Improving Collaborative Care in Managing Eating Disorders: A Pilot Study

Innovations

Improving Collaborative Care in Managing EatingDisorders: A Pilot Study

OLGA HEATH,1 PHD; DENISE ENGLISH,2 MN; JOANNE SIMMS,3 MN, NP; PAMELA WARD,2 PHD; ANN HOLLETT,1 MA;ANNA DOMINIC,1 MD

Introduction: The purpose of this pilot study was to evaluate the impact of a continuing interprofessional educa-tional workshop focused on eating disorders in a rural area in Newfoundland and Labrador (NL), Canada. The pilotstudy helped determine if the eating disorder workshop was feasible for implementation to a broader audience.A conceptual model developed by our eating disorder team and described in the article guided this innovativeprogram.

Methods: The intensive 2-day workshop was piloted in one community with 41 health and education profession-als in attendance. A key element was the focus on creating and sustaining collaborative care for eating disor-ders. Participants completed pre-post workshop measures of interprofessional attitudes and skills, self-reportedknowledge, confidence, and intention to change practice (post questionnaire only). A 6-month follow-up surveymeasured self-reported practice change.

Results: There were significant positive changes in interprofessional attitudes and skills as well as knowledgeand confidence in collaborative management of eating disorders. Post-workshop, 69% (n = 24/35) of participantsindicated intention to change practice, and on follow-up, 7 of 10 respondents reported implementing changes inpractice as a result of the workshop. Low response rate at follow-up was a limitation.

Discussion: Results support the impact of the workshop in improving knowledge, confidence, and attitudes to-ward collaboration and changing practice and the value of implementing the program province-wide.

Key Words: collaboration, interprofessional education, mixed-methods research, eating disorders, chronicdisease

Introduction

Primary care providers often feel unprepared to identify1–3

and manage1,4–6 complex chronic disorders, especially inthe area of mental health,7–10 suggesting a need for edu-cation and support. Rural health professionals report evengreater struggles, including lack of resources, training con-straints, and professional isolation.11–13 Eating disorders, of-ten chronic in nature, are characterized by multiple psy-chiatric and medical comorbidities14,15 making management

Disclosures: The authors report none.

1Faculty of Medicine, Memorial University, St. John’s, NL, Canada; 2Centrefor Nursing Studies, Eastern Health, St. John’s, NL, Canada; 3EasternHealth, St. John’s, NL, Canada.

Correspondence: Olga Heath, Faculty of Medicine, Memorial University,St. John’s, NL, A1C 5S7, Canada; e-mail: [email protected]

© 2013 The Alliance for Continuing Education in the Health Professions,the Society for Academic Continuing Medical Education, and the Councilon Continuing Medical Education, Association for Hospital Medical Educa-tion. • Published online in Wiley Online Library (wileyonlinelibrary.com).DOI: 10.1002/chp.21187

challenging. An interprofessional approach to working withany chronic, complex disorder is recommended.14,16–19 Ac-cording to the World Health Organization, interprofessionalcare occurs when multiple health workers from different pro-fessional backgrounds work together with patients, fami-lies, carers, and communities to deliver the highest qualityof care.20 There is growing evidence that collaborative ap-proaches to care contribute to positive patient outcomes par-ticularly in mental health.9,20–23

In response to patient, family, and professional concernsabout gaps in eating disorder care in Newfoundland andLabrador, Canada, our interprofessional team designed acontinuing education (CE) program on eating disorder man-agement. Our team developed the Interprofessional Commu-nity Capacity Building (ICCB) model based on the projectlogic model described by Goodstadt.24 The ICCB model (seeFIGURE 1) identifies critical elements of CE for complex,chronic diseases such as eating disorders: patient/family-centered management (placed at the center of the model);evidence-based practice content covering the continuum ofcare and recognition of the importance of the principles of

JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS, 33(4):235–243, 2013

Heath et al.

FIGURE 1. Interprofessional Community Capacity Building Model

primary health care, including collaboration and the nurtur-ing of partnerships; and involving community champions toincrease likelihood of practice change and the importanceof a logic24 approach to project design, implementation, andevaluation.

Consistent with the model’s focus on the patient andfamily, the team developed the eating disorders CE pro-gram in response to a number of concerns: provincial preva-lence data revealing significant numbers of people at riskof having an eating disorder25combined with gaps in ser-vices noted by patients, families, and professionals, mak-ing this a significant local issue; the serious chronic, com-plex nature of the illness26,27and surprisingly high mortalityrates28–30; improved response to treatment with early iden-tification and intervention,28–32 and professionals reportinga preference for practicing interprofessionally in managingeating disorders.4,5,33–35 Challenges identified by medicalproviders related to screening and treating eating disordersincluded gaps in knowledge and skills, limited awarenessof options for referral to local mental health specialists,and time constraints. Studies show that medical practition-ers have limited familiarity with local referral options but areenthusiastic about working collaboratively to provide care.For example, Linville et al6 and Linville et al1 highlightedphysician and nurse practitioner interest in interprofessionalcare for eating disorders. Similarly, in describing an inter-professional continuing mental health educational program,Heath et al36 noted that the opportunity for interprofessionalinteraction was the most highly valued component of the pro-gram, although the focus was not on eating disorders. Thereis recognition of the value of collaborative care for eating

disorders and other chronic illnesses; however, professionalsneed training in how to practice interprofessionally.37–40

