Use of Sociodemographic Information in Clinical Vignettes of Multiple-Choice Questions for Preclinical Medical Students

Purpose

This paper aims to characterize the use of demographic data in multiple-choice questions from a commercial preclinical question bank and determine if there is appropriate use of different distractors.

Background

Multiple-choice questions for medical students often include vignettes describing a patient's presentation to help guide students to a diagnosis, but overall patterns of usage between different types of nonmedical patient information in question stems have yet to be determined.

Methods

Three hundred eighty of 453 randomly selected questions were included for analysis after determining they contained a clinical vignette and required a diagnosis. The vignettes and following explanations were then examined for the presence/absence of 11 types of demographic information, including age, sex/gender, and socioeconomic status. We compared both the usage frequency and relevance between the 11 information types.

Results

Most information types were present in less than 10% of clinical vignettes, but age and sex/gender were present in over 95% of question stems. Over 50% of questions included irrelevant information about age and sex/gender, but 75% of questions did not include any irrelevant information of other types. Patient weight and environmental exposures were significantly more likely to be relevant than age or sex/gender.

Discussion

Students using the questions in this study will frequently gain practice incorporating age and sex/gender into their clinical reasoning while receiving little exposure to other demographic information. Based on our findings, we posit that questions could include more irrelevant information, outside age and sex/gender, to better approximate real clinical scenarios and ensure students do not overvalue certain demographic data.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01778-z.

Using vignettes about racism from health practice in Aotearoa to generate anti-racism interventions

Racism is a key modifiable determinant of health that contributes to health inequities in Aotearoa and elsewhere. Experiences of racism occur within the health sector for workers, patients and their whānau (extended family) every day. This paper uses stories of racism from nurses - reworked into vignettes - to examine the dynamics of racism to generate possible micro, meso and macro anti-racism interventions. A critical qualitative design was utilised, informed by kaupapa Māori approaches. The five vignettes in this paper were sourced from a pair of caucused focus groups with nine senior Māori (Indigenous peoples of Aotearoa) and Tauiwi (non-Māori) nurses held in Auckland Aotearoa in 2019. The vignettes were lightly edited and then critically analysed by both authors to identify sites of racism and generate ideas for anti-racism interventions. The vignettes illustrate five key themes in relation to racism. These include (i) mono-cultural practice, (ii) everyday micro-aggressions; (iii) complexity and the costs of racism, (iv) Pākehā (white settler) privilege and (v) employment discrimination. From analysing these themes, a range of evidence-based micro, meso and macro-level anti-racism interventions were derived. These ranged from engaging in reflective practice, education initiatives, monitoring, through to collective advocacy. Vignettes are a novel way to reveal sites of racism to create teachable moments and spark reflective practice and more active engagement in anti-racism interventions. When systematically analysed vignettes can be utilised to inform and refine anti-racist interventions. Being able to identify racism is essential to being able to effectively counter racism.

Data set and methodology involving pedagogical approaches to teach mental health and substance use in dental education

Objective

In this Data note, we provide a raw data set in the form of brief self-guided reflections. We also present the methodological approach to generate these reflections including an educational vignette so that other dental schools can plan for their teaching activities involving mental health and substance use topics.

Data description

Between 2015/16 and 2018/19, the University of British Columbia’s (UBC) undergraduate dental and dental hygiene students submitted optional written guided reflections to address ‘how can an educational vignette, depicting a patient with a history of substance use and mental health disorders accessing dental care, promote an open dialogue about stigma?’ From a total of 323 undergraduate students, 148 anonymous reflections between 200 and 400 characters each were received. The main ideas that may emerge from the reflections include ‘exploring power relations’ and ‘patient-centered care approach to counteract stigma’.

Using Vignette-Based Methodology to Examine Study Recruitment in Older African American Adults: A Methods Paper

This study's objective was to assess which caring recruitment behaviors correlate with the successful recruitment of older African-American adults-a two-step cross-sectional design employing a vignette-based survey methodology. Kristen Swanson's middle-range theory of caring was used to guide the examination of African-American adults' (65 years of age and older) perceptions of research-study-recruiter recruitment behaviors. This study's main findings are twofold: Step 1: Seven of ten invited experts identified major revisions of the two core vignettes, written at an eighth-grade reading level and high school comprehension. Step 2: A 51% response rate yielded findings that this methodology successfully captured older African-American adults' perception of research study recruiters' behavioral characteristics during the recruitment process. Older African-Americans who received the hypothetical caring vignette were twice as likely to indicate their willingness to enroll in a research study with a high commitment (i.e., brain donation) compared to their counterparts who received the hypothetical uncaring recruitment scenario. Vignette-based survey methodology holds promise as a tool for informing the recruitment of older African-American adults and other minorities into federally funded health-related research studies.

Design and use of vignettes to investigate referral decision-making by optometrists

PURPOSE

This study describes the design and application of a range of online clinical vignettes for measuring the impact of Continuing Education and Training (CET) and identifying unwarranted variation in optometric decision-making concerning referrals to secondary care.

METHODS

Twenty computerised vignettes were developed to assess clinical and referral management decisions taken in primary care optometry. The online system was specifically designed to present vignettes (ten pre-CET and ten post-CET) that avoided prompting correct answers. The main study group was qualified optometrists (N = 31) who chose any CET options available to United Kingdom optometrists over six months. Participants submitted a record of the CET undertaken, which was compared with an anonymised General Optical Council (GOC) reference sample. The vignettes were also completed by newly-qualified (N = 18) and pre-registration (N = 11) groups.

