2013. Vol.4, No.11A, 25-31
Published Online November 2013 in SciRes (http://www.scirp.org/journal/psych) http://dx.doi.org/10.4236/psych.2013.411A005
Open Access 25
Designing Effective CME—Potential Barriers to Practice Change
in the Management of Depression: A Qualitative Study
Mandana Shirazi1,2, Sagar V. P ar ik h3, Ideh Dadga ran4,5*, Charlotte Silén6
1Education Development Cent e r, Medical Education Department,
Tehran University of Medical Sciences, Tehran, Iran,
2Departments of LIM E and Cl ini ca l Science and Education, Söder s juk hu set,
Karolinska Institutet, Stockholm, Sweden
3University of Toronto, T oronto, Canada
4Medical-Surgical Nursing Department, Langroud Nursing and Midwifery School,
Guilan University of Medical Sciences (GUMS), Rasht, Iran
5Research in Medical Ed u ca t io n , Education Development Center (EDC),
Guilan University of Medical Sciences (GUMS), Rasht, Iran
6Center for Medical Educ at io n, Department of Learning, Informatics, Medical Management and Ethics (LIME),
Karolinska Institutet, Stockholm, Sweden
Email: firstname.lastname@example.org, email@example.com, *firstname.lastname@example.org, email@example.com
Received September 13th, 2013; revised October 16th, 2013; a c c e p te d N o v e mber 14th, 2013
Copyright © 2013 Mandana Shirazi et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
Aim: The main aim of the current study is to explore GPs’ micro level obstacles of behavior change
which affects diagnosis and management of Depressive Disorders following attendance at a Depression
CME event. Methods: In this qualitative study, semi-structured interviews exploring GPs’ perceptions
and experiences regarding the diagnosis and treatment of depression were done. A purposeful sampling to
obtain a broad range of views was carried out among GPs that had participated in an educational interven-
tion study three years earlier. Eleven GPs were interviewed and their views were probed in depth to get
rich descriptions to ensure trustworthiness of the data. The data were analyzed by using qualitative con-
tent analysis. Results: GPs’ beliefs regarding micro level barriers emerged as two important themes indi-
vidual and workplace factors. The individual themes included: educational and professional, and the con-
textual themes included: psychological disorders and work place categories. The results showed different
perceptions on the barriers between the two groups of GPs, those who did change and had a positive per-
ception of the CME program they participated in three years ago, and some who did not change. Conclu-
sion: The results of this study imply that a number of micro level obstacles were of great importance
when managing patients with depression disorders. In order to improve the effectiveness of CME events
they should be tailored for the individual and address workplace issues i.e. both individual and contextual
factors need attention.
Keywords: CME; Depression; Primary Care; Qualitative Study
Quality improvement in health care is a common concept af-
fecting all the field professionals. Several factors such as or-
ganization, policy and education influence the quality of health-
care. Health care quality assurance is a worldwide concern in
evaluating the effects of Continuing Medical Education (CME)
or Continuing Professional Development (CPD), not only on
the physicians’ knowledge and skills, but also on their per-
formance and the clinical results (Davis, Thomson, Oxman, &
Haynes, 1995; Oxman, Thomson, Davis, & Haynes, 1995).
Grol and Weising stated that effective CME interventional
events should be planned based on personal, workplace and
local health care system needs. They emphasize attention on
causal variables that support or hinder targeted health care tai-
lored intervention, using appropriate theories in social cognition
models and health care results (Grol & Wensing, 2004). The
aim of all types of learning is change—changing mental models
and creating new ways of thinking, so models of change are
relevant. One of the applicable theories (Shirazi et al., 2011) in
this field is Readiness to Change model, which underpins the
necessity to match interventions with the change stage and
corresponding cognitive style. This model, originally known as
the “trans-theoretical model”, was developed by James Pro-
chaska and Carlo DiClemente in the early 1980s to explain the
stages of change observed in persons striving to change addic-
tive behaviour (Prochaska, 1992). More specifically, the five
stages of change are defined on the basis of people’s propensity
to change a specific behaviour and understanding. In the initial
stage, individuals are not aware of any problem or contemplat-
ing change; in the second stage, they begin contemplating
change; in the third stage, they actively prepare, and in the
fourth stage, they actually change behaviour. A fifth stage is the
M. SHIRAZI ET AL.
consolidation or maintenance of the new change.