A review of the literature in the area of eating disordercontinuing education found that few programs have coveredthe continuum of care or specifically facilitate interprofes-sional collaboration. Continuing education on eating disor-ders for health professionals41 has generally focused on oneaspect of care and has not been designed to enhance inter-professional collaboration. Notably, interprofessional edu-cation, defined by the World Health Organization (WHO)as occurring when learners from two or more professionslearn about, from, and with each other to enable effective col-laboration and improve health outcomes,20 has seldom beenemployed. Moreover, most programs have not reached largenumbers of professionals and have not evaluated intention tochange practice or assessed changes in practice.

The study most closely resembling the current researchis McVey and colleagues’42 eating disorder training involv-ing large numbers of community professionals (N = 3315),who participated in workshops offered on a variety of top-ics. The study reported a significant positive impact on con-fidence and knowledge in managing eating disorder care, buteffect sizes were not reported. While a variety of profession-als attended, it is not clear which professionals attended eachworkshop. Most of the professionals attended only one ses-sion (McVey, personal communication, March 22, 2011). Al-though the sessions were generally led by an interdisciplinaryteam and the audience included a variety of professions, therewas no mention of training focused specifically on collabo-ration. Nevertheless, the authors reported that 65% of par-ticipants believed that the workshop would improve linkagesamong practitioners. Participants also reported believing thatservices in their region would improve as a result of the work-shop, but there was no specific measure of intended or imple-mented practice change.

The aim of the present study was to assess the im-pact of a comprehensive evidence-based continuing inter-professional eating disorder education workshop on par-ticipants’ attitudes, knowledge, confidence, and practice.Specifically, we predicted that the intervention would resultin: (1) increased recognition of the need for education oncollaborative care across the continuum of eating disordermanagement, (2) increased knowledge about and confidencein managing eating disorders collaboratively, (3) improvedattitudes toward interprofessional care of eating disordersand interprofessional teamwork in general, (4) an intentionto change practice, and (5) changes in practice.

Eating Disorder Continuing Education ProgramDescription

The major goals of the eating disorder education programwere to increase participant knowledge, confidence, and

236 JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—33(4), 2013DOI: 10.1002/chp

Improving Collaborative Care in Eating Disorders

positive attitudes related to collaborative management of eat-ing disorders and to change practice across the continuum ofmanagement to include evidence-based collaborative care.

Several unique, innovative features of the eating disor-der CE program and the guiding ICCB Model contribute totheir potential value as exemplars for the development ofCE for any chronic disease management. For example, fam-ily and consumer feedback were incorporated in the devel-opment of the program and the evidence based content inthe 2-day multimedia workshop covered the continuum ofservice delivery from prevention through to follow-up careincluding a focus on interprofessional process and content(see TABLE 1). Other learning activities included question-and-answer sessions and “test your knowledge” case–basedquestions following each section of the workshop. The ICCBModel identified the importance of interprofessional collab-oration and community capacity building, and these consid-erations guided the interprofessional care section in whichparticipants from different professions were grouped by ge-ographical proximity and were tasked with identifying howthey might be able to work together to provide better carefor clients and families affected by eating disorders. Each in-terprofessional group developed an action plan specific fortheir region. Additionally, in keeping with the model’s fo-cus on evidence-based practice, knowledge and confidencebuilding, and the continuum of care, the workshop was struc-tured so that all participants completed all components of theprogram and post-workshop had access to evidence basedmaterials and supports (eg, e-mail distribution group, refer-ral forms for specialized services and contact information forthe presenters). Finally, given the model’s recognition of theimportance of involvement, partnerships and leadership atthe local community level, the program included two initia-tives. First, selected local professionals participated as mem-bers of an interprofessional Community Facilitation Group(CFG) in each health region. These professionals served asregional champions in the implementation of the workshop,and agreed to be liaisons for ongoing efforts. Second, com-munity residents were empowered to advocate for improvedservices through the provision of public information aboutthe education and support being provided for local profes-sionals.

