Methods for questionnaire design: a taxonomy linking procedures to test goals

BACKGROUND

In the clinical field, the use of questionnaires is ubiquitous, and many different methods for constructing them are available. The reason for using a specific method is usually lacking, and a generally accepted classification of methods is not yet available. To guide test developers and users, this article presents a taxonomy for methods of questionnaire design which links the methods to the goal of a test.

METHODS

The taxonomy assumes that construction methods are directed towards psychometric aspects. Four stages of test construction are distinguished to describe methods: concept analysis, item production, scale construction, and evaluation; the scale construction stage is used for identifying methods. It distinguishes six different methods: the rational method utilizes expert judgments to ensure face validity. The prototypical method uses prototypicality judgments to ensure process validity. In the internal method, item sets are selected that optimize homogeneity. The external method optimizes criterion validity by selecting items that best predict an external criterion. Under the construct method theoretical considerations are used to optimize construct validity. The facet method is aimed at optimizing content validity through a complete representation of the concept domain.

CONCLUSION

The taxonomy is comprehensive, constitutes a useful tool for describing procedures used in questionnaire design, and allows for setting up a test construction plan in which the priorities among psychometric aspects are made explicit.

Use of the Brief Shame and Guilt Questionnaire in Deaf and Hard of Hearing Children and Adolescents

No assessment tools are available to measure shame and guilt in children who are deaf or hard of hearing (DHH), while these self-conscious emotions might play a role in the frequently noted social and behavioral problems in this group. Therefore, the aim of this study was to validate the Brief Shame and Guilt Questionnaire (BSGQ) in DHH children. In addition, we examined associations of shame and guilt with social anxiety, self-esteem, delinquency, and psychopathic behaviors. A sum of 225 hearing (M_age = 11.62 years) and 108 DHH (M_age = 11.82 years) participants completed the self-report BSGQ. Multigroup confirmatory factor analysis confirmed the two-factor structure (i.e., shame and guilt) of the BSGQ in the DHH group. Measurement invariance was established across both groups. However, the DHH group reported lower levels of self-conscious emotions in comparison with the hearing group. The BSGQ showed good concurrent validity, where shame was associated with higher levels of social anxiety and lower levels of self-esteem, and guilt was associated with lower levels of delinquency and psychopathic behavior in both groups. Future research should investigate the potential behavioral consequences of lower reported levels of self-conscious emotions in DHH youth.

An Eight-year Follow-up to a Randomized Clinical Trial of Participant Satisfaction with Three Types of Mandibular Implant-retained Overdentures

Studies have shown that mandibular implant overdentures significantly increase satisfaction and quality of life of edentulous elders. Improved chewing ability appears to have a positive impact on nutritional state. Therefore, it is important to determine the best design of this prosthesis over the long term. In this randomized controlled trial, three groups of edentulous participants with atrophic mandibles wore 3 types of implant overdentures. During an eight-year follow-up, only seven of the 110 participants had dropped out of this study. Almost all participants were still satisfied with their overdentures. Participant satisfaction concerning retention and stability of the mandibular overdenture had decreased significantly in the two-implant ball attachment group, whereas the opinion of participants in the single- and triple-bar groups was still at the same level. The long-term results suggest that a mandibular overdenture retained by 2 implants with a single bar may be the best treatment strategy for edentulous people with atrophic ridges.

The Nonverbal Assessment of Personality in Five Cultures

The Nonverbal Personality Questionnaire, a structured nonverbal measure of Murray’s needs, and the Personality Research Form, a standard verbal measure of the same traits, were administered to respondents in five countries: Canada, England, the Netherlands, Norway, and Israel. Analysis of the nonverbal scales showed generally good levels of internal consistency, reliability, and convergent validity when compared against their verbal counterparts. Furthermore, meta-analyses of factor structure of both the nonverbal and verbal inventories showed a very clear organization to the personality traits assessed. The factors, based on data combined across cultures, resembled the Big Five factors of personality.

Reactive/proactive aggression and affective/cognitive empathy in children with ASD

The main aim of this study was to examine the extent to which affective and cognitive empathy were associated with reactive and proactive aggression, and whether these associations differed between children with an Autism Spectrum Disorder (ASD) and typically developing (TD) children. The study included 133 children (67 ASD, 66 TD, Mage=139 months), who filled out self-report questionnaires. The main findings showed that the association between reactive aggression and affective empathy was negative in TD children, but positive in children with ASD. The outcomes support the idea that a combination of poor emotion regulation and impaired understanding of others' emotions is associated with aggressive behavior in children with ASD.