CME in Iran is mandatory for physicians who wish to continue
their professional practice (Shirazi et al., 2004). A comprehen-
sive project including interventions concerning education on
improving General Practitioners’ (GP) knowledge, attitude, and
performance in the management of depressive disorders was
carried through in 2006 .The evaluation of GPs’ performance
was done through the application of unannounced Standardized
Patients (SP) (Shirazi et al., 2011). That study showed that
some physicians changed their performance while others did
not; the reason for lack of change was not identified (Figure 1)
(Shirazi et al., 2011).
Research in CME interventions has failed to provide reliable
and effective methods to change the services and professional
performance for the better. In a study from the literature, barri-
ers to uptake of Evidence-Based Medicine were explored. That
study categorized GPs’ individual practice on the micro level,
commercial and consumer organizations on the meso-level
(institutions, organizations) and health care policy, media and
specific characteristics of evidence on the macro-level (policy
level and international scientific community). Existing barriers
and possible strategies to overcome these barriers were de-
scribed (Hannes et al., 2005). In the current study, we were
interested in the barriers to change from the individual physi-
cian’s perspective, so we used a qualitative approach for a
deeper understanding of the barriers (Pope, Van Royen, &
Baker, 2002). According to the literature, there are different
obstacles and multifactor barriers behind the GPs’ failure to
detect depression. Shortage of time, insufficie nt knowledge, the
patients’ failure to reach appropriate mental healthcare services,
social and cultural background, and the patients’ resistance to
admitting their mood disorders are just some of the underlying
factors (Hannes et al., 2005; Shirazi et al., 2013). These obsta-
cles may easily be classified into the micro and macro level
categories described earlier. The macro level barriers were
reported in our previous publication at the micro level (personal
and work place) barriers which affect doctors’ performance,
ultimately in order to improve the quality of care (Diner et al.,
2007). Specifically, we aim to explore GPs’ micro level obsta-
cles of behavior change which affect diagnosis and manage-
ment of Depressive Disorders following participation in a major
CME program for depression.
chang ed their
chang e their
The design of the project including t h e previous and curren t st u di es .
This qualitative research was carried out by the use of phe-
nomenology method. It consists of the semi-structured inter-
views with the data gathering method and qualitative content
analysis for data analysis. The interviews were conducted be-
tween May 2010 and June 2011 (by MS). Qualitative content
analysis is a method that accounts for the contradictory com-
ments and unresolved issues concerning the meanings and ap-
plication of concepts and procedures. Qualitative content analysis
is used in a large number of fields, ranging from marketing and
media studies to cultural studies, sociology, and cognitive sci-
ence, as well as ot her fields of inquiry (Palmquist, 2010).
Participants and Design
The participating GPs in this qualitative study originated
from a previously published randomized controlled trial (RCT)
where interactive teaching and learning methods were used to
support GPs in their practice when diagnosing and treating
patients with depression disorders (Krippendorff, 2004; Ma-
randi, 1996; Shirazi et al., 2011; World Health Organization,
2004). In summary, in that study the participating GPs (n = 192)
were randomized into an intervention group (n = 96) or into a
control group (n = 96) and assessed at the follow-up (78 and 81
GPs, respectively). At the follow-up the participants in the in-
tervention group were categorized as those who had changed
their behavior and those who had not. The twelve approached
GPs of the present study originated from the intervention group:
all five GPs that had not changed their behavior and/or per-
formance (i.e. GP, no change) and seven of those who had
changed (i.e. GP change) their behavior and/or performance
were approached but one of the latter declined to participate.
The seven were randomly chosen among all those who had
changed and the interviews continued until saturation of the
data was reached. The choice of participants was done pur-
posely in order to get a wide range of views about the barriers
they had met (Krippendorff, 2004) (Figure 1).
After signing an informed consentphysicians were asked to
agree upon a convenient time and place for the interview. The
principal interview questions were as follows: “What do you
feel about the barriers of GPs’ behavior change? What is your
perception regarding your behavior change following yourpar-
ticipation in the CME course three years ago?” The interviewer
probed participant responses using questions, such as “Could
you say something more about that?”, “What did you think
then?”, and “When you mention-what do you mean?” (Kvåle,
The GPs consisted of eight male and three female partici-
pants among whom there were three under the age of 40, five
between the ages of 40 and 50, and three over 50 years of age.