In the public presentation, presenters highlighted the edu-cation provided to the local health care providers and explic-itly encouraged those attending to connect with members ofthe local CFG (who agreed to have their names and contactinformation shared) to advocate for services. The workshopwas presented by 4 interprofessional representatives from thecurriculum development group including 2 of the authorsas indicated (medicine/nursing—AD; psychology—OH; so-cial work, occupational therapy, dietetics), all of whom hadexpertise in this content area. The pilot workshop includedshort videos illustrating elements of the training that were

TABLE 1. Key Components of Eating Disorder Education Workshop

Workshop Sections and Videos Topics Covered

Section 1: Prevention

Videos:

Parents as Role Models

Impact of Media

Physician Comments

Positive Messages About Fitness

Peer Comments

Bullying and Body-Based

Harassment

• Factors contributing to poor body

image and the development of

disordered eating and eating

disorders

• Implications of poor body image

• Strategies that promote poor body

image

• Importance of community

partnerships

Section 2: Identification

Videos:

Covering Up Eating Disorder

Behaviour

Behavioral Signs of Eating

Disorder

Lying About Eating Disorder

Behaviour

Parental Comments

Addressing Concerns

• Warning signs

• Screening tools and assessment

strategies

• Understanding and assessing

readiness for change

• How to approach and address

concerns when an eating disorder

is suspected

Section 3: Early Intervention

Videos:

Diagnosis and Treatment

Pre-contemplation

Contemplation

Preparation

Action

Maintenance

Family Coping with Diagnosis

Foods that are Challenging

Meal Support

Goal Setting

• Intervening in the early stages of

an eating disorder from a medical,

psychiatric, nutritional,

psychological, and family

perspective

• Using a psychoeducational

program for family members

Section 4: Referral

Videos:

Families Seek Support

Going Into Hospital

• When psychiatric comorbidities

and family dynamics complicate

treatment

• Signs of medical instability and

need for referral/hospitalization

• When involuntary hospitalization

may be indicated

• Provincial referral services

(Continued)

JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—33(4), 2013 237DOI: 10.1002/chp

Heath et al.

TABLE 1. Continued

Workshop Sections and Videos Topics Covered

Section 5: Follow-up

Videos:

Psychology Group

Challenging Forbidden Foods

Community Integration

How Long Will the Eating

Disorder Last?

• Follow-up care after specialized

services

• Recognizing and helping prevent

relapse

• Guidelines for developing a

relapse prevention program

• Developing and implementing a

family support group

• Accessing consultation with

specialists

Section 6: Interprofessional Care

Videos:

Interprofessional Team Meeting

• Importance of interprofessional

care

• Role of each discipline in treating

individuals with eating disorders

• Interactive Exercise: Maximizing

interprofessional care in your

community

difficult to convey in lecture format (see TABLE 1) and par-ticipants received materials which included the PowerPointslide handouts, speaker notes, case studies, relevant screen-ing tools and practice guidelines consistent with the ICCBModel’s value of providing resources.

Method

Following ethics approval from the Human InvestigationsCommittee at Memorial University, data were gathered fromNovember 2008 to April 2009. Participants were recruitedpurposively by the local CFG from different professions andsectors likely to benefit from attendance at the educationsessions.

Participants

Workshop participants (N = 41) consisted of a variety ofprofessionals, with the largest group being social workers(27%), followed by nurses (17%), physicians (16%), andpsychologists (14%). Eighty-eight percent of participantswere female (n = 36), and 12% were male (n = 5). Mostrespondents were 40 to 49 years, with ages ranging between20 and 60+ years. Seventy-seven percent of participants re-

ported seeing between 1 and 5 clients/families per week witheating-related concerns.

Measures

Participants were asked to complete in-person surveys pre-and post-workshop, which included three 7-point Likertscales: (1) participant view of their profession’s need to pos-sess knowledge in the area of interprofessional care of eatingdisorders rated from 1 = “not important” to 7 = “very impor-tant”; (2) self-reported current level of knowledge about var-ious aspects of eating disorders rated from 1 = “not knowl-edgeable” to 7 = “very knowledgeable”; and (3) participantconfidence in managing eating disorders rated from 1 = “notconfident” to 7 = “very confident.” Additionally, we utilized2 standardized adapted measures; Attitudes Towards Inter-professional Health Care Teams43 and Perceptions of Inter-professional Collaboration.44 The post-workshop survey in-cluded a satisfaction measure and an open-ended questionasking how participants intended to change their practice as aresult of having attended the workshop. The decision to mea-sure intention to change practice was based on the evidencethat intention coupled with the belief that one is capable ofdoing so (confidence and knowledge) are key factors in pre-dicting behavior change.45,46

The attitudes scale was adapted from Heinemann et al43

with minor changes in wording to reflect the focus on eatingdisorders. The adapted scale consists of 14 items measuringviews about the value of interprofessional care for eating dis-orders rated on a scale from strongly agree to strongly agree.A study in which this scale was adapted for use with mentalhealth care professionals in the community reported accept-able internal consistency with a Cronbach alpha reliabilitycoefficient of 0.82.36 An internal reliability coefficient cal-culated for participants in this study revealed an acceptableCronbach alpha of 0.70.