RESULTS

CET had no significant correlation (p = 0.37) with improvement in optometric clinical decision-making and referral practice (qualified group). Selection bias affected this group who had more CET points (p = 0.008) and peer discussion points (p = 0.003) than the GOC reference sample. Results were indicative due to small sample sizes. Newly-qualified practitioners were significantly more likely to refer than the qualified group (p = 0.004). Number of referrals decreased with time since qualification (p = 0.006).

CONCLUSION

Computerised vignettes are a useful tool for comparing referral decisions between groups. Recruiting clinicians for time-consuming vignette studies is challenging. Strategies to reduce unwarranted variation in optometry, including support for newly-qualified optometrists, require further investigation.

The role of an educational vignette to teach dental students on issues of substance use and mental health disorders in patients at the University of British Columbia: an exploratory qualitative study

BACKGROUND

Inverted classroom approaches and the use of vignettes have been suggested in health care education. The objective of this study was to use an educational vignette to discuss issues of stigma around substance use and mental disorders within undergraduate Doctor of Medicine in Dentistry (DMD) and Bachelor of Dental Science in Dental Hygiene (BDSc-DH) students at the University of British Columbia, Canada. Our research question was "how can an educational vignette, depicting a fictitious patient with a history of substance use and mental health disorders accessing dental care, promote an open dialogue about stigma?"

METHODS

An educational vignette was developed based on individuals' lived-experiences with a variety of substance use and/or mental health disorders. This vignette was used to generate in-class discussion involving all the DMD and BDSc-DH undergraduate students enrolled between 2015/16 and 2018/19 who attended a mandatory 2.5 h didactic session using an inverted classroom approach. Students were also encouraged to provide a post-class voluntary written reflection, between 200 and 300 words, around stigma. The authors took written field notes on students' response to the vignette and used excerpts from students' de-identified reflections to illustrate the impact of such an educational tool.

RESULTS

A total of 323 DMD and BDSc-DH students attended the didactic sessions between 2015/16 and 2018/19, and 148 reflections were submitted over the same time period. The inverted classroom approached showed to be engaging and collaborative. The vignette promoted open dialogue and was determined to be a conducive tool to generate in-class discussion and reflection. Major themes from the textual data included 'exploring power relations' and 'patient-centered care approach to counteract stigma'. The vignette also enabled the discussion of positive experiences characterized by empathy, reassurance and communication, although it might not have prompted all students to participate in class or in writing the reflections.

CONCLUSION

The inverted classroom approach and the vignette seemed to be an effective way to facilitate dialogue and reflection for most students. This study highlighted the need to explore innovative ways in which to continuously prepare current and future oral health care providers to professionally address the needs of patients with a history of substance use and/or mental health disorders.

Development and Validation of a Shared Secure Biochemistry Test Bank for Medical, Dental, and Pharmacy Schools

A shared secure biochemistry test bank (abeQbank) was developed by 61 members of the Association of Biochemistry Educators (ABE) who are from medical, pharmacy, and dental schools. The initial abeQbank contained 305 questions, which were almost all clinical vignettes, and were classified into 9 biochemistry megaThemes with subthemes as determined by ABE workshops 2009-2011. Three medical schools selected 163 board-style abeQbank questions approved by ABE and administered a proctored formative exam using ExamSoft to 97 second-year medical students prior to their USMLE or COMLEX 1 board exam followed by a review session in which students examined their answers and read the rationale for each question. The goals of this project were to (1) provide a resource to biochemistry educators; (2) evaluate the quality of these questions; and (3) ascertain students' relative knowledge in different biochemical concepts. Individual questions and 9 megaTheme groups performed similarly across schools, with the lowest and highest megaThemes ranging from 40 to 70% correct. Five questions were dropped due to miscoding, poor metrics, or questionable distractors requiring a rewrite. The results showed that the examination was strongly reliable with the average KR20 = 0.85, discrimination index and point-biserial > 0.2, and students scoring the examination 8 out of 10 in usefulness. This test bank represents the first attempt by an international biochemistry organization to create a standardized set of questions, with future expansion planned to help standardize the content of biochemistry topics in the curricula.

Observational vignette study to examine patient and healthcare provider perceived impact of asthma-related exacerbations in the US

Background

Little is known about how patients and healthcare providers (HCPs) perceive the impact of asthma-related exacerbations. This study examined the impact of asthma-related exacerbations on patients’ lives from these different perspectives.

Methods

Web-based surveys were administered to a US sample of adult patients with asthma, and HCPs. Participants reviewed six vignettes describing two hypothetical patients with asthma (25-year-old/single/unemployed/no dependents; and 45-year-old/married/employed/two young children) experiencing mild, moderate, or severe exacerbations and rated the impact on eight measures: EuroQoL-5 Dimensions (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression), sleep, household costs, and medical costs. The proportions reporting impact for each measure were calculated for each vignette; and patient responses were compared with HCP responses.

Results

302 patients with asthma and 300 HCPs completed the survey. As exacerbation severity increased, a higher proportion of patients and HCPs reported impact of exacerbations on patients with asthma. Compared with HCPs, a greater proportion of patients reported problems with pain/discomfort related to mild and moderate exacerbations. Compared with patients, HCPs were more likely to indicate sleep impact, mobility problems, and financial burden across all exacerbation severity levels; self-care problems with moderate and severe exacerbations; and problems with usual activities and anxiety/depression for severe exacerbations.