Nine of them had worked as a GP for 10 to 20 years and two of
them for over 20 years. As an incentive, each participant re-
ceived a CME credit point for his/her participation.
Collecting and Analyzing Data
The interviews were recorded on a digital voice recorder and
subsequently transcribed. All interviews were analyzed. The
process of qualitative content analysis often begins during the
early stages of data collection. This early involvement in the
analysis phase assists in moving back and forth between con-
cept development and data collection, and may help direct sub-
sequent data collection toward sources that are more useful for
M. SHIRAZI ET AL.
addressing the research questions (Zhang, 2012). This process
includes open coding, creating categories, and abstraction.
Open coding, axial coding, and generating themes were per-
formed during data gathering and analysis. Each category was
named using content-characteristic words. Subcategories with
similar events and incidents were grouped together as catego-
ries and categories were grouped as themes. The abstraction
process continued as far as it was reasonable and possible (Elo
& Kyngäs, 2008).
Quality Assu rance of Data A nalysis
During the analysis of data, certain techniques can help prove
our points (Westbrook, 1994). The data reliability of the current
study was checked through double-coding and abstracting the
data from the same transcripts which was performed by two
Sometimes other sources can be used to confirm inferences
from data such as previous successes, contextual experiences,
established theories, and representative interpreters. “A content
analysis is valid to the extent that its i nferences are upheld in t he
face of independently obtained evidence” (Westbrook, 1994). In
the present study sampling method was based on the previous
contextual findings of another study on “stages of change theory”.
The results of the other study were confir med thr o ugh the curre nt
study which in turn supports the credibility of data.
The analysis of data demonstrated barriers of micro level in
four categories and two themes. The micro level barrier themes
focused on individual and contextual obstacles based on the
GPs’ views regarding depression management. The results
showed different perceptions on the barriers between the two
groups of GPs, those who did change and had a positive per-
ception of the CME program they participated in three years
ago, and some who did not change.
The two themes and four categories are displayed in Table 1.
Themes, Categories and Subcategories of Micro Level Barriers to
Management of Depressive Disorders based on the GPs’ Perspectives.
Theme Category Subcategory
Professional Motivation Past
Patients’ attitude and
Depressive d isorder
Opinion (Interface GPs’
with other professio ns)
Lack of time
issues Financial issues
The main themes included: Individual factors (educational and
professional categories) and contextual factors (psychological
disorders and work place categories).
Academic psychiatric training: Potential barriers for diag-
nosis and management of depression disorders were based on
the GPs’ points of view from two extremes: those who did not
change their performance and behavior and those who did.
The Psychiatry courses for medical students in Iranare of-
fered for no more than a month during their internship which is
admittedly insufficient (P3c2).
Another participant mentioned inappropriate teaching meth-
ods, which were not applicable to doing interviews with pa-
tients during their general undergraduate courses in medicine.
“It seems that one of the hindering problems regarding the-
detection and treatment of depression is that we are not well
trained with any proper clinical interview techniques in the
general medical courses” (P4C45).
Normally the CME program is not designed based on GPs’
needs. A participant explained:
“I remember a meeting was held by a group of surgeons
about different ways of operating breast cancer. What are the
advantages of knowing different methods of operating breast
cancer for a general practitioner (GP)? If the meeting was
about different ways of diagnosis and screening of breast can-
cer, it would help us diagnose the disease. I only attended the
meeting to gain extra CME credit points. We neither under-
stood what the surgeons said nor did they care whether we
understood their points or not. The subject is of no use to us in
One of the GPs’ who did not change his performance and
“In a regular CME program, the sessions were mere lect ures
and were thus uninteresting to us. They do not affect our
knowledge and performance as the content will be forgotten
very soon” (P4c6).
“CME courses regarding one subject normally continue in
an excessively big interval which in turn leads to the loss of
Specific CME Program: “The specific CME course in-
creased my knowledge and changed my view. After the course,
the quality of my diagnosis and treatment improved. For in-
stance, prior to the course I didn’t care and ask if the patients
were suicidal because I thought they would not like to talk
about it. But now I follow through with that point with no ex-
ception and then I try to pay attention to whether or not they
are seriously considering suicide” (P3c1)?