The perception questionnaire, adapted from Clark’s44

work with gerontology teams, is a semantic differential scale(anchored on one end with a positive perception and at theother with a negative perception), which measures the partic-ipants’ perceptions of their own collaborative skills as wellas their views of the general value of interprofessional team-work. This scale does not specifically refer to collaborationin eating disorders but refers more generally to interpro-fessional teamwork. The original measure was modified byadding two levels to the continuum of the scale making it a7-point scale instead of a 5-point scale allowing for greaterdifferentiation of responses and for comparison to other localstudies such as Heath et al.36 Some items were reworded toincorporate the concept of interprofessional teamwork. Forthe present study, the adapted scale was reviewed for con-tent validity by an interprofessional eating disorder content



FIGURE 2. Changes in Participant Ratings for Need for Education, Knowledge, Confidence, Attitudes, and Perceptions

expert team. Heath et al36 reported acceptable internal con-sistency (Cronbach alpha reliability coefficient of 0.83) forthis adapted measure in their study. Reliability calculationsfor the present study also revealed good internal consistencywith a Cronbach alpha of 0.87.

The follow-up survey, administered online to those partic-ipants who had agreed to provide their contact information,included a number of questions developed by the researchersregarding intention to change practice and practice change.For example, one question was “Please describe any changesyou have made in your practice as a result of something youhave learned from this workshop.”

Results

A code on each survey enabled matching of 83% (n = 34/41)of pre and post surveys.

Perceived Need for Collaboration

Respondents rated the need for individuals in their profes-sion to have knowledge and skills in collaboratively manag-ing eating disorders as “important” to “very important” inboth the pre- and post measures. Although a paired samplet-test revealed that there was a slight increase from pre- (M =6.33, SD = 0.75) to post-measures (M = 6.45, SD = 0.74,t(33) = −1.17, p= .25), this increase was not significant (seeFIGURE 2).

Knowledge and Confidence

Paired sample t-tests revealed that there were significantincreases with large effect sizes in both self-reported cur-rent knowledge and confidence across the continuum ofcollaborative management of eating disorders (see FIGURE2). On the scale assessing knowledge (averaged across allmeasured components), participants reported a significant in-crease from the pre – (M = 4.37, SD = 1.11) to the post mea-sure (M = 5.72, SD = 0.71, t(33) = −7.37, p = .001) withan eta squared statistic (0.62) indicating a large effect size.There was also a significant increase on the confidence scalefrom pre- (M = 4.21, SD = 1.12) to post-measure (M = 5.70,SD = 0.76, t(33) = −9.24, p = .001). The eta-squared statis-tic for this measure (0.72) revealed a large effect size.

Attitudes Toward Interprofessional Health Care

A paired sample t-test revealed that respondents had a sig-nificant improvement in attitudes toward interprofessionalcare of clients with eating disorders from pre-workshop (M= 4.19, SD = 0.36) to post-workshop means (M = 4.42,SD = 0.40, t(33) = −3.60, p = .001). The eta-squared statis-tic (0.28) indicated a large effect size (see FIGURE 2).

Perceptions of Interprofessional Collaboration

The mean score for this scale was calculated based on the 16-item semantic differential scale scored on a continuum from1 (negative perceptions) to 7 (positive perceptions).


Heath et al.

Results of a paired sample t-test show significantly morepositive perceptions of own skills in, and the value of, in-terprofessional collaboration when comparing pre-workshop(M = 6.06, SD = 0.52) to post-workshop means (M = 6.33,SD = 0.41, t(33) = −3.84, p = .001). The eta-squared statis-tic (0.31) indicated a large effect size (see FIGURE 2).

Intended Practice Change

Data on post surveys revealed that 69% (n = 24/35) of partic-ipants intended to change their practice with 51% (n= 18/35)planning more than one practice change. Of the 52 commentsin this section, 35% (n = 18) reflected an intention to practicemore collaboratively. The themes for change that emergedin these comments included: “be more prepared to orga-nize/participate in teamwork”; “closer contact with otherprofessionals working with the patient”; “more consultationbetween myself and other professions” and “encourage teammeetings and focus on interprofessional teams.”

6-Month Follow-up

Participants who indicated they were willing to be part ofthe follow-up survey provided their contact information; 27of the 41 workshop participants (65.8%) provided their con-tact information, and 11 completed the follow-up evaluation,yielding response rates of 40.1% of participants who agreedto be contacted (n = 27) and of 26.8% of all workshop par-ticipants (n = 41). The 11 follow-up survey respondents in-cluded 3 nurses, 3 social workers, 2 clinical psychologists,2 guidance counsellors, and 1 psychoanalytic psychothera-pist. The follow-up survey focused on implemented changesin practice including the use of the materials provided andchanges in interprofessional collaboration. Of the 10 who re-sponded to the question on practice change, 7 noted a changeresulting from the workshop, and 6 indicated that they hadused the concepts presented. Of the 9 respondents who com-pleted the question on practice changes related to collab-oration, 6 reported increased collaboration and specificallynoted more frequent referrals to and involvement with otherhealth professionals; greater collaboration with health careprofessionals regardless of the issue, and more of an effortto develop a team approach to managing eating disorders.One participant commented that “building relationships withcommunity partners for our region as well as increasingawareness of provincial programs” had been important. Per-sonal communication with the CFG members post-workshopidentified that a family education and support group was de-veloped as a result of contacts between family members whohad attended the Public Information Evening and 2 CFGmembers.

