title: Process evaluation of a tailored intervention programme of cardiovascular risk management in general practices.
abstract: A tailored implementation programme to improve cardiovascular risk management (CVRM) in general practice had little impact on outcomes. The questions in this process evaluation concerned (1) impact on counselling skills and CVRM knowledge of practice nurses, (2) their use of the various components of the intervention programme and adoption of recommended practices and (3) patients' perceptions of counselling for CVRM.
  
  
  
  A mixed-methods process evaluation was conducted. We assessed practice nurses' motivational interviewing skills on audio-taped consultations using Motivational Interviewing Treatment Integrity (MITI). They also completed a clinical knowledge test. Both practice nurses and patients reported on their experiences in a written questionnaire and interviews. A multilevel regression analysis and an independent sample t test were used to examine motivational interviewing skills and CVRM knowledge. Framework analysis was applied to analyse qualitative data.
  
  
  
  Data from 34 general practices were available, 19 intervention practices and 14 control practices. No improvements were measured on motivational interviewing skills in both groups. There appeared to be better knowledge of CVRM in the control group. On average half of the practice nurses indicated that they adopted the recommended interventions, but stated that they did not necessarily record this in patients' medical files. The tailored programme was perceived as too large. Time, follow-up support and reminders were felt to be lacking. About 20% of patients in the intervention group visited the general practice during the intervention period, yet only a small number of these patients were referred to recommended options.
  
  
  
  The tailored programme was only partly used by practice nurses and had little impact on either their clinical knowledge and communication skills or on patient reported healthcare. If the assumed logical model of change is valid, a more intensive programme is needed to have an impact on CVRM in general practice at all.
authors.affiliation: Department IQ healthcare, Radboud Institute of Health Sciences, Radboud university medical center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands. Elke.Huntink@radboudumc.nl.
authors.forename: E
authors.initials: E
authors.lastname: Huntink
authors.affiliation: Department IQ healthcare, Radboud Institute of Health Sciences, Radboud university medical center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.|Department of General Practice and Health Services Research, Heidelberg University Hospital, Marsilius Arkaden, Turm West, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Wensing
authors.affiliation: Department IQ healthcare, Radboud Institute of Health Sciences, Radboud university medical center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
authors.forename: I M
authors.initials: IM
authors.lastname: Timmers
authors.affiliation: Department IQ healthcare, Radboud Institute of Health Sciences, Radboud university medical center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
authors.forename: J
authors.initials: J
authors.lastname: van Lieshout
mesh_terms: D000328:Adult; D002318:Cardiovascular Diseases / Q000517:prevention & control*; D002983:Clinical Competence; D016000:Cluster Analysis; D003376:Counseling / Q000379:methods*; D005260:Female; D058006:General Practice / Q000379:methods*; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D062405:Motivational Interviewing / Q000379:methods*; D009426:Netherlands; D009726:Nurses; D015397:Program Evaluation / Q000379:methods*; D012307:Risk Factors; D011795:Surveys and Questionnaires
keywords: CVRM knowledge; CVRM patients; Cardiovascular disease; Depressive symptoms; Motivational interviewing; Practice nurses; Process evaluation; Tailored implementation programme