“What we read in books did not even begin to compare with
the information provided by teachers in specific CME events.
The provided information was more practical and gave us more
useful information for our practice. Especially in the CME
course when i had interviewed with Standardized Patients and
get feedback from teachers I had learnt a lot” (P8).
“Following my participation in the course, my motivation for
self-study increased due to the useful printed materials and
references that the course instructors provided regarding the
management of depression” (P1C5).
Open Access 27
M. SHIRAZI ET AL.
“Even though I had previously counseled depressed patients
and diagnosed and treated them; after attending the CME event
I am more capable of distinguishing between different types of
depression and combining disorders” (P11, C11, C13).
“Following my participation in the course, I have followed
up with severely depressed patients who may have committed
suicide or are prone to do so and referred them to a psychia-
trist” (P11C12) (P8C1).
“After participating in the course I began to prescribe drugs
more carefully. Before our attendance in a specific course,
when a patient complained about her/his difficulty to sleep at
night, without asking him further questions in order to rule out
depression, I would prescribe sleeping pills for him, instead of
prescribing Fluoxetine or another antidepressant” (P3c19).
Some of GPs’ who did not change their performance and
behavior made the following statements:
“I think the previous CME course (specific course) in which I
participated, had no effect on my performance as there are
several more important disorders than depression” (P7C1).
“I do not remember crucial points of the specific CME
course that you are asking of it. I just remember that Depres-
sion is an important disorder and we should pay more attention
to it but I have participated in that course simply to gain CME
credits” (P4C36, P4C37).
“The mentioned course had no significant effect on my per-
formance. I mean, I refer depressed patients to the psychiatrist
who works in our hospital” (P4C38)?
Contextual Fa ct ors
Work Place Issues
The results of this study also indicated that work place and
conditions can affect the GPs’ professional requirements re-
garding management of Depressive Disorders’.
Some GPs’ who did change their performance and behavior
stated the following:
“I work in my private office and the number of depressed pa-
tients who consult with me has increased following my partici-
pation in the course. I may have missed some c ases prior to the
One of the GPs’ who did not change his performance and
“Since we have a very crowded and terrible emergency ward
in the hospital…, we don’t have enough time to assess the pa-
tients’ health and to talk and consult with them to diagnose
“I closed my private clinic eight months after participating in
that course so the value of what has been taught to me was
reduced due to the fact that I was working in the emergency
ward. In that place there is no time for treating depressed pa-
Shortage of Time
Among other problems regarding workplace is the shortage
of time for consulting with depressed patients. In this regard, a
physician who did change his practice and behavior claimed:
“In my office normally I spent 25 - 30 minutes on consulta-
tion with a depressed patient and I remember a case in which
after a 30 minute discussion, the patient refused to accept his
depressive disorder. Other patients sitting in waiting room
complained to my secretary saying that I am a talkative doctor.
This happened to me several times and other patients became
angry with me and complained to me when they entered my
Even though interviewing depressed patients is a time con-
suming process, most of the patients will accept my diagnosis
and are satisfied with it so they suggest my services to their
Another participant who did not change his method of prac-
“For instance, since I am working in a very crowded emer-
gency ward, other patients have to wait there for a long time
which is not possible for me to provide them with the proper
services. If I had more than 10 minutes to talk to each patient, I
would be able to diagnose whether the patient is depressed or
Other factors such as GPs’ motivation, past experience and
their competencies have been labeled as an individual theme.
The main research questions “why did some of the physicians
following their participation in tailored CME intervention
change their performance and others’ did not”? and “How to
explore GPs’ obstacles of behavior change which effects their
diagnosis and management of Depressive Disorders?” These
are the main concerns of the current study which remain unan-
swered in almost all parts of the world (Jewell, 2003).
Based on the present research findings, several factors affect
GPs’ behavior change such as individual factors and setting
specifications. Underpinning the andragogia view such as
“Bandura”, adult learning theory depends on three important
factors: personal, contextual, and behavioral factors. So our
findings are in line with Bandura and stages of change theories
which emphasized on individual motivation to change their
behavior (Rimer & Glanz, 2005). We have found that behavior
change occurs, when the personal and contextual factors are
considered based on the GPs’ points of view.