Discussion

This pilot study indicated that the eating disorder workshopwas successful in achieving its goals—all measures movedsignificantly in the desired direction with the exception of therecognition of need for education in the collaborative man-agement of eating disorders.

Need for Education

The nonsignificant findings for change in recognizing theneed for education may reflect a ceiling effect as pre scoreswere already high. There was strong endorsement both pre-and post-workshop of the need for continuing education, inboth the content area and in effective collaborative practice.This is consistent with the literature, which suggests that pro-fessionals feel that they are underprepared to handle the com-plexities of both eating disorders12–14 and interprofessionalcare.37–40

Interprofessional Attitude and Perception Change

The significant positive shift (large effect size) in attitudesabout interprofessional practice in eating disorders validatesthe workshop’s impact on increasing recognition of the valueof collaboration in managing eating disorders care. This is acritical step in increasing interprofessional care.38

A significant positive change (large effect size) in percep-tions about interprofessional practice in health care teamsreflected a more positive evaluation of collaboration andperhaps more importantly, of themselves in the context of in-terprofessional teamwork. This impact is likely related to theworkshop’s explicit and detailed focus on the value and me-chanics of working collaboratively. Positive attitudes aboutworking together to provide care and one’s own ability tocollaborate are fundamental to increasing interprofessionalpractice.38

Knowledge, Confidence, and Practice Change

The significant changes with large effect sizes in self-assessed knowledge and confidence from pre- to post-workshop revealed that the participants felt better prepared tocollaboratively manage eating disorders following the work-shop. Consistent with the findings of a systematic review onthe effectiveness of continuing medical education commis-sioned by the US Agency for Healthcare Research and Qual-ity (AHRQ)47 and other research,48,49 use of a multimediaapproach (print, live, and video) in workshop delivery mayhave contributed to participant attentiveness and understand-ing of the information. In keeping with the AHRQ review,47

participant confidence may have improved as a result ofthe inclusion of interactive case-based test-your-knowledge



questions during the workshop. These changes in knowledgeand confidence are crucial because when professionals feelunderprepared to manage the care of a disorder, they are un-likely to provide optimal care.3,5 Of note, the literature pro-vides evidence that increased confidence following contin-uing education results in increased utilization of the inter-vention taught.50 This is consistent with findings from thisstudy. Specifically, our results revealed that the majority ofrespondents reported intended and implemented changes inpractice both in terms of using workshop materials and in-creasing collaboration. The literature on translation of clin-ical practice guidelines into medical practice has identifiedthat accessibility of the guidelines and understanding how touse them51,52 are key factors. In this study, providing partici-pants with copies of practice tools and instructions on how touse them may have contributed to their decision to incorpo-rate them into practice. Also, the interprofessional exercise inwhich participants in small region-specific groups exploredways to increase collaboration may have been instrumentalin helping professionals develop strategies for surmountingthe barriers to working interprofessionally.

There were a number of challenges and opportunitiesencountered in the process, which resulted in changes tothe program for the province-wide implementation. Specifi-cally, the roles of the community, and the CFG in particular,emerged as critical components in identifying participantsand generating and maintaining local interest and enthusi-asm for the program. Feedback from participants resulted insignificant changes prior to the delivery of program provin-cially. For example, participants requested more videos, par-ticularly related to complex and challenging interventionssuch as certification for involuntary admission to hospital.Participants also indicated that they would prefer a more pro-fessionally diverse presenting team so that questions specificto all professions involved could be answered in depth. Thesingle greatest challenge we encountered was getting ade-quate numbers of follow-up surveys and while this is not anuncommon problem,53 it significantly impacted our abilityto interpret our results. For the larger program we decidedto use incentives and personal requests to increase responserates, both strategies suggested in the literature.53

Limitations

The most significant limitation of this study is generalizabil-ity due to the small sample size. In spite of our small partici-pant group (N = 41), results showed significant changes andlarge effect sizes. Unlike many educational interventions, theparticipants who attended were not completely self-selected.They were identified by peers as being likely to be involved inproviding care to this population, thus reducing self-selectionbias. However, we did not track the numbers of invitations

and acceptances, so it remains possible that we had a biasedgroup.

The research design was quasi-experimental and therewas no control group which restricts our ability to determinewith certainty that changes, particularly at the 6-month eval-uation, were due to the intervention.