The predictive validity of criminogenic needs for male and female offenders: comparing the relative impact of needs in predicting recidivism

Most instruments used to assess offenders' risk of recidivism were developed and validated on male samples. Use of these instruments with female offenders is, however, common practice. This use with female offenders implies the assumption that the risk of recidivism can be predicted on the basis of the same risk factors for women as for men. Yet, this implied gender-neutrality of offender risk instruments has been the topic of much debate. This study compared criminogenic needs in male and female offenders and their relevance in predicting recidivism. A large sample of male and female offenders (N = 16,239) charged with a range of index offenses was studied. Results mainly support the gender neutrality of existing offender risk and needs assessment. However, results do suggest that some criminogenic needs may indeed have a different impact on recidivism for men and women. Problems with accommodation, education and work, and relationships with friends were more strongly correlated to general recidivism in men than in women. For women, difficulties with emotional well-being had a stronger correlation with recidivism than for men. In addition, relative to all other criminogenic needs, problems with emotional well-being were more important for women than for men in predicting general as well as violent recidivism. However, because the bivariate correlation for female offenders between emotional difficulties and recidivism is weak (as it is for male offenders), the question remains whether the relative importance of emotional difficulties in predicting recidivism in women actually has clinical relevance.

Pathways underlying somatic complaints in children and adolescents who are deaf or hard of hearing

Frequent somatic complaints are not only a problem in themselves but also related to other difficulties. So far, no conclusive findings have been reported about the prevalence of and factors underlying these complaints in children and adolescents who are deaf or hard of hearing (DHH). Such information would be valuable for prevention and intervention. Therefore, the aim of this study was to examine the prevalence of somatic complaints and their relation with emotional functioning in DHH youngsters, as compared with hearing youngsters. This was established by assessing how somatic complaints, mood states, and sense of coherence were experienced by 186 Dutch participants (mean age = 11;07 years). DHH and hearing groups were compared using multivariate analysis of variance and structural equation modeling. The results showed that somatic complaints were reported equally often for both groups, but that the pathways leading to these complaints were partly different. Only in DHH participants were feelings of fear associated with more somatic complaints. The results suggest that DHH children and adolescents would benefit from support in the regulation of fear and its causes. Other aspects affecting adjustment outcomes of DHH youngsters were education type and communication mode.

Emotion regulation and internalizing symptoms in children with autism spectrum disorders

The aim of this study was to examine the unique contribution of two aspects of emotion regulation (awareness and coping) to the development of internalizing problems in 11-year-old high-functioning children with an autism spectrum disorder (HFASD) and a control group, and the moderating effect of group membership on this. The results revealed overlap between the two groups, but also significant differences, suggesting a more fragmented emotion regulation pattern in children with HFASD, especially related to worry and rumination. Moreover, in children with HFASD, symptoms of depression were unrelated to positive mental coping strategies and the conviction that the emotion experience helps in dealing with the problem, suggesting that a positive approach to the problem and its subsequent emotion experience are less effective in the HFASD group.

Tooth display and lip position during spontaneous and posed smiling in adults

OBJECTIVE

To analyze differences in tooth display, lip-line height, and smile width between the posed smiling record, traditionally produced for orthodontic diagnosis, and the spontaneous (Duchenne) smile of joy.

MATERIAL AND METHODS

The faces of 122 male participants were each filmed during spontaneous and posed smiling. Spontaneous smiles were elicited through the participants watching a comical movie. Maxillary and mandibular lip-line heights, tooth display, and smile width were measured using a digital videographic method for smile analysis. Paired sample t-tests were used to compare measurements of posed and spontaneous smiling.

RESULTS

Maxillary lip-line heights during spontaneous smiling were significantly higher than during posed smiling. Compared to spontaneous smiling, tooth display in the (pre)molar area during posed smiling decreased by up to 30%, along with a significant reduction of smile width. During posed smiling, also mandibular lip-line heights changed and the teeth were more covered by the lower lip than during spontaneous smiling.

CONCLUSIONS

Reduced lip-line heights, tooth display, and smile width on a posed smiling record can have implications for the diagnostics of lip-line height, smile arc, buccal corridors, and plane of occlusion. Spontaneous smiling records next to posed smiling records are therefore recommended for diagnostic purposes. Because of the dynamic nature of spontaneous smiling, it is proposed to switch to dynamic video recording of the smile.

Validity of the visual analogue scale as an instrument to measure self-efficacy in resuscitation skills

CONTEXT

Self-efficacy is an important factor in many areas of medical education, including self-assessment and self-directed learning, but has been little studied in resuscitation training, possibly because of the lack of a simple measurement instrument.

OBJECTIVE

We aimed to assess the validity of a visual analogue scale (VAS) linked to a single question as an instrument to measure self-efficacy with respect to resuscitation skills by comparing the VAS with a questionnaire and using known-groups comparisons.

METHODS

We developed questionnaires to measure self-efficacy for a number of resuscitation tasks and for computer skills. These were compared with VASs linked to a single question per task, using a multi-trait, multi-method matrix. We also used known-groups comparisons of self-efficacy in specific professional groups.