We interprets and show pictures of GPs’ barriers of behavior
change into the context of the theoretical back ground of CME
which is the base of the recent study (Figure 2).
Academic Training: The preliminary task of medical schools
through a well-designed curriculum is to train medical students
in order to gain adequate knowledge, skills and attitudes and
graduate them as competent physicians who can guarantee the
patient safety (Pellegrino, 2002). But the current case is re-
garding some incompetent graduate GPs’ in the field of Psy-
chiatry due to their shortage of Psychiatry course during their
undergraduate study (P3 and P4) (Lecrubier, 2007; Mitchell,
Vaze, & Rao, 2009; Wilhelm, Brownhill, Harris, & Harris,
2006). It could be reflecting the educational organizational
difficulties such as the medical school psychiatry curriculum:
Syllabus, teaching and evaluation methods, educational envi-
ronment etc. Based on the findings of the study at hand, GPs’
believed that their academic psychiatry courses and their
knowledge and skill especially in the field of management of
depressive disorders were insufficient. They claimed that their
clinical psychiatry education period was too short P3 P4. In line
with our results Wilson directed a study regarding what GPs’
essential needs are regarding the management of psychiatry
M. SHIRAZI ET AL.
Open Access 29
GPs' as a
Profession Psych ologica l
W ork place
Micro level Barriers of GPs’ behavior change.
disorders based on their view points and which knowledge,
skills and attitudes should be included in the current medical
curriculum in the University of Aberdeen. They have found that
depression is the most common psychiatry disorder for the
management of which they would like to gain competence. In
contrast with our findings, GPs’ in their study stated that their
needs for management of depression is in the domain of
knowledge but the result of our study expressed GPs’ needs in
the skill and attitude domains (Wilson, Eagles, Platt, &
McKenzie, 2007). Nisha Dogra et al. stated that psychiatry
curriculum development for medical students is a complex
process due to the fact that successful implementation should
be kept in their curriculum developers’ mind (Dogra et al.,
2010). Overall at present time in Iran at TUMS medical cur-
riculum is reforming but there is still a necessity to include
current study results to the curriculum.
In some countries such as Iran, when a difficulty regarding
physicians’ competency for management of disease happens,
CME would be responsible to overcome the current barriers.
General issue and Specific issues of CME: Based on our
data the GPs’ had two perspectives; the first, focused on their
general idea regarding the CME events and the second was
related to their specific views of tailored CME courses in which
they had participated. Their general idea of CME events in both
groups demonstrated that they were not satisfied with regular
CME events for several reasons such as: impractical topics
which did not address the GPS’ main issues, and applying di-
dactic educational methods, etc (P8, P4, P10).
Their opinion of the specifically tailored CME (Shirazi et al.,
2011) was totally different. Some of GPs who had changed
their performance, in contrast with the other group, found it
practical, interactive, and more relevant to their real needs
based on the data which was extracted from interviewing the
two groups of GPs’ (P1, P3, P8, P11).
In accordance with our findings, applying interactive meth-
ods, Marinopolos et al. directed a systematic review for assess-
ing the physicians’ behavior change and improving their clini-
cal outcomes through participation in a CME Intervention.
They suggested that it has been successful, at least to some
extent, in not only attaining, but also in sustaining the intended
objectives. They illustrated shared factors throughout the stud-
ies. For instance, using printed materials was proven to be less
effective than using live media and multi-media. Applying
multifaceted teaching and learning methods was more effective
than applying a single method. Hence the staff considered these
factors in planning CME events to enhance its effectiveness
(Marinopoulos et al., 2007). Another systematic review focused
on “assessing barriers to physicians’ adherence to practice
guidelines”. They found seven general categories of barriers
such as: knowledge, attitudes, behavior, awareness, familiarity,
agreement, and lack of self-efficacy. Thus our general finding
regarding participants’ dissatisfaction in Iranian CME events
are due to the use of didactic methods and do not consider the
main attributes of an effective CME program by CME provid-
ers. Those programs should be modified and adopted to the
specific design, based on GPs’ needs and applying a theoretical
framework and utilizing multifaceted methods, the same as our
previous studies which satisfied most attendees (Shirazi et al.,
2011, 2007, 2009, 2008).