The sample size for the follow-up online survey was small(N = 11). It must be considered that those who had not madechanges to their practice were less likely to respond to thesurvey. In addition, practice change was measured throughself-report and we have no objective measure. The follow-upperiod of 6 months may not have been sufficient for some ofthe practitioners to have used the materials or to effectivelymeasure long-term maintenance of practice change. The ex-clusive use of self-report for knowledge and practice changeis a noteworthy limitation. The recognition of the strengthsand limitations of the pilot study is important in informingthe revision of the program prior to its introduction acrossthe province. Future research should consider including a testof knowledge about important concepts that may provide amore robust measure of changes in knowledge. In addition,future studies need to objectively examine the nature, fre-quency, and sustainability of practice changes.

Overall, the findings led us to conclude that the guidingmodel, the workshop and accompanying materials had thedesired impact and validated the potential benefit of imple-menting the program across the province.

References

1. Linville D, Brown T, O’Neil M. Medical providers’ self-perceivedknowledge and skills for working with eating disorders: Anational survey. Eat Disord. 2012;20(1):1–13. doi:10.1080/10640266.2012.635557.

2. Bryant-Waugh RJ, Lask BD, Shafran RL, Fosson AR. Do doctors rec-ognize eating disorders in children? Arch Dis Child. 1992;67:103–105.doi:10.1136/adc.67.1.103.

3. Maradiegue A, Ceclic B, Francis G, Bozelle MJ. Do primarycare providers screen for eating disorders? Gastroenterol Nurs.1996;19(2):65–69.

4. Boule, CJ, McSherry JA. Patients with eating disorders: Howwell are family physicians managing them? Can Fam Physi-cian. 2002;48:1807–1813. Available from http://europepmc.org/articles/PMC2213962/pdf/12489246.pdf.

5. Clarke ED, Polimeni-Walker I. Treating individuals with eatingdisorders in family practice: A needs assessment. Eat Disord.2004;12(4):293–330. doi:10.1080/10640260490521343.

6. Linville D, Benton A, O’Neil M, Sturm K. Medical providers’ screen-ing, training and intervention practices for eating disorders. Eat Disord.2010;18:110–131. doi:10.1080/10640260903585524.

7. Barbopoulos A, Clark JM. Practising psychology in rural set-tings: issues and guidelines. Can Psychol. 2003;44:410-424.doi:10.1037/h0086962.

8. Bethune C, Worrall G, Freake D, Church E. No psychiatry?Assessment of family medicine residents’ training in mentalhealth issues. Can Fam Physician. 1999;45:2636–2641. Available


Heath et al.

from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2328665/pdf/canfamphys00045-0090.pdf

9. Macfarlane D. Current State of Collaborative Mental Health Care. Mis-sissauga, ON: Canadian Collaborative Mental Health Initiative. 2005.Available from http://www.ccmhi.ca.

10. Thorngren JM. Rural mental health: a qualitative inquiry. JRural Comm Psychol. 2003;E6(2). http://www.marshall.edu/jrcp/JRCP E6 2 Thorngren.htm. Accessed August 28, 2008.

11. Brems C, Johnson ME, Warner TD, Roberts LW. Barriers to healthcareas reported by rural and urban providers. J Interprof Care. 2006;20:105–118. doi:10.1080/13561820600622208.

12. Moore T, Sutton K, Maybery D. Rural mental health workforce difficul-ties: A management perspective. Rural Remote Health. 2010;10:1519Available from http://www.rrh.org.au.

13. Coll KM, Kovach T, Cutler MM, Smith M. Exploring wellness andthe rural mental health counselor. J Rural Comm Psychol. 2007;E10(2). Available from http://www.marshall.edu/jrcp/V10%20N2/coll.pdf.

14. Katon WJ, Von Korff M, Lin EH, et al. The Pathways Study:a randomized trial of collaborative care in patients with dia-betes and depression. Arch Gen Psychiatry. 2004;61(10):1042–1049.doi:10.1001/archpsyc.61.10.1042.

15. Walsh J, Wheat M, Freund K. Detection, evaluation, and treat-ment of eating disorders: the role of the primary care physi-cian. J Gen Intern Med. 2000;15:577–590. Available from http://link.springer.com/content/pdf/10.1046%2Fj.1525-1497.2000.02439.x

16. Katon WJ, Lin EH, Von Korff M, et al. Collaborative care forpatients with depression and chronic illnesses. N Engl J Med.2010;363(27):2611–2620. Available from http://www.nejm.org/doi/full/10.1056/NEJMoa1003955.

17. Health Council of Canada. Getting It Right: Case Studies of Effec-tive Management of Chronic Disease Using Primary Health CareTeams. Toronto: Health Council of Canada; 2009. Available fromhttp://healthcouncilcanada.ca/rpt det.php?id=164.