RESULTS

There was good correlation between the questionnaires and the VASs for self-efficacy for specific resuscitation tasks. There was a less clear correlation for self-efficacy for paediatric resuscitation overall. There was no correlation between self-efficacy for resuscitation and computer tasks. In specific professional groups, measured self-efficacy accorded with theoretical predictions.

CONCLUSIONS

A VAS linked to a single question appears to be a valid method of measuring self-efficacy with respect to specific well defined resuscitation tasks, but should be used with caution for multi-faceted tasks.

The children's DEBQ for assessment of restrained, emotional, and external eating in 7- to 12-year-old children

OBJECTIVE

Construct an age adapted version of the Dutch Eating Behaviour Questionnaire (DEBQ) for measurement of restrained, emotional and external eating in 7- to 12-year-old children: the DEBQ-C.

METHOD

The DEBQ-C was constructed and tested for its reliability, factorial validity, factorial invariance for sex, overweight (BMI-status), and age, and correlations with measures for unhealthy life style in one sample (382 boys and 387 girls). In a second sample (252 boys and 263 girls) correlations were obtained with measures for body dissatisfaction and parental feeding styles. Single and multigroup confirmatory factor analyses were used.

RESULTS

The fit measures for the three factor model and the factorial invariance models with respect to sex, BMI-status, and age were satisfactory. In the (sub) samples of the 7- to 12-year-olds Cronbach's alpha's ranged from .73 to .82 and there were satisfactory correlations (p < .01) with other measures.

CONCLUSION

The DEBQ-C should provide a useful measure for young children's emerging dietary restraint and overeating tendencies. The low prevalence of emotional eating indicates that most young children show the natural reaction to emotional stressors (loss of appetite when feeling lonely, depressed or afraid) and that emotional (over) eating at this age is quite abnormal.

Smile attractiveness. Self-perception and influence on personality

OBJECTIVES

To investigate self-perception of smile attractiveness and to determine the role of smile line and other aspects correlated with smile attractiveness and their influence on personality traits.

SUBJECTS AND METHODS

Participants judged their smile attractiveness with a patient-specific questionnaire. The questionnaire contained a spontaneous smiling photograph of the participant. Objective smile-line height was measured using a digital videographic method for smile analysis. Personality was assessed with the Dutch Personality Index.

RESULTS

Cronbach's alpha for the smile judgment questionnaire was .77. The results showed that size of teeth, visibility of teeth, and upper lip position were critical factors in self-perception of smile attractiveness (social dimension). Color of teeth and gingival display were critical factors in satisfaction with smile appearance (individual dimension). Participants, smiling with teeth entirely displayed and some gingival display (two to four millimeters), perceived their smile line as most esthetic. Smiles with disproportional gingival display were judged negatively and correlated with the personality characteristics of neuroticism and self-esteem. Visibility and position of teeth correlated with dominance.

CONCLUSION

The results of this research underpin the psychosocial importance and the dental significance of an attractive smile.

Digital videographic measurement of tooth display and lip position in smiling and speech: Reliability and clinical application

INTRODUCTION

Tooth display and lip position in smiling and speech are important esthetic aspects in orthodontics and dentofacial surgery. The spontaneous smile and speech are considered valuable diagnostic criteria in addition to the posed social smile. A method was developed to measure tooth display in both smile types and speech.

METHODS

The faces of 20 subjects were individually filmed. Spontaneous smiles were elicited by a comical movie. The dynamics of the spontaneous smile were captured twice with a digital video camera, transferred to a computer, and analyzed on videoframe level. Two raters were involved. Posed social smiles and speech records were also included. Reliability was established by means of the generalizability theory. It incorporated rater, replication, and selection facets.

RESULTS

Generalizability coefficients ranged from .99 for anterior teeth to .80 for posterior teeth. The main sources of error were associated with rater and selection facets. The replication facet was a minor source of error.

CONCLUSIONS

This videographic method is reliable for measurement of tooth display and lip position in spontaneous and posed smiling and speaking. Application of the method is warranted especially when obtaining an emotional smile is difficult, such as cleft lip and palate or disfigured patients.

Project quality rating by experts and practitioners: experience with Preffi 2.0 as a quality assessment instrument

Preffi 2.0 is an evidence-based Dutch quality assessment instrument for health promotion interventions. It is mainly intended for both planning and assessing one's own projects but can also be used to assess other people's projects (external use). This article reports a study on the reliability of Preffi as an external quality assessment instrument. Preffi is used to assess quality at three levels: (i) specific criteria, (ii) clusters of criteria and (iii) entire projects. The study compared Preffi-based assessments of 20 projects by three practitioners with their intuitive assessments of the same projects and with assessments by three experts, which were to be used as external criteria. The intuitive assessments only related to the cluster and project levels. Our main hypothesis was that intuitive assessments by practitioners would be less reliable and accurate than their Preffi-based assessments and the experts' assessments. On the whole, we failed to confirm this hypothesis: the experts' assessments proved less reliable and accurate than the practitioners' intuitive and Preffi-based assessments and differed too much from each other to be used as external criteria. The Preffi-based assessments by the practitioners had an acceptable generalizability coefficient (G) and accuracy (standard error of measurement). At the level of the entire project, two assessors are needed to produce sufficiently reliable and accurate assessments, whereas three are needed for assessment at cluster level. The study also showed that different assessors use different perspectives and base their assessment on a variety of aspects. This was regarded as inevitable and even useful by the assessors themselves. Discussions between assessors are important to achieve consensus. The article suggests some improvements to Preffi to further increase its reliability.

