the «interest» reported by health personnel in participating in the identification, treatment and referral of problem drinkers, significant effects were obtained related to, 1) the interest expressed by health personnel in obtaining information and teaching moderation to their patients with problems of alcohol consumption, and 2) the use of a consumption pattern in diagnosis. Items which did not show significant changes from the first to the second application, are related to the interest reported by participants in receiving training in the self-change model. According to these results, we may observe that before the interactive workshop, participants already reported having an interest in participating in the training program on «Self- Change for Problem Drinkers». Thus, this small increase could be due to the fact that the selection 6

7 of members was done by invitation and not randomly, and when they attended the interactive workshop, they maintained the interest they already reported before participating in this event (see procedure). The workshop provided an interactive setting to sensitize health professionals to the problem of alcohol consumption in Mexico and put them into contact with researchers in this area, in this case, the Self-Change Program for Problem Drinkers. Besides, it allowed health professionals to be included as a complementary part in the research process, 9 with the application of effective techniques and treatments and their continuous evaluation, through supervision and training in this program. c) In general, participants in the interactive workshops reported feeling very satisfied with the workshop s general characteristics and its didactic techniques. It is important to point out that workshops were given according to what was proposed by Montgomery and Ayllon, 22 with respect to the homogenization of language and the discussion of the relevance of the problem, to achieve an effective interaction between investigators of the problem drinking program and health professionals working at IMSS clinics (Mexican Institute of Social Security). Like this, interactive workshops are important in the dissemination of the Self-Change Program for Problem Drinkers, since the social, economic and health costs associated with alcoholism and its abuse are powerful incentives for the early diagnosis and treatment of potentially curable diseases. Health professionals may play a crucial role in reducing morbidity and mortality associated with alcohol abuse; in the same way, they have the special opportunity of asking their patients personal questions, as well as evaluating social, biological and behavioral aspects which indicate alcohol abuse. References 2. McCrady BS. Implications for behavior therapy of the changing alcoholism health care delivery system. Behav Ther 1986;9: Wilson KG. The revolution to come: Commentary on promises to keep. Behav Ther 1997;28: Persons JB. Dissemination of effective methods: Behavior therapy s next challenge. Behav Ther 1997;28: Miller WR, Brown JM, Simpson TL, Handmaker NS, Bien TH, Luckie LF et al. What works? A methodological analysis of the alcohol treatment outcome literature. En: Hester RK, Miller WR, ed. Handbook of alcoholism treatment approaches: Effective alternatives. Boston (MA): Allyn and Bacon, 1995: Barlow H. Psychological interventions in the era of managed competition. Clin Psychol Science Pract 1994;1: Boudewyns SP, Fry T, Nightingale E. Token economy programs in the V. A. medical centers: Where are they today? Behav Ther 1986;6: Rushton HG. Nocturnal enuresis: Epidemiology, evaluation, and currently available treatment options. J Pediatr 1989;114: Barlow DH. Promises to keep. Behav Ther 1997; 28: Crosswaite C, Curtice L. Disseminating research results - The challenge of bridging the gap between health research and health action. Health Promot Internation 1994;9(4): Rogers EM. Diffusion of innovations. 4 th edition. Nueva York (NY): Free Press, Hayward S, Ciliska D, DiCenso A, Thomas H, Underwood EJ, Rafael A. Evaluation research in public health: Barriers to the production and dissemination of outcomes data. Can J Public Health 1996;87: Zayfert C, Black C. Implementation of empirically supported treatment for PTSD: Obstacles and innovations. Behav Ther 2000;23(8): Sobell LC. Bridging the gap between scientists and practitioners: The challenge before us. Behav Ther 1996;27: Goldfried MR, Wolfe BE. Toward a more clinically valid approach to therapy research. J Consult Clin Psychol 1998;66(1): American Psychological Association. Task force on the promotion and dissemination of psychological procedures. En: The meeting of the American Psychological Association; 1993 August; Toronto, Canadá. 17. Rivers PC, Sarata BP, Book T. Effect of an alcoholism workshop on attitudes, job satisfaction and job performance of secretaries. Q J Stud Alcohol 1974;35: Shanley C, Lodge M, Mattick R. Dissemination of research findings to alcohol and other drug practitioners. Drug Alcohol Rev 1996;15: Ayala H, Echeverría L, Sobell M, Sobell L. Una alternativa de intervención breve y temprana para bebedores problema en México. Acta Comportamentalia 1998;6: Ayala H, Echeverría L. Detección temprana e intervención breve. En: Medina-Mora ME, ed. Beber de tierra generosa: ciencia de bebidas alcohólicas en México. México, D.F.: Fundación de Investigaciones Sociales, 1998: Sobell LC, Sobell MB. Guided Self-Change clinical treatment manual. Toronto: Addiction Research Foundation, Montgomery R, Ayllon T. Matching verbal repertoires: Understanding the contingencies of practice in order to functionally comunicate with clinicians. J Behav Ther Exp Psychiatry 1995;26(2): Barlow DH. On the relation of clinical research to clinical practice: Current issues, new directions. J Consult Clin Psychol 1981;49(2):