To determine the relationship between perceived adherence and perceived barriers, we first calculated the average percentage of respondents who agreed that the barriers applied to knowledge barriers, attitudinal barriers, external barriers, and all barriers. Next, we calculated Pearson`s correlation between perceived adherence and each of the major barrier categories and the sum of all barriers. Descriptive statistics were used to describe the demographic and occupational characteristics of general practitioners (mean, standard deviation, percentages). In our analysis of responses to statements about attitudes toward guidelines in general, we grouped values 4 and 5 (agree/strongly agree), indicating consent; scores 3, which indicate a neutral attitude, and scores 1 and 2 (strong/somewhat disagree), which indicate disagreement. Many factors can influence the implementation of a guide in practice. Barriers to adherence may be related to individual patient, individual health care provider, group of health care providers, organizational context, and social and cultural context of the health system [8-10]. Proper analysis of the barriers that prevent health care providers from applying the guidelines in practice has proven to be an important first step towards improving compliance and thus the quality of care [8, 9]. Some limitations of our study should be mentioned. Although our response rate is only slightly lower than the average response rates of physician surveys [33, 34], it may still limit the ability to generalize our results. Those with a positive attitude towards policies may be over-represented in our sample.
To minimize this possible bias, we offered accreditation points to complete the questionnaire to encourage all GPs to participate. Although GPs were somewhat over-represented in the 55-64 age group, our overall sample corresponded quite well to the total dutch GENERAL PRACTITIONER POPULATION in terms of basic characteristics [20]. Second, perceived barriers depend on GPs` perception of the situation and may not accurately reflect the barriers (the full spectrum). Similarly, perceived adherence rates may be subject to the phenomenon of social desirability, which leads to an overestimation of adherence rates [35]. On the other hand, there is evidence that physician self-reporting is a valid and reliable source for assessing clinical performance, with a high degree of consistency with medical record data [36]. We conducted an electronic cross-sectional survey of 703 family physicians in the Netherlands. Sixteen key recommendations were made from four national guidelines. Six notices were included to address attitudes towards guidelines in general. In addition, general practitioners were asked to assess their perceived compliance (one statement) and perceived barriers (fourteen reports) for each of the key recommendations against an existing framework.
The main strength of our study is that we focused specifically on the main recommendations for assessing compliance with the guidelines and the barriers to compliance with the guidelines. Our research shows that the factors that influence compliance vary considerably from recommendation to recommendation, resulting in specific patterns of barriers to individual key recommendations. It also shows that identifying obstacles at the recommendation level is a useful approach. Some barriers may seem unimportant at the guideline level, but they appear to be very relevant to some of the recommendations. A single approach to the implementation of the guidelines will therefore be ineffective. The most perceived barriers related to external factors, in particular patient abilities and behaviour (average: 30%) and patient preferences (average: 23%). The lack of applicability of recommendations in general (average: 22%) and specifically to individual patients (average: 25%) was also often perceived as an obstacle. The values of perceived barriers differed significantly between the recommendations [minimum range 14%; maximum range 67%]. The perceived adherence rates for each of the most important recommendations were determined by calculating the percentage of respondents who agreed or strongly agreed (scores 4 and 5) to follow the recommendations in practice. In order to identify perceived barriers, we first recoded positively worded barrier statements so that a higher score indicates a higher level of perceived barriers. We then calculated the percentage of GPs who agreed or strongly agreed (scores 4 and 5) that there was a barrier to each of the most important recommendations. .
