Relationships between the intention to use guidelines, behaviour of insurance physicians and their determinants

Abstract

Background: We studied the intention of a group of insurance physicians to use the guidelines for depression, and their behaviour in disability assessments. We considered attitude, social norm and self-efficacy, knowledge/skills and stimuli, based on the Attitude-Social norm-self-Efficacy model (ASE model) as possible determinants of both intention and behaviour.The aim of this study was to understand the determinants of insurance physicians' behaviour when they are expected to use guidelines in daily practice.

Method: A representative sample of 42 insurance physicians participated in this study. Cross-sectional data were collected by means of a questionnaire based on the ASE model. We developed the questionnaire on the basis of literature and ascertained the content validity of it. Behaviour was made to comprise both "use of the guidelines" and "change in disability assessment behaviour" by the insurance physicians. Reliability analyses were performed to form additive scales of the ASE constructs. These scales were analysed with structural equations modelling (LISREL), by modifying a start model into a final model with a good fit, within theoretical constraints. In these analyses special attention was paid to the fact that the sample size was small.

Results: The most important determinants of the intention and the self-reported use of the guidelines, were: the influence of colleagues, the self-efficacy of the insurance physicians in their use of the guidelines, and the way the guidelines were implemented. The intention to use the guidelines for depression was not associated with the self-reported use of these guidelines, but there proved to be a faint, positive association with the self-reported change in assessment behaviour.

Conclusions: Almost all the insurance physicians in this study intended to use at least elements of the guidelines. Their intention, self reported use of the guidelines and self-reported change in assessment behaviour were explored with help of the ASE model. The model suggested relationships between intention, self reported use of the guidelines and self-reported change in assessment behaviour on the on the one hand and various determinants on the other hand. Be that as it may, we see opportunities to improve insurance physicians' guideline adherence by offering them a multifaceted training in which they learn to apply the guidelines for depression.

Figure 1

ASE-model [8].

Figure 2

Start model Legenda: GD = Guideline Depression, AB = Assesment Behaviour. Model fit parameters: Chi-square 91.732, df = 73, p = 0.07; RMSEA = 0.036; SRMR = 0.067, CFI = 0.974. Straight lines indicate direct effects (beta matrix), double-arrowed dotted lines indicate associations in the disturbance terms (psi matrix); single arrowed dotted lines indicate direct effects which had to be included in the model to get positive definite matrices. All coefficients p < 0.05; except (*), p is not significant, at N = 200, artificially. Explained variance (R²) of endogenous variables: Attitude to the GD (0.10); Social Norm, influence of colleagues on acceptation of the GD (0.05); Social Norm, influence of important others in adherence to the GD (0.10); Self-efficacy the use of the GD (0.14); Knowledge and skills concerning the GD (0.10); Stimulus in the use of the GD due to the format of the guideline (0.05); Stimulus in the use of the GD due to the implementation of the guidelines (0.14); Stimulus in the use of the GD by the quality of the guideline (0.09); Intention to use the GD (0.24); Use of the GD (0.12); Change in assessment behaviour due to the GD (0.25).

Figure 3

Final Model Legenda: GD = Guideline Depression; AB = Assessment Behaviour. Model fit parameters at N = 200, artificially: Chi Square 45.438, df = 72, p = 0.994; RMSEA = 0.0; SRMR = 0.0411, CFI = 1.000. All coefficients p < 0.05; except (*), p < 0.10, at N = 200, artificially. Explained variance (R²) of endogenous variables: Attitude to the GD (0.10); Social Norm, influence of colleagues on acceptation of the GD (0.05); Social Norm, influence of important others in adherence to the GD (0.10); Self-efficacy the use of the GD (0.14); Knowledge and skills concerning the GD (0.16); Stimulus in the use of the GD due to the format of the guideline (0.10); Stimulus in the use of the GD due to the implementation of the guidelines (0.16); Stimulus in the use of the GD by the quality of the guideline (0.14); Intention to use the GD (0.25); Use of the GD (0.14); Change in assessment behaviour due to the GD (0.30).

Figure 4

Final Model of endogenous variables only Legenda: GD = Guideline Depression; AB = Assessment Behaviour. 1) Model fit parameters at N = 200, artificially: Chi Square 26.058, df = 31, p = 0.719; RMSEA = 0.0; SRMR = 0.0499, CFI = 1.000. All coefficients p < 0.05; except (*), p < 0.10; at N = 200, artificially. Explained variance (R²) of endogenous variables: Knowledge and skills concerning the GD (0.11); Stimulus in the use of the GD due to the format of the guideline (0.06); Stimulus in the use of the GD due to the implementation of the guidelines (0.03); Stimulus in the use of the GD by the quality of the guideline (0.08); Intention to use the GD (0.23); Use of the GD (0.06); Change in assessment behaviour due to the GD (0.23). 2) Model fit parameters at N = 42: Chi Square 5.369, df = 31, p = 1.0; RMSEA = 0.0; SRMR = 0.0499, CFI = 1.000.Coefficients are the same as for the model with N = 200. All coefficients are not significant (p > 0.10), except bold coefficients (p < 0.05) and underlined coefficients (p < 0.10); at N = 42. Explained variance (R²) of endogenous variables are the same as for N = 200.