Conclusions

Understanding the distinctions between how patients and HCPs perceive the impact of exacerbations is important for optimizing patient care. HCPs may be less aware of patient’s concerns about exacerbation-related pain/discomfort. Studies are needed to further understand patient-HCP interactions regarding asthma-related exacerbations.

Electronic supplementary material

The online version of this article (10.1186/s40248-019-0196-1) contains supplementary material, which is available to authorized users.

Decision-Making Factors in the Mandatory Reporting of Child Maltreatment

The goal of this exploratory study was to investigate the factors that may impact a social worker's decision to report suspected child maltreatment. A volunteer sample of social workers (n = 439) from Ontario, Canada completed an online survey where they reviewed three hypothetical vignettes of potential child maltreatment (exposure to intimate partner violence, physical, emotional). Social workers responded to questions regarding their decision-making and the factors which would impact their reporting decision (legal requirements, ethnicity of caregivers, circumstances around disclosure, reporting history, consultation or supervision, field of practice). A series of multiple logistic regression analyses were performed for each version of the three vignettes. The study found that consultation or supervision were significant predictors in social worker's decision to report suspected child maltreatment. Peer consultation may assist with emotional regulation and provide an outside perspective to guide decision-making.

Personality and treatment-related correlates of trustworthiness: A web-survey with chronic pain narratives

OBJECTIVES

This study examined personality and treatment-related correlates of trustworthiness in chronic pain narratives.

METHODS

727 adults participated in an online survey and rated eight narratives written by patients with chronic pain. Eighty-six percent of the participants identified themselves as having experienced chronic pain (n = 626) and 14% identified themselves as people with a medical background (n = 101). The survey examined psychological characteristics, trustworthiness and expressions of pain severity, desire for medication, and frustration with pain care.

RESULTS

Pain narratives that were rated as likable, stoic, or appreciative were significantly associated with higher trustworthiness; narratives that were rated as depressed, hostile, or histrionic were significantly associated with lower trustworthiness. Similar results were found for patient peers and clinicians. Patients that expressed a high level of pain severity were rated as significantly less trustworthy (P < .001). Pain narratives that expressed frustration with pain care were also rated as significantly less trustworthy (P = .009). For pain narratives that expressed frustration with pain care, patient peers gave higher ratings of trustworthiness compared to providers (P = .008), whereas both gave similar ratings when no frustration with pain care was expressed in the narrative.

DISCUSSION

Our results show that the way in which patients communicate about their pain are significantly associated with how trustworthy they are perceived. Future research should explore how trustworthiness is related to subsequent pain management and interpersonal dynamics.

A brief assessment tool for investigating facets of moral judgment from realistic vignettes

Humans make moral judgments every day, and research demonstrates that these evaluations are based on a host of related event features (e.g., harm, legality). In order to acquire systematic data on how moral judgments are made, our assessments need to be expanded to include real-life, ecologically valid stimuli that take into account the numerous event features that are known to influence moral judgment. To facilitate this, Knutson et al. (in Social Cognitive and Affective Neuroscience, 5(4), 378-384, 2010) developed vignettes based on real-life episodic memories rated concurrently on key moral features; however, the method is time intensive (~1.4-3.4 h) and the stimuli and ratings require further validation and characterization. The present study addresses these limitations by: (i) validating three short subsets of these vignettes (39 per subset) that are time-efficient (10-25 min per subset) yet representative of the ratings and factor structure of the full set, (ii) norming ratings of moral features in a larger sample (total N = 661, each subset N = ~220 vs. Knutson et al. N = 30), (iii) examining the generalizability of the original factor structure by replicating it in a larger sample across vignette subsets, sex, and political ideology, and (iv) using latent profile analysis to empirically characterize vignette groupings based on event feature ratings profiles and vignette content. This study therefore provides researchers with a core battery of well-characterized and realistic vignettes, concurrently rated on key moral features that can be administered in a brief, time-efficient manner to advance research on the nature of moral judgment.

Factors associated with Human Papilloma Virus (HPV) vaccine recommendation by physicians in Lebanon, a cross-sectional study

Persistent Human Papilloma Virus (HPV) infection is associated with the development of cervical cancer, a leading cause of female death worldwide. In Lebanon, cervical cancer is the 6th most common cancer amongst girls and women aged 14-44 years. Cervical cancer is preventable through HPV vaccination; however, Lebanon does not include HPV vaccination in its national routine vaccination schedule. Hence, physician recommendation is key for patient vaccine uptake. We conducted a cross-sectional study in Beirut, Lebanon to assess factors affecting physician recommendation regarding HPV vaccination. Physicians practicing in Obstetrics and Gynecology (OBGYN), Pediatrics, Family Medicine and Infectious Diseases were included in the study. In total, 228 physicians completed the survey (28.79% response rate). The survey consisted of a set of demographic and HPV knowledge questions along with clinical vignettes. The vignettes presented theoretical patients who differed in gender, age, sexual activity, social background and whether the patient presented with his mother or not. The results show that physicians tend to recommend the vaccine more commonly for vignettes presenting female patients, with an Adjusted Odds Ratio (AOR) of 6.8. Also, physicians were more likely to recommend the vaccine for vignettes with patients coming from a non-conservative background (AOR = 2.1), vignettes where patients claim to be sexually active (AOR = 2.7) and vignettes where patients presented with their mother (AOR = 1.4). Physicians tend to recommend the vaccine less in vignettes with married patients (AOR = 0.5). Physicians with higher knowledge scores recommended the vaccine more often (AOR = 3.4). Overall, OBGYN physicians recommended the vaccine less than pediatricians (AOR = 0.5). These results show that Lebanese physicians' recommendations rely on factors external to international guidelines. The results also highlight the importance of knowledge in adequate patient consultation. Thus, improved physician awareness towards international guidelines and physician education regarding HPV vaccination is essential in order to improve patient care in Lebanon.