18. Soubhi H, Bayliss E, Fortin M, et al. Learning and caring in communi-ties of practice: Using relationships and collective learning to improvecare for patients with multimorbidity. Ann Fam Med. 2010;8(2):170–177. doi:10.1370/afm.1056.

19. Canadian Health Services Research Foundation. Evidence Synthe-sis for the Effectiveness of Interprofessional Teams in Primary Care.Canadian Health Services Research Foundation; 2012. http://www.cfhi-fcass.ca/publicationsandresources/researchreports/ArticleView/12-06-27/0f362096-8b8e-4f67-b2c0-65f6e95b2bdf.aspx.

20. World Health Organization. World Health Report: Framework forAction on Interprofessional Education & Collaborative Practice.Geneva, Switzerland: World Health Organization; 2010. Available fromhttp://www.who.int/hrh/resources/framework action/en/index.html

21. D’Amour D, Ferrada-Videla M, Rodriguez LSM, Beaulieu M-D. Theconceptual basis for interprofessional collaboration: core concepts andtheoretical frameworks. J Interprof Care. 2005;19(2)Suppl. 1:116–131.doi:10.1080/13561820500081604.

22. Gagne MA. What Is Collaborative Mental Health Care? An Introduc-tion to the Collaborative Mental Health Care Framework. Mississauga,ON: Canadian Collaborative Mental Health Initiative; 2005. Availablefrom www.ccmhi.ca.

23. Craven MA, Bland R. Better practices in collaborative mentalhealth care: An analysis of the evidence base. Can J Psychiatry.2006;51(Suppl. 1):1S–72S. Available from http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=3&sid=fc17c049-b213-489d-bc46-e83c4500543d%40sessionmgr104&hid=122.

24. Goodstadt M. The use of logic models in health promotionpractice. 2005. Available from http://www.course-readings-and-resources.bestpractices-healthpromotion.com/attachments/File/Good-

stadt%20Logic%20Model%20Paper/Goodstadt Introduction to logicmodels paper.pdf.

25. Canadian Community Health Survey—Mental Health and Well-Being. Ottawa, ON: Statistics Canada; 2002. Available fromhttp://www.statcan.gc.ca/pub/82-617-x/index-eng.htm.

26. Bulik CM, Reba L, Siega-Riz AM, Reichborn-Kjennerud T. Anorexianervosa: definition, epidemiology, and cycle of risk. Int J Eat Disord.2005;37(Suppl.):S2–S9. doi:10.1002/eat.20107.

27. Klump KL, Bulik CM, Kaye WH, Treasure J, Tyson E. Academyfor eating disorders position paper: eating disorders are seriousmental illnesses. Int J Eat Disord. 2009;42:97–103. Available fromhttp://web.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=b0998f68-d344 - 41d5 - b972 - e708369a56b4 % 40sessionmgr115&vid=5&hid=122.

28. Steinhausen HC, Seidel R. Outcome in adolescent eating dis-orders. Int J Eat Disord. 1993;14:487–496. doi:10.1002/1098-108X(199312)14:4<487::AID-EAT2260140412>3.0.CO;2-7.

29. van Son G, van Hoeken D, Donker G, Hoek H. Course and outcomeof eating disorders in a primary care-based cohort. Int J Eat Disord.2010;43:130–138. doi:10.1002/eat.20676.

30. Papodopoulous FC, Ekbom A, Brandt L, Ekselius L. Excess mortality,causes of death and prognostic factors in anorexia nervosa. Br J Psychi-atry. 2009;194:10–17. doi:10.1192/bjp.bp.108.054742.

31. Stice E, Marti N, Shaw H, Jaconis M. An 8-year longitudinal study ofthe natural history of threshold, subthreshold, and partial eating dis-orders from a community sample of adolescents. J Abnorm Psychol.2009;118(3):587-597. doi:10.1037/a0016481.

32. Strober M, Johnson C. The need for complex ideas in anorexia ner-vosa: why biology, environment, and psyche all matter, why thera-pists make mistakes, and why clinical benchmarks are needed formanaging weight correction. Int J Eat Disord. 2012;45(2):155–178.doi:10.1002/eat.22005.

33. Kraus B, Stronski S, Michaud PA. Training needs in adoles-cent medicine of practicing doctors: a Swiss national survey ofsix disciplines. Med Educ. 2003;37:709–714. doi:10.1046/j.1365-2923.2003.01565.x.

34. Rome ES, Ammerman S, Rosen DS, Keller RJ, Lock J, et al. Childrenand adolescents with eating disorders: the state of the art. Pediatrics.2003;111:e98–e108. doi:10.1542/peds.111.1.e98. Available fromhttp://pediatrics.aappublications.org/content/111/1/e98.full.pdf+html.

35. Williamson DA, Martin CK, Stewart TM. Psychological aspects of eat-ing disorders. Best Pract Res Clin Gastroenterol. 2004;18(6):1073–1088. doi:10.1016/j.bpg.2004.06.023.

