their impact and cost-effectiveness (see, for example, Eisenberg, 1986). The continuing challenge is to make this most commonly used approach for changing behavior more consistently productive.
Many individuals and organizations are trying to meet this challenge, building on extensive behavioral research and practical experience (Eisenberg, 1986; Chassin, 1988; Kanouse and Jacoby, 1988; Green, 1991; Siu and Mittman, 1991). The Agency for Health Care Policy and Research (AHCPR), in particular, is committed to an extensive dissemination and education effort to support the guidelines it is developing (AHCPR, 1991).
One important feature of educational strategies such as those cited above is their diversity. Education can be
informal or formal
impersonal or personal
one-way or interactive
isolated or connected to ongoing relationships
knowledge oriented or change oriented
sponsored by individuals or organizations of varying credibility.
The most prominent educational strategies for practitioners focus on relatively formal, organized activities. These activities include medical school, graduate medical education, and continuing education courses that tend to be impersonal and involve only one-way communication. Computer or other self-teaching modules, on the other hand, are impersonal but can be interactive.
Research on the impact of different educational strategies indicates that personal, interactive strategies tend to be more influential in changing practitioner behavior than are more formal or indirect approaches (Avorn and Soumerai, 1983; Eisenberg, 1986; Chassin, 1988; Soumerai and Avorn, 1990; Siu and Mittman, 1991). Programs undertaken by respected authorities in the context of ongoing organizational relationships are also effective, and sometimes the involvement of respected leaders may be the key to success or failure of efforts to modify the clinical practice. Small group education, individualized "academic detailing," and operations-level feedback of information on practice patterns are personal, interactive strategies with both formal and informal aspects.2 All of these activities can vary in the degree to which they go beyond knowledge building to stress behavioral change.
Adequate evaluation of strategies for change requires that benefits be
For example, Avorn and Soumerai (1983) and Soumerai and Avorn (1990) describe academic detailing as including interviews to establish baseline knowledge and motivation associated with a practice; programs focused on specific categories of physicians and their opinion leaders; clearly stated educational and behavioral objectives; sponsorship by a respected organization; use of authoritative and unbiased information and concise graphic materials, and repetition of essential messages; active participation by physicians; and positive feedback on improved practice. The approach is built on marketing strategies used by pharmaceutical companies.