Developing a valid and reliable assessment of knowledge translation (KT) for continuing professional development program of health professionals

Introduction

Knowledge Translation (KT) is expected to be a critical learning outcome of a Continuing Professional Development (CPD) program. It continues to serve as an area of interest among educators and healthcare providers due to its importance to evidence-based practice. This study endeavored to develop a valid and reliable KT learning assessment tool in CPD.

Methods

The Inventory of Reflective Vignettes (IRV), an innovative approach of integrating research vignettes, was utilized in crafting the 20-item IRV-KT tool. This instrument includes knowledge creation and action as essential KT constructs. KT competency was assessed in three segments (i.e., before and after CPD event and if in a lecture) using a one-group post-posttest pre-experimental design. Health professionals who successfully completed a CPD program on a knowledge translation topic were asked to complete the IRV-KT during the pilot study (n = 10) and actual implementation (n = 45). Responses were subjected to Cronbach’s reliability and criterion-validity testing.

Results

The initial test of the IRV-KT tool demonstrated a high internal reliability (α = 0.97) and most items yielded acceptable validity scores. During the actual implementation, a higher reliability score of 0.98 was generated with significant correlations between the before-after segments for both KT constructs of creation (r = 0.33, p < 0.05) and action (r = 0.49, p < 0.05). All items have significant positive validity coefficients (r > 0.35, p < 0.05) in all segments of the tool.

Discussion

The study produced a reflective assessment tool to validly and reliably assess KT learning in a CPD. IRV-KT is seen to guide the curriculum process of CPD programs to bridge learning and healthcare outcomes.

Framing orientation selectivity

The ongoing debate on the neural basis of orientation selectivity in the primary visual cortex continues.

Evidence from Burkina Faso

The quality of care is a crucial determinant of good health outcomes, but is difficult to measure. Survey vignettes are a standard approach to measuring medical knowledge among health care providers. Given that written vignettes or knowledge tests may be too removed from clinical practice, particularly where "learning by doing" may be an important form of training, we developed a new type of provider vignette. It uses videos presenting a patient visiting the clinic with maternal/early childhood symptoms. We tested these video vignettes with current and future (students) health professionals in Burkina Faso. Participants indicated that the cases used were interesting, understandable and common. Their performance was consistent with expectations. Participants with greater training (medical doctors vs. nurses and midwives) and experience (health professionals vs. students) performed better. The video vignettes can easily be embedded in computers, tablets and smart phones; they are a convenient tool to measure provider knowledge; and they are cost-effective instruction and testing tools.

"I Feel It In My Heart When My Parents Fight": Experiences of 7-9-Year-Old Children of Alcoholics

Children are vulnerable when exposed to parental alcohol abuse. Although much is known about children of alcoholics (COA), research examining the experiences of younger COA is scarce. To gain knowledge of the consequences for these children, it is important to ask the children themselves. This study explored the consequences for a child of having an alcoholic parent, from the point of view of 7-9-year-old COA. Eighteen children were interviewed, whose alcoholic parent was undergoing treatment, using a vignette. In the analysis, using qualitative content analysis, the findings show that the children of this young age had much experiences and took a great responsibility for their alcoholic parent, and the family. The most significant feeling of the children was a feeling of sadness. They tried to control the situation in different ways. They wished for a change in the future, but despite problems in the family they described things they did together with a loving parent. Implications include the importance of listening to and supporting all COA, also children as young as 7-9 years old. Further studies should address the support that can and should be offered to COA.

School Counselors' Recognition of the Ultra-High Risk for Psychosis

The ability to identify students at ultra-high risk (UHR) for psychosis in school settings is crucial for enabling appropriate referral to a clinician and positive therapeutic results. The aim of this study was to examine school counselors' recognition of the diagnosis and appropriate treatment recommendations for students at UHR for psychosis. In total, 132 school counselors completed surveys, including questions relating to a vignette about a student at UHR for psychosis. In total, 12.4% of the sample provided the correct diagnosis, much lower than that for other schizophrenia spectrum disorders and non-psychotic disorders, including depressive disorder. Although most school counselors preferred psychiatrists as the first-line treatment for students at UHR for psychosis, counseling centers were also mentioned as potential treatment options. In terms of medication, antipsychotics were preferred over other medication classes. It is necessary to design appropriate educational and training programs for school counselors to promote identification and effective referral of those at UHR for psychosis.

Factors influencing the clinical decision-making of midwives: a qualitative study

Background

Although midwives make clinical decisions that have an impact on the health and well-being of mothers and babies, little is known about how they make those decisions. Wide variation in intrapartum decisions to refer women to obstetrician-led care suggests that midwives’ decisions are based on more than the evidence based medicine (EBM) model – i.e. clinical evidence, midwife’s expertise, and woman’s values - alone. With this study we aimed to explore the factors that influence clinical decision-making of midwives who work independently.