36. Heath O, Cornish P, Callanan T, Flynn K, Church E, Curran V,Bethune C. Building interprofessional primary care capacity inmental health services in rural communities in Newfoundland andLabrador: an innovative training model. Can J Commun MentHealth. 2008;27(2):165–178. Available from http://cjcmh.metapress.com/media/fc22ht5jfp6kxm5c7h1k/contributions/7/3/1/1/73112l328v476800.pdf

37. Health Force Ontario. Final report of the interprofessional care strate-gic implementation committee. 2010. Available from http://www.healthforceontario.ca/WhatIsHFO/AboutInterprofessionalCare.aspx.

38. Oandasan I, Baker G, Barker K, et al. Teamwork in Health-care: Promoting Effective Teamwork in Healthcare in Canada. Ot-tawa, ON: Canadian Health Services Research Foundation; 2006.Available from http://www.chsrf.ca/Migrated/PDF/ResearchReports/CommissionedResearch/teamwork-synthesis-report e.pdf

39. Reeves S, Lewin S, Espin S, Zwarenstein M. Interprofessional Team-work for Health and Social Care. Oxford, UK: Wiley-Blackwell. 2010.doi:10.1002/9781444325027.fmatter.

40. San Martin-Rodriguez L, Beaulieu M, D’Amour D, Ferrada-Videla M.The determinants of successful collaboration: a review of theoretical



and empirical studies. J Interprof Care. 2005 May;19(S1):132–147.doi:10.1080/13561820500082677.

41. McVey G, Gusella J, Tweed S, Ferrari M. A controlled evalua-tion of web-based training for teachers and public health practition-ers on the prevention of eating disorders. Eat Disord. 2009;17:1–26.doi:10.1080/10640260802570064.

42. McVey GL, Davis R, Kaplan A, et al. A community-based train-ing program for eating disorders and its contribution to the develop-ment of a provincial network of specialized services. Int J Eat Disord.2005;37:S35–S40. doi:10.1002/eat.20114.

43. Heinemann GD, Schmitt MH, Farrell MP. Attitudes toward health careteams. In Heinemann GD, Zeiss AM, eds. Team Performance in HealthCare: Assessment and Development. New York, NY: Kluwer Aca-demic/Plenum; 2002:155–159.

44. Clark PG. Learning on interdisciplinary gerontological teams: in-structional concepts and methods. Educ Gerontol. 1994;20:349-364.doi:10.1080/0360127940200402.

45. Armitage C, Conner M. Efficacy of the theory of planned behavior: ameta-analytic review. Br J Soc Psychol. 2001;40:471.

46. Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Pro-cess. 1991;50(2):179–211. doi:10.1016/0749-5978(91)90020-T.

47. Marinopoulos SS, Dorman T, Ratanawongsa N, et al. Effectivenessof Continuing Medical Education. Evidence Report/TechnologyAssessment No. 149 (prepared by the Johns Hopkins Evidence-Based Practice Center, under Contract No. 290-02-0018.)

AHRQ Publication No. 07-E006. Rockville, MD: Agency forHealthcare Research and Quality; January 2007. Available fromhttp://archive.ahrq.gov/downloads/pub/evidence/pdf/cme/cme.pdf.

48. Mayer RE, ed. The Cambridge Handbook of Multimedia Learning. NewYork, NY: Cambridge University Press; 2005.

49. Anglin GJ, Vaez H, Cunningham KL. Visual representations and learn-ing: the role of static and animated graphics. In: Jonassen DH, DriscollMP, eds. Handbook of Research on Educational Communications andTechnology. 2nd ed. Mahwah, NJ: Erlbaum; 2004; 865–916.

50. Umble K, Cervero R, Baiyin Y, Atkinson W. Effects of traditionalclassroom and distance continuing education: a theory-driven evalu-ation of a vaccine preventable diseases course. Am J Public Health.2000;90:1218–1224. Available from http://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.90.8.1218.

51. Cabana MD, Rand CS, Powe NR, et al. Why dont physicians followclinical practice guidelines? A framework for improvement. JAMA.1999;282(15):1458–1465.

52. Farmer AP, Legare F, Turcot L, Grimshaw J, Harvey E, McGowan J,Wolf FM. Printed educational materials: effects on professional practiceand health care outcomes. Cochrane Database Syst Rev. 2008;3. Art.No.: CD004398. doi:10.1002/14651858.CD004398.pub2.

53. Cook, C, Heath, F, Thompson RL. A meta-analysis of response rates inWeb- or Internet-based surveys. Educ Psychol Meas. 2000;60(6):821–836. Available from http://www.celt.iastate.edu/pdfs-docs/classclimate/research/2002 cook meta-analysis web-based surveys.pdf.


Documents

Improving Collaborative Care in Managing Eating Disorders: A Pilot Study