Modeling CME Intervention
Interestingly, those GPs’ who had changed their performance
and stages of change were in intervention groups and few of
them who had not changed assumed that the CME course they
participated in was not sufficient for them which could be in-
terpreted as their inadequate motivation for learning about de-
pression management (P4). Their lack of motivation could be
related to their work place since most of them were working in
the emergency wards of the hospital and they did not feel that
their needs were aligned with depressive disorders. In contrast,
other GPs working in a primary health care setting suggested
the usefulness of the previous course and its content sustain-
ability of course content (for example some of them remember
some specific educational sessions after three years, which they
M. SHIRAZI ET AL.
had interviewed with Standardized Patients) (SP) (P8).
In line with our findings, in a review article, a writer quoted
“Continuous Medical Education (CME) generally has failed to
address the physicians’ educational needs”. They have empha-
sized that if CME providers wish to improve doctors learning
translating knowledge into physicians’ practice, there is a cru-
cial need to understand theories of physician behavior change
and characteristics of effective CME interventions. The writers
have then discussed the necessity of person center education in
which physicians preferred independence and self-directed
learning. So if these issues are overlooked, then the CME pro-
gram is doomed to fail (Amin, 2000). Following CME pro-
gram’s exploring the barriers of behavior change based on the
participants’ view, there is also a very important component
which can help us overcome the obstacles and there for design
more effective CME courses in the future. It is thus highly
recommended to design CME programs based on accepted
theories of behavior change.
Based on theoretical perspectives of “stages of change” those
GPs who did not change their performance, also remained in
the attitude stage after participation in CME specific courses.
Data analysis showed that those GPs’ views supported “stages
of change” theory, where they had participated three years ago.
GPs’ who were in the attitude stage and did not change their
performance did not feel they need to change their performance
in the field of management of depression (P4). Based on the
data they did not feel they need to participate in management
depression disorder course. So, they participated in it merely to
gain CME credit points. Thus CME providers and policy mak-
ers should consider these issues in designing future CME pro-
grams. They should assess GPs’ readiness to change before
they participate in the courses. If participants are not ready then
participating in the course is useless for them (Shirazi et al.,
2011, 2007, 2009, 2008).
Work place and Practice Setting: In current study the physi-
cians’ work place played an important role. For instance, some
physicians who worked in primary health care settings stated
that a tailored CME course (participated three year ago) was
efficient in their performance (P11). However, for some others
who were working in the emergency wards from another ex-
treme the program was not useful (P4). According to one pub-
lished study work place could affect the doctors’ perceived
needs for the management a depression; they have found that
those doctors who work in a hospital had different psychiatric
needs in comparison with those who work in the primary care
(Wilson et al., 2007). Setting and workplace could be acted as a
potential barriers for GPs’ behavior change. Interestingly the
basement data from previous study demonstrated that GPs’
work place had direct effects on their professional needs and
also on their readiness to change and learn more about specific
courses (P11, P4).
Shortage of time: Inadequate time is an issue that was raised
by both groups of GPs’ from two extremes regarding barriers of
behavior change. But their explanation of this process was var-
ied. The ones who had changed their performance believed that
due to an increased patient satisfaction the total number of their
patients will increase (P3). In contrast, others who worked in
the crowded work places such as emergency wards, need to
spend more time to explore depression which they thoughts it
As confirmed in our study, time shortage is commonly de-
scribed as a barrier to adherence by more than 10% of GPs’
who participated on their study (3). Other researchers found the
same issue which has been arisen as barrier, due to the nature of
the depression disorder, for eliciting the symptoms from pa-
tients there is a need to dedicate more time than other disorders
and it will be increased socio-economic deficit of physician
(Chew-Graham, Mullin, May, Hedley, & Cole, 2002; Pierce &
Strengths and limitations of this study: This study has some
limitations. Firstly, to transfer the results to other countries, the
context of the Iranian healthcare system has to be taken into
account. Secondly, the rather small number of participants can
be seen as a limitation. The interviews were carried out until no
new information was added, which can be seen as a strength,
even if it is probable that the reason for reaching saturation with
a rather small number of participants might be related to the
fact that they were recruited from the RCT of a previous study.