Methods

We used a qualitative approach, conducting in-depth interviews with a purposive sample of 11 Dutch primary care midwives. Data collection took place between May and September 2015. The interviews were semi-structured, using written vignettes to solicit midwives’ clinical decision-making processes (Think Aloud method). We performed thematic analysis on the transcripts.

Results

We identified five themes that influenced clinical decision-making: the pregnant woman as a whole person, sources of knowledge, the midwife as a whole person, the collaboration between maternity care professionals, and the organisation of care. Regarding the midwife, her decisions were shaped not only by her experience, intuition, and personal circumstances, but also by her attitudes about physiology, woman-centredness, shared decision-making, and collaboration with other professionals. The nature of the local collaboration between maternity care professionals and locally-developed protocols dominated midwives’ clinical decision-making. When midwives and obstetricians had different philosophies of care and different practice styles, their collaborative efforts were challenged.

Conclusion

Midwives’ clinical decision-making is a more varied and complex process than the EBM framework suggests. If midwives are to succeed in their role as promoters and protectors of physiological pregnancy and birth, they need to understand how clinical decisions in a multidisciplinary context are actually made.

Acute care nurses' responses and recommendations for improvement of hand hygiene compliance: A cross-sectional factorial survey research study

BACKGROUND

Hand hygiene is promoted as an effective practice to counter health care-acquired infections; however, compliance is less than optimal. Nurses have many patient contact opportunities and therefore are frequent participants in intervention research. The optimal combination of efficient and effective intervention components has not been conclusively identified.

METHODS

A factorial survey research design offers an efficient method to assess multiple factors simultaneously by combining elements into vignettes. This article describes a process, grounded in the framework of Bandura's social cognitive theory, that explored environmental and individual factors that potentially influence nurses' hand hygiene behavior in acute care settings. Survey respondents consisted of nurses employed in patient care; respondents also could address an open response item.

RESULTS

A total of 466 participants scored a total of 3,685 vignettes. Statistically significant parameters included goal, supervisor priority, electronic monitoring, and rewards. The most frequently mentioned open response item was the need to keep hand hygiene product dispensers refilled. Participants also suggested that culture and intrinsic motivation influenced hand hygiene behavior.

CONCLUSIONS

Researchers might consider assessing promising factors, especially use of goal setting, as an intervention rather than as components of an intervention. Further research is indicated to better understand how nurses define and view hand hygiene culture.

Understanding variations in patient screening and recruitment in a multicentre pilot randomised controlled trial: a vignette-based study

BACKGROUND

The INVESTIGATE-I study was designed to inform a future definitive randomised trial of invasive urodynamic testing, compared to basic clinical assessment with noninvasive tests prior to surgical treatment, in women with stress urinary incontinence or stress-predominant mixed urinary incontinence. In a pilot randomised controlled trial, women from seven participating sites were screened, consented and randomised. Overall, 771 patients were identified from clinic notes and correspondence as being potential recruits and were sent the Patient Information Leaflet. Of those screened, 284 were deemed eligible, giving an overall 'screen positive' rate of 37 %. The numbers screened at individual centres varied between 14 and 399; the 'screen positive' rate varied between 22 and 79 % and the percentage of eligible women recruited varied between 55 and 100 %. The aim of this additional substudy was to explore why 'screen positive' rates may have varied so widely between apparently similar sites.

RESULTS

All 11 trial staff involved in screening in the seven recruiting sites were asked to evaluate a series of 20 identical vignettes, mainly based on actual general practitioner referral letters. Of the vignettes, 16 mentioned one or more definite inclusion criteria; the remainder had possible inclusions. Four had definite exclusions; 12 had possible exclusions. Free-text comments were sought to clarify the screeners' decisions. For six vignettes everyone agreed that the patient was eligible; for one all agreed she was not eligible; the breakdown for the remainder was mixed. Free-text comments illuminated uncertainties that may have led to variability in judging potential eligibility.

CONCLUSIONS

Variability in judgements about potential trial eligibility highlights the importance of explicit and objective inclusion and exclusion criteria, and of agreed strategies for making judgements when information is missing. During the development and planning of trials, vignettes might be a valuable tool for training those involved in screening and recruiting patients, for identifying potential problems and ensuring greater consistency in the application of eligibility criteria.

TRIAL REGISTRATION

ISTCTN registry: ISRCTN71327395 , registered on 7 June 2010.

When are clinical trials beneficial for study patients and future patients? A factorial vignette-based survey of institutional review board members

OBJECTIVE

The ethicists believe that the goal of clinical research is to benefit future and not current (trial) patients. Many clinicians believe that the clinical trial enrolment offers best management for their patients. The objective of our study was to identify the situations when a clinical trial is beneficial for the patients enrolled in the trial and future patients.

DESIGN

Factorial vignette-based cross-sectional survey via the internet.

PARTICIPANTS

Institutional review board (IRB) members of the US Medical Schools.

MAIN OUTCOME MEASURES

Each participant was invited to review 9 clinical vignettes related to (1) study approval and (2) the assessment if the study is designed to help future or current patients more.

