Drug and Alcohol Review (1995) 14, t49-150

EDITORIAL

Making research more relevant to practice

Drug and alcohol researchers often lament the fact that practitioners have been slow to act on what seem to be direct implications of research. A short and by no means exhaustive list of examples of the apparent failure of practitioners to act on research evidence would include the following. The failure of generalist health workers to take up brief and early interventions for hazardous and harmful alcohol use; the continued hostility to methadone maintenance as a treatment for opioid dependence when it has been shown to be the most effective of the current treatments on offer; the preference for low doses of methadone within many methadone maintenance programs when research shows that higher doses are more effective at retaining users in treatment and in reducing their drug use while in treatment; and the continued adherence in alcohol programs to residen- tial treatment based on the 12-step model as the first choice for all alcohol problems.

The usual response to the "recalcitrance" of prac- titioners is frustration, irritation and puzzlement, wqth researchers persisting in using methods that their own research shows are ineffective in changing behaviour, namely, exhortation, exasperation and moralizing. Such insensitive behaviour reminds me of the common response of medical students to the information that on average only about half of their patients "comply" with medical advice. This was usually- taken as evidence of patient irrationality. A more insightfia] response was prompted when it was pointed out that only about 60% of pharmacists, doctors, optometrists and psychologists typically comply with the recommendations of their own professional bodies. Moreover, the reasons for pro- fessional non-compliance are largely the same as for patient non-compliance, namely, they did not know what the recommendations were, or they had forgot- ten them, they did not believe that the recommen- dations applied to them, and they felt free to vary

the recommendations in accord with their "personal experience".

Drug and alcohol researchers need to move be- yond moralizing about the "non-compliance" of practitioners by taking our cue from Miller's work on motivational interviewing. Rather than regarding the "non-compliance" of practitioners as evidence of their "obstinacy" we would do better to look to the possible reasons for our failures to motivate the adoption of the practices we advocate.

We could begin by exploring analogies between the reasons for patient and practitioner non-compli- ance. How well are we disseminating our research findings? Are our reports of research findings friendly and accessible to practitioners? How suc- cessful have we been in bridging the considerable gap between the typical research article or literature review and intelligible advice on how to put things into practice? Perhaps more attention needs to be given to providing simple and accessible versions of research findings and to spelling out their impfica- tions out in ways that can be used in day to day work. More effort certainly needs to be made to ensure that research findings are translated into education and training programs.

Our efforts at dissemination also need to be based on a sound understanding of what our audience believes. This requires an appreciation of the poss- ible cognitive incompatibility between our views and those whom' we wish to influence. For example, general practitioners and other generalist health workers rarely share the enthusiasm of proponents of brief interventions for routinely asking patients about their alcohol use and advising those drinking hazardously to moderate their consumption. When we take the trouble to ask we find that they have their reasons. They do not believe that they have a "mandate" to inquire about their patients' drinking, let alone to intervene, unless there is a good reason

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for suspecting that the patients' presenting problems are related to their alcohol use. They are also pessi- mistic about their ability to influence alcohol use by simple advice since similar efforts in the past with severely dependent drinkers have failed. Some also perceive an incompatibility between their traditional role as the solver of problems presented by their patients with the public health role of screening and intervention, especially when there is likely to be a relatively low pay-off in terms of behaviour change for their efforts.

Researchers must also recognize the very different weights given to rigorous research evidence and clinical experience by practitioners and researchers. Researchers may be most persuaded by the rigour of evidence from controlled studies while practitioners prefer the compelling immediacy of clinical experi- ence with patients. The different cognitive constitu- tions of researchers and practitioners also affect their responses to uncertainty. Sceptically trained and in- clined researchers prefer to withhold judgement in the face of uncertainty, calling for more research and a suspension of action until the data are in. Practi- tioners needs must act in the face of uncertainty, and with poor feedback on the consequences of their decisions to guide them in future decisions. Re- searchers need to be more tolerant of the difficult task that practitioners face while practitioners need to be more aware of the limitations of "clinical

experience" as a basis for action, and less inclined to dogmatism in defence of practices that are unsup- ported by evidence.

In emphasizing these cognitive factors we should not neglect to address the structural disincentives that discourage changing practice. These include the lack of payment to general practitioners for engaging in brief interventions, the lack of opportunities for busy practitioners to undertake professional training in new developments and the lack of work-place support for changing practice.

In short, researchers need to regard the lack of adoption of research findings by practitioners as a research issue. It means being prepared to concede that what sounds like a good idea in principle (as do brief interventions by general practitioners) may'not work in practice for reasons that we fail to anticipate and can only discover by research. In short, re- searchers need to expose their beliefs to research evidence in the way we so often exhort practitioners to do in listening to our findings.

WAYNE H ~ L Deputy Editor and Director, National Drug and Alcobd Research Centre, University of New South Wales, Kensington, NSW 2052, Australia