The oral pigmentation chart: a clinical adjunct for oral pigmentation in removable prostheses

PURPOSE

Non-Caucasian patients exhibit different characteristics of oral pigmentation and may request that the acrylic resin parts of their dentures look natural, simulating the original mucosal color. Tooth loss, bone resorption, and lack of attached gingiva may, however, make it difficult to determine what the original pigmentation was like. The purpose of this investigation was to study the distribution in oral pigmentation around the natural dentition in non-Caucasians, in a preliminary effort to classify these variations into a chart of oral pigmentation, and to analyze its reproducibility.

MATERIALS AND METHODS

For the study, 106 dentate non-Caucasians were selected from two universities: ACTA (patient group) and UCLA (nonpatient group). A pigmentation scheme was devised on the basis of half of the participants, and the others were divided into categories by four observers independently. Cohen's kappa was then calculated.

RESULTS

On the basis of information obtained from the ACTA participants, six categories of mucosal pigmentation were defined. The kappa statistics for the four observers varied from .58 to .79 for intraobserver agreement and from .15 to .55 for interobserver agreement.

CONCLUSION

The Oral Pigmentation Chart is a simple device that makes it possible to simulate oral pigmentation in the acrylic resin parts of removable dentures. The reproducibility appeared to be acceptable when clinician and dental technician were calibrated. Patients can be offered a choice of the kind of pigmentation geography they want in their removable prostheses.

Measuring Strength of Motivation for Medical School

PURPOSE

Students vary in their strength of motivation to start and pursue medical training. This study was conducted to investigate the psychometric properties of a Strength of Motivation for Medical School (SMMS) questionnaire.

METHOD

The questionnaire was designed using an iterative method. The instrument was applied to medical students (N= 296) at the start of medical school and to potential applicants (N= 147). The stability of the concept over a six month's time and associations with other motivation measures were studied. A separate group of potential applicants and their parents (N= 169) were asked to validate the items of the questionnaire.

RESULTS

Cronbach's alpha reliability of .79 was found. Test-retest reliability of SMMS-scores with a six months interval was .71. Little to no association with specific dimensions of motivation was found, except for a negative correlation with 'ambivalence towards studying'. SMMS-scores were associated with potential applicants' plans to apply for medical school (Spearman's rho .65) and differentially with potential applicants' and their parents' judgements of item validities (.13 to .57).

CONCLUSIONS

The SMMS-questionnaire appears to be a reliable and valid instrument to measure strength of motivation for medical training in students who have just entered medical school. It may be used to evaluate the validity of selection procedures and to identify associated variables that could be used in selection procedures.

Generalizability of a study sample assessment procedure for entrance selection for medical school

To optimize the validity of instruments for the selection of students for admission to medical school a close resemblance between selection criteria and activities in medical school and patient care is proposed. A study sample assessment procedure (SSAP), focusing on independent studying, collaboration with peers and providing information to standardized patients, was designed and has been applied as a selection tool at UMC Utrecht Medical School since 2001. The interviews with standardized patients are observed and rated on the quality of information provided and the quality of communication. This study investigates the psychometric properties of this observational procedure. Generalizability theory was applied to estimate the reliability of the SSAP and to compare it with other procedures carried out in the same populations, such as the rating of application forms and a structured interview procedure. Data from three years were analysed. The G-coefficients for the SSAP (0.84 to 0.90) were higher than those for the interview and the application form (0.74 to 0.83 and 0.53 to 0.61 respectively). In conclusion, the SSAP appears to be a feasible and reliable procedure. The number of raters could, if necessary, be reduced from three to two.

Effect of GBR and fixture installation on gingiva and bone levels at adjacent teeth

Guided bone regeneration (GBR) is frequently used in oral implantology. It is unclear to what extent GBR affects the periodontium of adjacent teeth. Therefore, the present study quantifies changes in the proximal gingiva and bone levels at these teeth in 30 patients. Staged surgery involved a standard GBR treatment, randomly using resorbable membranes with a bone substitute or non-resorbable membranes with or without a bone substitute, followed by fixture installation at 6 months and abutment connection a further 6 months later. The data were sampled at each surgery and analysed using MANOVA. Twelve months after GBR, there was on average a small but statistically significant amount of proximal gingival recession (0.75 mm) and bone resorption (0.34 mm) observed, of which 50% was the result of GBR surgery. No significant differences were found between the different GBR treatment modalities. It is concluded that GBR treatment may have a small negative effect on the levels of the free gingival margin and alveolar bone at adjacent teeth, which is in most patients not clinically relevant.