RESULTS

A total of 232 IRB members from 42 institutions participated. When considering approval of the trial, we found that uncertainty about treatment effects (OR=1.13; 95% CI 1.08 to 1.19) and requirement for continuation of standard therapy (OR=3.84; 95% CI 2.7 to 5.55) were the only statistically significant factors affecting IRB members' decisions to approve the study. The odds of IRB members approving a trial increased when a trial proposed to enrol patients with life-threatening versus chronic debilitating disease (OR=2.04; 95% CI 1.47 to 2.86). We also found that similar factors affected judgements related to the assessment whether the trial will benefit future or current patients more-(1) future patients: uncertainty (OR=1.27; 95% CI 1.18 to 1.37); continuation of standard treatment (OR=1.66; 95% CI 1.07 to 2.56); seriousness of condition (OR=1.78; 95% CI 1.15 to 2.28); (2) current patients: uncertainty (OR=1.54; 95% CI 1.4 to 1.7); continuation of standard therapy (OR=2.17; 95% CI 1.39 to 3.44).

CONCLUSIONS

IRB members view the proposed studies to be beneficial for current patients and future patients if there is uncertainty regarding treatment effects and if studies do not require stopping the current treatment. This finding supports the design and use of pragmatic trials which may reduce therapeutic misconception and improve trial enrolment, speeding up therapeutic discoveries.

What is normal progress in the first stage of labour? A vignette study of similarities and differences between midwives and obstetricians

OBJECTIVE

intrapartum referrals are high-risk situations. To ensure patient safety, care professionals need to have a shared understanding of a labouring woman's situation. We aimed to gain insight into similarities and differences between midwives and obstetricians in the assessment of a prolonged first stage of labour and the decision to refer a woman to a clinical setting in the Netherlands.

DESIGN

factorial survey.

SETTING

in the Netherlands, the main caregivers for women with low risks of pathology are primary-care midwives working in the locality. Approximately half of all women start labour under supervision of primary-care midwives. Roughly 40% of these women are referred to a hospital during labour, where obstetricians take over responsibility. In 2013, the reason for referral for 5161 women (14.1% of all referrals during labour) was a prolonged first stage of labour.

PARTICIPANTS

respondents consisted of primary-care midwives (N=69), obstetricians (N=47) and hospital based midwives, known as clinical midwives (N=31).

MEASUREMENTS

each respondent assessed seven hypothetical vignettes. The assessment of a prolonged first stage of labour and the decision to refer a woman to a clinical setting based on this indication were used as outcome measures, rated on a 7-point Likert scale (1=very unlikely to 7=very likely). Data were analysed using a linear multilevel model with a two-level hierarchy.

FINDINGS

compared to primary-care midwives, obstetricians were more likely to define a prolonged first stage of labour when progress in cervical dilation was slow (b: 1.11; 95% CI: 0.66 - 1.57). The attributes parity, progress, intensity of uterine contractions and the woman's state of mind, were used by all three groups in the decision to refer a woman to clinical setting based on a prolonged first stage of labour. KEY CONCLUSION AND IMPLICATIONS FOR PRACTICE: we found relevant interprofessional differences and similarities in the assessment of a prolonged first stage of labour and consequent referral. Further interprofessional alignment of clinical assessments, for instance through interprofessional discussions and a review of professional guidelines, might help to improve collaborative care.

PETS-D (parents education through simulation-diabetes): Parents' qualitative results

OBJECTIVE

Parents who have a child newly diagnosed with type 1 diabetes (T1D) must quickly learn daily diabetes self-management. An RCT was conducted using human patient simulation (HPS) to enhance parents learning diabetes self-management with children with new-onset T1D. The purpose of this study was to describe parents' perspectives of using HPS to augment diabetes education.

METHODS

A qualitative descriptive design was used with open-ended in-depth interviews of parents (n=49) post-intervention. Qualitative directed content analysis was used.

RESULTS

The majority of parents were positive about learning with HPS. Although a few parents said the HPS was "hokey" or "creepy," most reported the visual and hands-on learning was realistic and very beneficial. Seeing a seizure increased their fear although they would have panicked if they had not had that learning experience, and it helped build their diabetes self-management confidence. Recommendations included teaching others with the HPS (grandparents, siblings, babysitters, and school nurses).

CONCLUSION

HPS-enhanced education is an acceptable and viable option that was generally well-received by parents of children with new-onset T1D.

PRACTICE IMPLICATIONS

The technique should be studied with parents of children with other chronic illnesses to see if the benefits found in this study are applicable to other settings.

Provision of dementia-related services in Canada: a comparative study

BACKGROUND

Dementia is common, particularly among older adults, and is one of the major causes of dependency later in life. We sought to provide an overview and comparison of key services related to dementia care as the disease progresses in three large Canadian healthcare centres.

METHODS

We identified family physicians, geriatric specialists, and dementia case managers from three major population centres in Canada with universal healthcare coverage. Using a standardized longitudinal dementia case vignette, participants were interviewed on services they would provide at each stage of the disease. We used principles of content analysis to generate codes and identify themes; appropriate time frames from the vignette fitting the necessary provision of services were derived from the Canadian consensus statement and determined in consultation with clinical experts. Proportions of participants that identified dementia-related care services were analyzed at each time point of the vignette using chi-square tests.

RESULTS

Thirty-four healthcare providers from Calgary (Alberta), Edmonton (Alberta), and Ottawa (Ontario) participated. Review of our data identified seven overarching themes of dementia-related care services. Services provided in the community setting include future planning and related services, educational and social support services, and home care and respite services. Although all providers consistently identified educational and social support services (e.g. the Alzheimer Society) within the appropriate time frame, the provision of other services was variable. The proportion of providers reporting potential access of future planning services was significantly different across the three sites (Calgary, 91.7 %; Edmonton; 58.3 %; and Ottawa, 30.0 %), p = 0.012. Also, the proportion of providers that identified day program services were significantly different across the three sites (Calgary, 100.0 %; Edmonton, 91.7 %; and Ottawa, 60.0 %), p = 0.023 according to a chi-square test.

