How can we teach EBM in clinical practice? : an analysis of barriers to implementation of on-the-job EBM teaching and learning.

Introduction: Evidence-based medicine (EBM) improves the quality of health care. Courses on how to teach EBM in practice are available, but knowledge does not automatically imply its application in teaching. We aimed to identify and compare barriers and facilitators for teaching EBM in clinical practice in various European countries. Methods: A questionnaire was constructed listing potential barriers and facilitators for EBM teaching in clinical practice. Answers were reported on a 7-point Likert scale ranging from not at all being a barrier to being an insurmountable barrier. Results: The questionnaire was completed by 120 clinical EBM teachers from 11 countries. Lack of time was the strongest barrier for teaching EBM in practice (median 5). Moderate barriers were the lack of requirements for EBM skills and a pyramid hierarchy in health care management structure (median 4). In Germany, Hungary and Poland, reading and understanding articles in English was a higher barrier than in the other countries. Conclusion: Incorporation of teaching EBM in practice faces several barriers to implementation. Teaching EBM in clinical settings is most successful where EBM principles are culturally embedded and form part and parcel of everyday clinical decisions and medical practice.

Penser la médecine communautaire s'apprend avec les pairs. [The spirit of community medicine: students learning from students].

At the University of Lausanne third-year medical students are given the task of spending a month investigating a question of community medicine. In 2009, four students evaluated the legitimacy of health insurers intervening in the management of depression. They found that health insurers put pressure on public authorities during the development of legislation governing the health system and reimbursement for treatment. This fact emerged during the scientific investigation led jointly by the team in the course of the "module of immersion in community medicine." This paper presents each step of their study. The example chosen illustrates the learning objectives covered by the module.

Por uma política da diferença

O artigo defende que a educação, para fazer face às sociedades multiculturais, precisa pensar a cultura como lugar de enunciação e não como repertório de sentidos partilhados. Inicialmente, analisa os projetos conservadores, liberais e multiculturais para lidar com a diferença cultural, argumentando que esses projetos tratam a diferença como diversidade, não conseguindo, dessa forma, responder, como se propõem às demandas de uma sociedade multicultural. Para além desses projetos, discute perspectivas de tradução e diálogo entre culturas, valendo-se, principalmente, das contribuições de Santos e Burbules, concluindo pela incomensurabilidade das culturas. Ainda que as culturas sejam incomensuráveis, a autora rechaça descrições fragmentadas da contemporaneidade, posicionando-se em favor da negociação da diferença cultural. Para isso, apóia-se na noção de ambivalência de Bhabha e na noção de hegemonia, tal como é defendida por Laclau e Mouffe, Hall e pelo próprio Bhabha. Dessa forma, procura estabelecer uma agenda pós-colonial para pensar a diferença.

Evaluer la peur de tomber chez les personnes âgées à domicile: Un modèle qualitatif

Cet article (2006) décrit la démarche qui a fondé le développement de l'instrument d'évaluation de la peur de tomber à travers des "portraits" chez des personnes âgées vivant à domicile "chuteuses ou non chuteuses" (non publiés). Une analyse qualitative originale a été développée dans ce contexte la QUAPA (QUAlitative Pattern Analysis): une analyse des patterns permettant de décrire les différents degrés d'intensité auxquels la peur de tomber est décrites par les personnes âgées elles-mêmes. Cet instrument se base sur une validité "écologique". Il s'ancre dans le vécu des personnes âgées tel qu'il est rapporté et décrit par elles. L'évaluation de la peur de tomber réalisée à l'aide de ces portraits doit être confrontée à celle effectuée à l'aide d'autres instruments validés et largement utilisés dans le domaine de l'évaluation de la peur de tomber: FES, FES-I. Autres références publiées: Piot-Ziegler C (2002). La peur de tomber: comment l'évaluer ? Actualités Psychologiques, 12, 51-68. In C. Piot-Ziegler, (Vol. Ed.), Actualités Psychologiques: Vol. 12. Les chutes chez les personnes âgées: une approche interdisciplinaire (pp. 1-120). Piot-Ziegler C, Cuttelod T et Santiago M (2007). Définir la "peur de tomber" chez les personnes âgées à domicile. Etude qualitative. Bulletin de psychologie, 60(6), nov-déc, 515-525. Références non publiées: Piot-Ziegler C, Cuttelod T (2004). Evaluation de la peur de tomber: portraits issus du vécu des patients (questionnaire-portraits pour évaluer la peur de tomber chez des personnes âgées « chuteuses et non chuteuses ». Piot-Ziegler C, Cuttelod T (2004). Evaluation de la peur de tomber: portraits issus du vécu des patients (Guide de l'utilisateur).L'objectif de cet article (rédigé en 2006) est de dégager un modèle permettant d'évaluer l'intensité de la peur de tomber chez des personnes âgées vivant à domicile sur la base de données qualitatives récoltées dans une première étude (étude publiée: Piot-Ziegler et al. 2007).Dans cette étude qualitative, 58 entretiens semi-structurés ont été réalisés chez des personnes âgées vivant à domicile. Les thèmes abordés par les personnes âgées montrent que la peur de tomber se définit transversalement à travers les conséquences fonctionnelles, sociales et psychologiques consécutives à leur(s) chute(s).Afin d'explorer la possible existence de patterns, permettant de rendre compte de l'intensité de la peur de tomber, une méthode originale d'analyse qualitative (non informatisée) a été développée: la QUAPA (QUAlitative Patterns Analysis).Les résultats de cette analyse montrent l'existence d'une cohérence interne transversale (patterns) dans les trois dimensions définissant la peur de tomber (fonctionnelles, sociales et psychologiques) en fonction de l'intensité de la peur de tomber. Quatre patterns différents ont été mis en évidence. Ils débouchent sur une modélisation rendant compte des différents degrés d'intensité à laquelle la peur de tomber s'exprime chez les personnes âgées.Ce modèle en "patterns" permet d'évaluer la peur de tomber ressentie par une personne âgée en fonction des conséquences fonctionnelles, sociales et psychologiques à long terme consécutives à une ou plusieurs chutes. Ce modèle devra être mis à l'épreuve sur un grand échantillon de personnes âgées vivant à domicile ou dans d'autres espaces de vie (institutions), mais il constitue une alternative originale aux questionnaires utilisés actuellement qui se basent principalement sur le concept d'efficacité personnelle. Surtout il se base sur le vécu tel qu'il est rapporté par les personnes âgées elles-mêmes.Pour obtenir le questionnaire d'évaluation par "portraits" de la peur de tomber (e.mail: Chantal.Piot-Ziegler@unil.ch). Les documents suivants seront mis à disposition.Piot-Ziegler et C, Cuttelod T (2004). Evaluation de la peur de tomber: portraits issus du vécu des patients (questionnaire-portraits pour évaluer la peur de tomber chez des personnes âgées « chuteuses et non chuteuses » (Questionnaire).Piot-Ziegler et C, Cuttelod T (2004). Evaluation de la peur de tomber: portraits issus du vécu des patients (Guide de l'utilisateur).Mots-clés : chute ; peur de tomber ; personne âgée ; domicile ; recherche; approche compréhensive ; évaluation ; méthode qualitative ; pattern, QUAPA.