Reproducibility and accuracy of automated probe measurements of gingiva and bone levels on stone casts following guided bone regeneration treatment

OBJECTIVES

For evidence-based evaluation of guided bone regeneration (GBR), accurate registration of changes in gingiva and bone levels is needed. A new method is introduced and evaluated.

METHODS

In a clinical trial with 30 patients, alginate impressions of the surgical area including the interproximal gingiva and alveolar bone at the adjacent teeth were made in duplicate prior to and during GBR surgery, fixture installation and abutment connection. Poured in hard stone, the casts were used for repeated measurements of the level of the free gingival margin and the alveolar bone with an automated probe (Florida disc-probe(R)), using the incisal edge as a fixed reference point. The reproducibility and accuracy of these measurements were evaluated by means of the Intraclass Correlation Coefficients and Generalizability Theory. The effect of treatment was evaluated by multivariate analysis of variance.

RESULTS

Generalizability Theory indicated a high accuracy of the gingiva- and bone-level measurements: the Intraclass Correlation Coefficients for gingiva and bone levels were 0.99 and 0.98, respectively. The intra-cast reproducibility was 0.09+/-0.07 mm (mean+/-SD) and the inter-cast reproducibility was 0.10+/-0.09 and 0.20+/-0.07 mm for gingiva and bone levels, respectively. Clinical applicability is demonstrated by the fact that manova revealed on average a small but highly significant (p=0.001) effect of the staged surgical intervention on the gingiva and bone levels at the adjacent teeth.

CONCLUSION

It is concluded that the presented method makes it possible to evaluate reproducibly and accurately changes in gingiva and bone levels for GBR studies.

Detection of genetically divergent clone mates in apomictic dandelions

This study aims to identify genetically diverged clone mates in apomictic dandelions. Clone mates are defined as individuals that may have diverged as a result of mutation accumulation and that have undergone only clonal reproduction since their most recent common ancestor. Based on distinctive morphology and an aberrant and rare chloroplast haplotype, northwest European individuals of Taraxacum section Naevosa are well suited for the detection of clonal lineages in which mutation has occurred. In the case of strictly clonal reproduction, nuclear genetic variability was expected to be hierarchically organized. Nucleotide polymorphisms in internal transcribed spacer (ITS) sequences, however, were incompatible with a clonal structure of the Norwegian individuals, probably due to persistent ancestral polymorphisms that pre-date the origin of the Naevosa clone. This interpretation is supported by the presence of ITS variants in section Naevosa that were also found in distantly related dandelions. In contrast to the ITS sequence data, amplified fragment length polymorphisms (AFLPs), isozymes and microsatellites strongly supported the contention of prolonged clonal reproduction and mutation accumulation in Norwegian Naevosa. Because these markers are generally considered to be more variable and more rapidly evolving than ITS sequences, mutations in these markers probably evolved after the origin of the clone. Within the Norwegian clone, a surprising number of markers distinguished the clone mates. As a consequence, incorporation of mutation in the detection of clone mates is anticipated to have a big impact on estimates of size, geographical range and age of clones as well as on experimental designs of studies of clonal plants.

The decisional conflict scale: further validation in two samples of Dutch oncology patients

The importance of patient involvement in medical decision making is indisputable. Yet, decision making concerning medical treatment options is a difficult task for most patients. In order to study decision-making processes in health care, O'Connor developed the decisional conflict scale (DCS). The DCS assesses the level of 'decisional conflict' that patients experience while making health care decisions, and encompasses the following three subscales: (1) uncertainty about choosing among alternatives; (2) factors contributing to uncertainty; (3) perceived effectiveness of the decision. The aim of the present study is to investigate the reliability and validity of the Dutch version of the DCS. A written version of the DCS was administered in two samples of Dutch cancer patients. One sample consisted of cancer patients faced with the decision whether or not to undergo palliative chemotherapy (N=29). The other sample included women with early stage breast cancer who had to choose between mastectomy or lumpectomy followed by radiation therapy (N=141). The response rates were 76% and 91%, respectively. The reliability coefficients of the three subscales were 0.52, 0.80, 0.84, and 0.74, 0.83, 0.83 in the two samples, respectively. Construct validity was partly supported. Criterion validity was substantiated. In evaluating the factorial validity, it was found that the original three-factor model had to be rejected (chi(2)(87)=293, root mean square error of approximation (RMSEA)=0.137). A subsequent exploratory factor analysis suggested an alternative four-factor model. The psychometric properties of the DCS were partly confirmed in Dutch cancer patients. Improved 'wording' of certain items, e.g. to avoid double negatives, could further increase the factorial validity of the DCS. Then, this scale may be a valuable tool for studies that address the quality of medical decision making.