CONCLUSIONS

We found important types of variability in service delivery among different regions in Canada for a typical patient with dementia and their family caregiver. Health systems can be calibrated by aligning services from different settings to appropriate time points in the vignette, which illustrates the dynamic course of service delivery and opportunities for improvement throughout the disease trajectory.

Recognition of mental disorders among a multiracial population in Southeast Asia

BACKGROUND

Mental health literacy is an important mediating factor in help-seeking behavior. An important component of this literacy is the proper recognition of mental disorders. The aim of this population-based study in Singapore was to determine the proportion of adults in the resident population who were able to recognize vignettes pertaining to alcohol abuse, dementia, depression, obsessive compulsive disorder (OCD) and schizophrenia correctly. The sociodemographic characteristics that were associated with the ability to correctly recognize these disorders were also examined.

METHODS

This was a nationwide cross-sectional study that involved establishing mental health literacy using a vignette approach. Respondents were recruited using a disproportionate stratified sampling design by age and ethnic groups. Face-to face-interviews were conducted with respondents aged 18 to 65 years belonging to Chinese, Malay, Indian and Other ethnic groups.

RESULTS

A total of 3,006 respondents completed the survey (response rate of 71%). The most well recognized conditions were dementia (66.3%), alcohol abuse (57.1%) and depression (55.2%). The least recognized were OCD (28.7%) and schizophrenia (11.5%). Younger age and higher educational levels were found to be significant factors associated with the better recognition of specific disorders.

CONCLUSION

The relatively high rate of recognition of dementia was likely to be due to the emphasis on public education programmes on dementia which is viewed as an emerging challenge due to Singapore's rapidly ageing population. The role of education and the portrayal of depression and alcohol related problems in the local mass media are possible influences in their better recognition as compared to OCD and schizophrenia. Sociodemographic characteristics influencing mental health literacy need to be considered in planning intervention strategies that target mental health literacy.

Disorders specifically associated with stress: A case-controlled field study for ICD-11 mental and behavioural disorders

As part of the development of the Eleventh Revision of International Classification of Diseases and Related Health Problems (ICD-11), the World Health Organization Department of Mental Health and Substance Abuse is conducting a series of case-controlled field studies using a new and powerful method to test the application by clinicians of the proposed ICD-11 diagnostic guidelines for mental and behavioural disorders. This article describes the case-controlled field study for Disorders Specifically Associated with Stress. Using a vignette-based experimental methodology, 1,738 international mental health professionals diagnosed standardized cases designed to test key differences between the proposed diagnostic guidelines for ICD-11 and corresponding guidelines for ICD-10. Across eight comparisons, several proposed changes for ICD-11, including the addition of Complex PTSD and Prolonged Grief Disorder, produced significantly improved diagnostic decisions and clearer application of diagnostic guidelines compared to ICD-10. However, several key areas were also identified, such as the description of the diagnostic requirement of re-experiencing in PTSD, in which the guidelines were not consistently applied as intended. These results informed specific revisions to improve the clarity of the proposed ICD-11 diagnostic guidelines. The next step will be to further test these guidelines in clinic-based studies using real patients in relevant settings.

Exploring preferences for domain-specific goal management in patients with polyarthritis: what to do when an important goal becomes threatened?

Usually priorities in goal management—intended to minimize discrepancies between a given and desired situation—are studied as person characteristics, neglecting possible domain-specific aspects. However, people may make different decisions in different situations depending on the importance of the personal issues at stake. Aim of the present study therefore was to develop arthritis-related vignettes to examine domain-specific goal management and to explore patients’ preferences. Based on interviews and literature, situation-specific hypothetical stories were developed in which the main character encounters a problem with a valued goal due to arthritis. Thirty-one patients (61 % female, mean age 60 years) evaluated the face validity of the newly developed vignettes. Secondly, 262 patients (60 % female, mean age 63 years) were asked to come up with possible solutions for the problems with attaining a goal described in a subset of the vignettes. Goal management strategies within the responses and the preference for the various strategies were identified. The 11 developed vignettes in three domains were found to be face-valid. In 90 % of the responses, goal management strategies were identified (31 % goal maintenance, 29 % goal adjustment, 21 % goal disengagement, and 10 % goal re-engagement). Strategy preference was related to domains. Solutions containing goal disengagement were the least preferred. Using vignettes for measuring domain-specific goal management appears as valuable addition to the existing questionnaires. The vignettes can be used to study how patients with arthritis cope with threatened goals in specific domains from a patient’s perspective. Domain-specific strategy preference emphasizes the importance of a situation-specific instrument.

Beliefs and attitudes towards mental illness: an examination of the sex differences in mental health literacy in a community sample

Objectives. The current study investigated mental health literacy in an Australian sample to examine sex differences in the identification of and attitudes towards various aspects of mental illness. Method. An online questionnaire was completed by 373 participants (M = 34.87 years). Participants were randomly assigned either a male or female version of a vignette depicting an individual exhibiting the symptoms of one of three types of mental illness (depression, anxiety, or psychosis) and asked to answer questions relating to aspects of mental health literacy. Results. Males exhibited poorer mental health literacy skills compared to females. Males were less likely to correctly identify the type of mental illness, more likely to rate symptoms as less serious, to perceive the individual as having greater personal control over such symptoms, and less likely to endorse the need for treatment for anxiety or psychosis. Conclusion. Generally, the sample was relatively proficient at correctly identifying mental illness but overall males displayed poorer mental health literacy skills than females.