Evaluating fear of falling among community-dwelling older people: A qualitative pattern model based on the experience of falls

This research was conducted in the context of the project IRIS 8A Health and Society (2002-2008) and financially supported by the University of Lausanne. It was aomed at developping a model based on the elder people's experience and allowed us to develop a "Portrait evaluation" of fear of falling using their examples and words. It is a very simple evaluation, which can be used by professionals, but by the elder people themselves. The "Portrait evaluation" and the user's guide are on free access, but we would very much approciate to know whether other people or scientists have used it and collect their comments. (contact: Chantal.Piot-Ziegler@unil.ch)The purpose of this study is to create a model grounded in the elderly people's experience allowing the development of an original instrument to evaluate FOF.In a previous study, 58 semi-structured interviews were conducted with community-dwelling elderly people. The qualitative thematic analysis showed that fear of falling was defined through the functional, social and psychological long-term consequences of falls (Piot-Ziegler et al., 2007).In order to reveal patterns in the expression of fear of falling, an original qualitative thematic pattern analysis (QUAlitative Pattern Analysis - QUAPA) is developed and applied on these interviews.The results of this analysis show an internal coherence across the three dimensions (functional, social and psychological). Four different patterns are found, corresponding to four degrees of fear of falling. They are formalized in a fear of falling intensity model.This model leads to a portrait-evaluation for fallers and non-fallers. The evaluation must be confronted to large samples of elderly people, living in different environments. It presents an original alternative to the concept of self-efficacy to evaluate fear of falling in older people.The model of FOF presented in this article is grounded on elderly people's experience. It gives an experiential description of the three dimensions constitutive of FOF and of their evolution as fear increases, and defines an evaluation tool using situations and wordings based on the elderly people's discourse.

Particle exposure scenarios for research and production activities involving nanomaterials

Nanomaterials with structures in the nanoscale (1 to 100 nm) often have chemical, physical and bioactive characteristics different from those of larger entities of the same material. This is interesting for industry but raises questions about the health of exposed people. However, little is known so far about the exposure of workers to inhalable airborne nanomaterials. We investigated several activities in research laboratories and industry to learn about relevant exposure scenarios. Work process analyses were combined with measurements of airborne particle mass concentrations and number−size distributions. Background levels in research settings were mostly low, while in industrial production, levels were sometimes elevated, especially in halls near busy roads or in the presence of diesel fork lifts without particle filters. Peak levels were found in an industrial setting dealing with powders (up to 80,000 particles/cm³ and up to 15 mg/m³). Mostly low concentrations were found for activities involving liquid applications. However, centrifugation and lyophilization of nanoparticle containing solutions resulted in very high particle number concentrations (up to 300,000 particles/cm³), whereas no increases were seen for the same activities conducted with nanoparticle−free liquids. No significant increases of particle concentrations were found for processes involving nanoparticles bound to surfaces. Also no increases were observed in laboratories that were visualizing properties and structures of small amounts of nanomaterials. Conclusion: When studying exposure scenarios for airborne nanomaterials, the focus should not only be on processes involving nano−powders, but also on processes involving intensively treated nanoparticle−containing liquids. Acknowledgement: We thank Chantal Imhof, MSc and Guillaume Ferraris, MSc for their contributions.