Assessment of medical students' communicative behaviour and attitudes: estimating the reliability of the use of the Amsterdam attitudes and communication scale through generalisability coefficients

It is widely accepted that adequate attitudes and communicative skills are among the essential objectives in medical education. The Amsterdam attitude and communication scale (AACS) was developed to assess communicative skills and professional attitudes of medical students. More specifically, it was designed to evaluate the clinical behaviour of clerks to establish their suitability for the medical profession. The AACS covers nine dimensions. Moreover, an overall judgement of the student's performance is included. The present paper reports first results on the reliability of the use of the AACS. Data were collected in the course of an AACS training programme for future judges: senior medical and nursing staff members (N=98). Participants judged three videotapes of clerks interviewing patients at the bedside. For the assessment of videotapes, the first four dimensions of the AACS and the overall judgement are relevant. By applying Generalisability Theory to the training data we can forecast the reliability of the AACS in practice and gain insight in the number of raters that is needed to achieve sufficient reliability in clinical practice. If clerk behaviour is rated by six judges, summative assessment is sufficiently precise, i.e. <0.25. When using the full AACS, covering 10 items, the same number of judges is needed. Scores on individual AACS items are not sufficiently reliable. In conclusion, the results indicate that students' behaviour can be evaluated in a reliable manner using the AACS as long as enough judges and items are involved.

Decision support for patients with early-stage breast cancer: effects of an interactive breast cancer CDROM on treatment decision, satisfaction, and quality of life

PURPOSE

To investigate the effects of the Interactive Breast Cancer CDROM as a decision aid for breast cancer patients with a choice between breast conserving therapy (BCT) and mastectomy (MT).

PATIENTS AND METHODS

Consecutive patients with stage I and II breast cancer were enrolled. A quasi-experimental, longitudinal, and pretest/posttest design was used. Follow-up was scheduled 3 and 9 months after discharge from the hospital. Control patients (n = 88) received standard care (oral information and brochures). The CDROM was provided to patients in the experimental condition (n = 92) as a supplement to standard procedures. Outcome variables were treatment decision, satisfaction, and quality of life (QoL).

RESULTS

No effect on treatment decision was found. CDROM patients expressed more general satisfaction with information at 3 and 9 months (95% confidence interval for the difference (d) between the means (d: 4.1 to 12.5 and 5.7 to 14.2 respectively). CDROM patients were also more satisfied with their treatment decision at 3 and at 9 months (d: 0.1 to 0.4; 0.2 to 0.5). Moreover, at 9 months, CDROM patients were more satisfied with breast cancer-specific information (d: 0.9 to 16.5), the decision-making process (d: 0.1 to 0.4), and communication (d: 0.2 to 11.0). At 3 and 9 months, a positive effect was found on general health (d: 0.2 to 14.5 and 0.3 to 15.0). Moreover, at 9 months, CDROM patients reported better physical functioning (d: 5.1 to 19.8), less pain (d: -17.9 to -4.5), and fewer arm symptoms (d: -14.1 to -0.5).

CONCLUSION

The Interactive Breast Cancer CDROM improved decision making in patients with early-stage breast cancer with a choice between BCT and MT, as evaluated in terms of patients' satisfaction and QoL.

Hairpins involving both inverted and direct repeats are associated with homoplasious indels in non-coding chloroplast DNA of Taraxacum (Lactuceae: Asteraceae)

Sequence variation in 2.2 kb of non-coding regions of the chloroplast genome of eight dandelions (Taraxacum: Lactuceae) from Asia and Europe is interpreted in the light of the phylogenetic signal of base substitutions vs. indels (insertions-deletions). The four non-coding regions displayed a total of approximately 30 structural mutations of which 9 are potentially phylogenetically informative. Insertions, deletions, and an inversion were found that involved consecutive stretches of up to 172 bases. When compared to phylogenetic relationships of the chloroplast genomes based on nucleotide substitutions only, many homoplasious indels (33%) were detected that differed considerably in length and did not comprise simple sequence repeats typically associated with replication slippage. Though many indels in the intergenic spacers were associated with direct repeats, frequently, the variable stretches participated in inverted repeat stabilized hairpins. In each intergenic spacer or intron examined, nucleotide stretches ranging from 30 to 60 bp were able to fold into stabilized secondary structures. When these indels were homoplasious, they always ranked among the most stabilized hairpins in the non-coding regions. The association of higher order structures that involve both classes of repeats and parallel structural mutations in hot spot regions of the chloroplast genome can be used to differentiate among mutations that differ in phylogenetic reliability.