On the other hand, since the participants had been part of an
educational intervention with a follow-up, they were engaged
and their characteristics were known which guaranteed a broad
view of the issues in focus. Thirdly, all participating GPs had
more than 10 years’ of experience, which could be seen as a
limitation even though GPs with more experience might have a
deeper understanding of the questions probed in this study. One
of the strengths in this study was that all authors were engaged
in the analysis and their different experiences made it possible
to challenge each other’s assumptions and constantly return to
the data for confirmation of interpretations.
An additional strength of the current study was the use of
sampling method based on the previous contextual findings of
previous studies according to the “stages of change theory”.
The previous results were confirmed through the current study
which appears to approve the credibility of the data.
To make complex changes in the physicians’ performance,
we need to overcome potential barriers at various levels (Grol
& Wensing, 2004). Common CME programs do not have sci-
entific design based on the behavior change theory and also
they do not explore participants’ perceptions and performance
following attending in those activities. In order to make them
more effective, there is a need to deepen the understanding of
GPs’ experience regarding the obstacles of behavior change.
Otherwise, CME providers could not be able to estimate the
potential barriers of behavior change. CME organizers should
take it into account that the nature of individual and contextual
factors (Micro level)—Educational, professional, Psychological
disorders and Work place issues—to design a successful CME
intervention and utilize underpinning and testable theories such
as the “stages of change”.
Amin, Z. (2000). Theory and practice in continuing medical education.
Annals of the Academy of Medic ine, Sin gapore, 29, 498-502.
Chew-Graham, C. A., Mullin, S., May, C. R., Hedley, S., & Cole, H.
(2002). Managing depression in primary care: Another example of
the inverse care law? Family Practice, 19, 632-637.
Davis, D. A., Thomson, M. A., Oxman, A. D., & Haynes, R. B. (1995).
Changing physician performance. JAMA: The Journal of the Ameri-
can Medical Association, 274, 700-705.
M. SHIRAZI ET AL.
Open Access 31
Diner, B. M., Carpenter, C. R., O’Connell, T., Pang, P., Brown, M. D.,
Seupaul, R. A., Mayer, D., et al. (2007). Graduate medical education
and knowledge translation: Role models, information pipelines, and
practice change thresholds. Academic Emergency Medicine, 14, 1008-
Dogra, N., Höschl, C., Moussaoui, D., Gask, L., Coskun, B., & Baron,
D. (2010). Developing a medical student curriculum in psychiatry. In
L. Gask, B. Coskun, & D. A. Baron (Eds.), Teaching Psychiatry:
Putting Theory into Practice (pp. 27-46), Hoboken, NJ: Wiley.
Elo, S., & Kyngäs, H. (2008). The qualitative content analysis process.
Journal of advanced nursing, 62, 107-115.
Grol, R., & Wensing, M. (2004). What drives change? Barriers to and
incentives for achieving evidence-based practice. The Medical Jour-
nal of Australia, 180, S57.
Hannes, K., Leys, M., Vermeire, E., Aertgeerts, B., Buntinx, F., &
Depoorter, A.-M. (2005). Implementing evidence-based medicine in
general practice: A focus group based study. BMC Family Practice,
6, 37. http://dx.doi.org/10.1186/1471-2296-6-37
Jewell, D. (2003). How to change clinical behaviour: No answers yet.
The British Journal of General Practice, 53, 266.
Krippendorff, K. (2004). Book review: Content analysis: An introduc-
tion to its methodology (2nd ed.). Organizational Research Methods,
Kvåle, K. (2007). Do cancer patients always want to talk about difficult
emotions? A qualitative study of cancer inpatients communication
needs. European Journal of Oncology Nursing, 11, 320-327.
Lecrubier, Y. (2007). Widespread underrecognition and undertreatment
of anxiety and mood disorders: Results from 3 European studies. The
Journal of Clinical Psychia t ry , 68, 36-41.
Marandi, A. (1996). Integrating medical education and health services:
The Iranian experience. Med Educ, 30, 4-8.
Marinopoulos, S. S., Dorman, T., Ratanawongsa, N., Wilson, L. M.,
Ashar, B. H., Magaziner, J. L., Qayyum, R., et al. (2007). Effective-
ness of continuing medical education. Evidence Reports/Technology
Assessments, 149, 1-69.
Mitchell, A. J., Vaze, A., & Rao, S. (2009). Clinical diagnosis of de-
pression in primary care: A meta-analysis. The Lancet, 374, 609-619.