Mental health first aid training for the Bhutanese refugee community in the United States

BACKGROUND

The aim of this study was to investigate the impact of Mental Health First Aid (MHFA) training for Bhutanese refugee community leaders in the U.S. We hypothesized that training refugee leaders would improve knowledge of mental health problems and treatment process and decrease negative attitudes towards people with mental illness.

METHODS

One hundred and twenty community leaders participated in MHFA training, of whom 58 had sufficient English proficiency to complete pre- and post-tests. The questionnaires assessed each participant's ability to recognize signs of depression, knowledge about professional help and treatment, and attitudes towards people with mental illness.

RESULTS

Between the pre- and post-test, participants showed significant improvement in the recognition of symptoms of depression and expressed beliefs about treatment that became more concordant with those of mental health professionals. However, there was no reduction in negative attitudes towards people with mental illness.

CONCLUSIONS

MHFA training course is a promising program for Bhutanese refugee communities in the U.S. However, some adaptations may be necessary to ensure that MHFA training is optimized for this community.

Public stigma and the perception of rights: differences between intellectual and physical disabilities

Stigma may have detrimental effects on the rights of individuals with disabilities. This study examined the association between stigma and the perception of rights of people with intellectual disabilities and people with physical disabilities. Telephone interviews using vignette methodology were conducted with a nationally representative sample of 605 adults. Items included stereotypes, prejudice, behavioral reactions and the perception of rights of these individuals. More negative stereotypes, greater social distance and greater withdrawal behaviors were found toward people with intellectual disabilities as compared to people with physical disabilities. Lower support of rights was found toward people with intellectual disabilities as compared to people with physical disabilities. Lower degree of acceptance and higher perception of dangerousness were associated with greater social distance, which was related to lower perception of rights. Programs should aim at decreasing social distance to improve support to exercise rights, especially among people with intellectual disabilities.

Identifying depression and schizophrenia using vignettes: a methodological note

The aim of this study was to assess lay people's ability to identify depression and schizophrenia from well established vignettes using hypothetical patients of both sexes. In all 122 participants answered a questionnaire, consisting of six vignette case studies describing psychological symptoms; three each associated with depression and schizophrenia. They answered three questions: what is the person's main problem; how could they be best helped; what would you do to help? Overall, depression was more often correctly identified compared to schizophrenia. The gender of the participant and the individual presented in the vignette did have an effect on the vignette identification task. Limitations and implications of these results and the use of vignette methodology were discussed.

A vignette-based survey to assess clinical decision making regarding antibiotic use and hospitalization of patients with probable aseptic meningitis

BACKGROUND

The many etiologies of meningitis influence disease severity - most viral causes are self-limiting, while bacterial etiologies require antibiotics and hospitalization. Aided by laboratory findings, the physician judges whether to admit and empirically treat the patient (presuming a bacterial cause), or to treat supportively as if it were viral.

OBJECTIVE

To determine factors that lead infectious disease specialists to admit and treat in cases of suspected meningitis.

METHODS

A clinical vignette describing a typical case of viral meningitis in the emergency department was presented to clinicians. They were asked to indicate on a Likert scale the likelihood of administering empirical antibiotics and admitting the patient from the vignette and for eight subsequent scenarios (with varied case features). The process was repeated in the context of an inpatient following initial observation and/or treatment.

RESULTS

Participants were unlikely to admit or to administer antibiotics in the baseline scenario, but a low Glasgow Coma Score or a high cerebrospinal fluid (CSF) white blood cell count with a high neutrophil percentage led to empirical treatment and admission. These factors were less influential after a negative bacterial CSF culture. These same clinical variables led to maintaining treatment and hospitalization of the inpatient.

CONCLUSIONS

Most participants chose not to admit or treat the patient in the baseline vignette. Confusion and CSF white blood cell count (and neutrophil predominance) were the main influences in determining treatment and hospitalization. A large range of response scores was likely due to differing regional practices or to different levels of experience.

Fear of crime in old age: precautious behaviour and its relation to situational fear

This study aimed to provide further insight into the question of why older adults show a higher precautionary behaviour regarding crime (behavioural fear), although they do not estimate their victimisation risk as higher than young adults and they do not experience fear more often. In two cross-sectional studies, the hypothesis was tested that the age-related increase in precautionary behaviour is an expression of higher dispositional fear with age. The vignette technique was employed to induce situational fear of crime across various situations as a proxy for dispositional fear. In contrast to the hypothesis, in Study 1 (young: 18-30 years, N = 179 vs. middle-aged: 50-64 years, N = 106), only younger adults reported higher situational fear in two vignettes. In Study 2 (young: 18-30 years, N = 129 vs. young-old: 65-84 years, N = 114), younger adults indicated higher situational fear again; however, young-old adults reported higher situational fear in other vignettes. The findings suggest that there is no general increase in the intensity of situational fear of crime with age and thus no age-related change in dispositional fear. Moreover, situational fear did not serve as mediator in the relationship between age and precautionary behaviour. Alternative accounts for the increase in behavioural fear of crime are discussed as well as emotion regulation mechanisms in response to the induction method.