Quality of life after total colectomy with ileorectal anastomosis or proctocolectomy and ileal pouch-anal anastomosis for familial adenomatous polyposis

BACKGROUND

Knowledge of postoperative health status is important in decision-making about the type of operation necessary in patients with familial adenomatous polyposis (FAP). This study compared the quality of life (QoL) between patients with an ileorectal anastomosis (group 1) and those with an ileal pouch-anal anastomosis (group 2).

METHODS

QoL was assessed with both a generic questionnaire (Short Form-36 Health Survey; SF-36) and a disease-specific questionnaire (European Organization for Research and Treatment of Cancer Colorectal QoL Questionnaire; EORTC QLQ-CR38). The SF-36 consists of 36 items representing eight generic health domains, and the EORTC QLQ-CR38 comprises 38 items representing disease-specific health domains. Both questionnaires were distributed among 323 patients with FAP known at the Dutch Polyposis Registry who had previously undergone either operation. The results of the SF-36 were compared with the scores of age- and sex-matched respondents from the general population.

RESULTS

Some 279 patients (86 per cent), 161 in group 1 and 118 in group 2, completed the questionnaire. Generic and disease-specific QoL was the same for groups 1 and 2. The SF-36 scores of both groups were significantly lower than those of the general population.

CONCLUSION

There were no differences with respect to health status between patients in groups 1 and 2, and preference for either procedure cannot be based on QoL.

Validation of the gastrointestinal quality of life index for patients with potentially operable periampullary carcinoma

BACKGROUND

A disease-specific quality of life questionnaire is not available for patients with periampullary carcinoma, although cancer-specific questionnaires and the Gastrointestinal Quality of Life Index (GIQLI) have been used. The aim of this study was to validate the GIQLI for patients with periampullary tumours and to evaluate if subscales of the GIQLI could be identified to allow a more detailed assessment of the patients' quality of life.

METHODS

Patients with periampullary carcinoma, included in a study concerning diagnostic laparoscopy, were asked about symptoms and completed a questionnaire comprising the Medical Outcomes Study (MOS) 24 questionnaire, the GIQLI and one question of the Rotterdam Symptom Check List (RSCL). Clinical interpretation and statistical factor analysis were used to identify subscales of the GIQLI.

RESULTS

The GIQLI could be divided into four subscales, measuring physical well-being, mental well-being, digestion and defaecation. All four subscales had a good internal reliability and the construct validity was supported by the pattern of correlations with the MOS and RSCL as well as differences in subscale scores for patients with or without certain symptoms.

CONCLUSION

In patients with periampullary tumours the GIQLI can be divided into four subscales, measuring different aspects of quality of life. These subscales provide insight into the different problems affecting the patient.

Functional outcome after colectomy and ileorectal anastomosis compared with proctocolectomy and ileal pouch-anal anastomosis in familial adenomatous polyposis

OBJECTIVE

To compare the long-term functional results of ileorectal anastomosis (IRA) with those of ileal pouch-anal anastomosis (IPAA) in patients with familial adenomatous polyposis (FAP).

SUMMARY BACKGROUND DATA

In patients with FAP, hundreds of colorectal adenomas develop, and the patient will die of colorectal cancer if left untreated. The surgeon must choose between colectomy with IRA and restorative proctocolectomy with IPAA. One factor crucial to decision making is the functional outcome after either procedure. To date, studies on this issue have reported conflicting results and have been based on small series of patients.

METHODS

To assess various functional variables, a questionnaire was sent to 323 patients with FAP who underwent either IRA or IPAA and who were registered at the Netherlands Foundation for the Detection of Hereditary Tumors. The overall response rate was 86%; the responders comprised 161 patients who underwent IRA and 118 patients who underwent IPAA.

RESULTS

Patients who underwent IRA scored significantly better for daytime and nighttime stool frequency, soiling, occasional passive incontinence, flatus and feces discrimination, stool consistency, and need for antidiarrheal medication. There was no difference with regard to perianal irritation, episodes of bowel discomfort, or dietary restrictions. The functional results according to the aggregate score of the Gastro-Intestinal Functional Outcome Scale, where the items specified above were integrated (0 indicating a poor and 100 a good overall function), were significantly better in patients with an IRA (74.5) than in patients with an IPAA (66.0) (p < 0.01).

CONCLUSION

The functional outcome after IRA is significantly better than after IPAA. On the basis of these results, IRA might still be considered in patients with a mild phenotypic expression of the disease in the rectum.

Revealing response shift in longitudinal research on fatigue--the use of the thentest approach

In this study we examined whether response shift resulting from changes in internal standards occurs in cancer patients undergoing radiotherapy. Ninety-nine newly diagnosed patients undergoing radiotherapy were administered two standardized self-report measures of fatigue prior to receiving radiotherapy. After completion of radiotherapy, patients filled out these questionnaires as a conventional posttest and in reference to how they perceived themselves as they were prior to radiotherapy (a so-called 'thentest'). A transition (direct change) score on fatigue was used as a stratification measure. Patients were subsequently interviewed about their responses. The pattern of mean scores indicative of response-shift effects was found in two distinct subgroups: patients experiencing diminishing levels of fatigue and patients facing early stages of adaptation to increased levels of fatigue. Since response shift may adversely affect the results of self-reported outcomes in clinical trials or other longitudinal research, further research is very much needed.