Oxman, A. D., Thomson, M. A., Davis, D. A., & Haynes, R. B. (1995).
No magic bullets: A systematic review of 102 trials of interventions
to improve professional practice. CMAJ: Canadian Medical Associa-
tion Journal, 153, 1423.
Palmquist, M. (2010). Writing guide: Content analysis. Fort Collins,
CO: Colorado State University.
Pellegrino, E. D. (2002). Professionalism, profession and the virtues of
the good physician. Mount Sinai Jo urnal of Medicine, 69, 378-384.
Pierce, D., & Gunn, J. (2007). GPs’ use of problem solving therapy for
depression: A qualitative study of barriers to and enablers of evi-
dence based care. BMC Family Practice, 8, 24.
Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In
search of how people change. Applications to Addictive Behaviours,
Pope, C., Van Royen, P., & Baker, R. (2002). Qualitative methods in
research on healthcare quality. Quality and Safety in Health Care, 11,
Rimer, B. K., & Glanz, K. (2005). Theory at a glance: A guide for
health promotion practice. Bethesda, MD: US Department of Health
and Human Services, National Institutes of Health, National Cancer
Shirazi, M., Gandomkar, R., Ponzer, S., & Silén, C. (2013). Exploring
the macro level barriers that affect Iranian GPs’ diagnosis and man-
agement of depression disorders. European Journal for Person Cen-
tered Healthcare, 1. (in Press) www.bjll.org/index.php/ejpch
Shirazi, M., Lonka, K., Parikh, S. V., Ristner, G., Alaeddini, F.,
Sadeghi, M., & Wahlstrom, R. (2011). A tailored educational inter-
vention improves doctor’s performance in managing depression: A
randomized controlled trial. Journal of Evaluation in Clinical Prac-
tice, 19, 16-24. http://dx.doi.org/10.1111/j.1365-2753.2011.01761.x
Shirazi, M., Assadi, S. M., Sadeghi, M., Zeinalo o, A. A., Kashani, A. S.,
Arbabi, M., Wahlstrom, R., et al. (2007). Applying a modified Pro-
chaska’s model of readiness to change for general practitioners on
depressive disorders in CME programmes: Validation of tool. Jour-
nal of Evaluation in Clinical Pract ice, 13, 298-302.
Shirazi, M., Parikh, S. V., Alaeddini, F., Lonka, K., Zeinaloo, A. A.,
Sadeghi, M., Wahlstrom, R., et al. (2009). Effects on knowledge and
attitudes of using stages of change to train general practitioners on
management of depression: A randomized controlled study. Canadian
Journal of Psychiatry, 54, 693-700.
Shirazi, M., Sadegh i, M., E mami, A., Kashan i, A. S., Pa rikh, S., Alaed-
dini, F., Wahlstrom, R., et al. (2011). Training and validation of stan-
dardized patients for unannounced assessment of physicians’ man-
agement of depression. Academic Psychiatry, 35, 382-387.
Shirazi, M., Zeinaloo, A., Parikh, S., Sadeghi, M., Taghva, A., Arbabi,
M., Wahlstrom, R., et al. (2008). Effects on readiness to change of an
educational intervention on depressive disorders for general physi-
cians in primary care based on a modified Prochaska model—A ran-
domized controlled study. Family Practice, 25, 98-104.
Shirazi, M., Zeinaloo, A., Sabouri, K., & Alaedini, F. (2004). Assessing
the gap between current and desirable needs in TUMS CME Unit:
Participants viewpoints. Iranian Journal of Medical Education, 5,
Westbrook, L. (1994). Qualitative research methods: A review of major
stages, data analysis techniques, and quality controls. Library & In-
formation Science Research, 1 6 , 241-254.
Wilhelm, K., Brownhill, S., Harris, J., & Harris, P. (2006). Depres-
sion—What should the doctor ask? Australian Family Physician, 35,
Wilson, S., Eagles, J. M., Platt, J. E., & McKenzie, H. (2007). Core
undergraduate psychiatry: What do non-specialists need to know?
Medical Education, 41, 698-702.
World Health Organization (2004). Prevention of mental disorders:
Effective interventions and policy options: Summary report. Geneva:
World Health Organization
Zhang, Y. (2012). College students’ uses and perceptions of social
networking sites for health and wellness informatio n.