Reasons why patients bypass their GP to visit a hospital emergency department

Knowledge about what motivates patients to visit the emergency department (ED) of a hospital for minor complaints, instead of visiting their general practitioner (GP), can help to reduce unnecessary utilization of expensive services. This paper reports on a study designed to investigate the reasons why patients visit the ED and to determine the influence of patient characteristics on specific motives. A multidimensional measurement instrument was designed to identify the motives of patients who bypass their GP and visit the ED. The instrument assessed 21 motives, all measured by means of three questions in Likert format. During a period of 1 week, all patients who visited the ED of two hospitals in Amsterdam were asked to complete a questionnaire when they were 'self-referred' with minor complaints. A total of 403 questionnaires were analysed, and the results show that motives relating to the GP play a minor role in the decision of patients to visit the ED. Profiles of two major patient groups could be identified. One group comprised patients with a high socio-economic status living in suburbs, whose motives for visiting the ED are mainly of a financial nature. Patients in the second group mainly lived in the inner-city, and preferred the expertise and facilities provided by the ED.

Compliance in dentistry: general adherence, specific adherence and perceived dental health

In this study it was attempted to replicate findings on the relationship between general and specific adherence and perceived health in the context of dental treatment. Furthermore the psychometric characteristics of a modified adherence scale for use in dental populations were investigated. A sample of 167 freshmen completed a questionnaire containing a general adherence scale (GAS) developed by DiMatteo et al. (Oncology 1992;6:50-7), a perceived health scale, a perceived dental health scale, and two items about adherence to recommendations on dental behaviour. The GAS showed adequate internal consistency. Positive correlations were found for general adherence on the one hand and for specific adherence, perceived health, and perceived dental health on the other. The results concerning the GAS and specific adherence do not correspond with the findings of DiMatteo et al. It is suggested that this discrepancy is due to the situation-specificity of adherence in combination with differences in the samples and the specific adherence measures used in both studies.

Understanding the level of fatigue in cancer patients undergoing radiotherapy

This study tests the hypothesis that a discrepancy between resources and demands explains most of the variance in fatigue in cancer patients undergoing radiotherapy. Patients (n=250) were interviewed at pretreatment, posttreatment, and at 9-month follow-up. Resources involved physical condition, neuroticism, optimism, social support, gender, age, and level of education. Demands entailed prognosis, radiotherapy dose, the effort associated with actual activity, and the patient's perception of overall burden. Regression analyses were performed, using interaction terms to operationalize the discrepancy between resources and demands. The hypothesis was not supported. At pretreatment, physical condition explained most of the fatigue, whereas, at posttreatment, both the patients' physical condition and perception of burden contributed to fatigue. At follow-up, demands did not add to the variance already explained by resources, and vice versa. Factors that contribute to the patient's physical condition before starting radiotherapy and to his/her perception of burden need to be addressed to further our understanding of their fatigue.

The Differential Predictive Validity of Two Measurements of Cognitive Ability

In this study was compared the relative predictive power of an achievement test and a self-report questionnaire for cognitive abilities in the context of prediction of educational achievement. With average grades, the multiple correlation of scores on both tests administered to a sample of 232 pupils in secondary education showed only marginal differences.

Note on Reliability and Validity of Self-Evaluation of Ability Scales

A four-scale questionnaire on self-evaluation of ability was developed, testing 402 pupils. The Differential Aptitude Test was used as the criterion for estimating validity. Values of Cronbach alpha for the Verbal, Reasoning, Spatial, and Numerical Ability scales ranged from .74 to .86. The Reasoning Ability scale lacked validity.

Taraxacum species as environmental indicators for grassland management

A classification of the microspecies of the genus Taraxacum was made in a range from low to highly dynamic habitats based on qualitative inventories of grasslands under different management conditions. After several years of constant management, a characteristic species composition occurs. Under mowing (hayfield) conditions, dandelions disappear over a period of about twenty years in a sequence where the low-dynamic species T. adamii and T. nordstedtii are the last to vanish. Different microspecies in the section Vulgaria in one field can show small differences in response to environmental conditions, even where no other directly visible indication exists. New appearance of highly dynamic species can indicate disturbance of some kind or other within a relatively short period.The classification adopted seems to be correlated with the phosphate content of the soil. Differences in two easily perceptible morphological characteristics, namely position of the outer bracts and colour of the leaf-stem, fit into the established sequence. Small changes in these characteristics indicate conditions in the field that are improving or worsening from a nature-conservation point of view. A system is introduced in which merely these two morphological characters, without further taxonomical knowledge, can be used for an evaluation of grasslands and the impact of management practice.