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Questionnaire development.
The mail questionnaire is one of the most common forms of research conducted in applied health. It is used primarily for assessing community health needs, exploring opinions on health issues, determining self-reports of health behavior, and aiding program evaluations (Torabi, 1991). The accuracy of conclusions based on questionnaire responses depends upon many factors, including the wording of questions, the physical appearance of the questionnaire (Berdie, Anderson & Niebuhr, 1986; Sudman & Bradburn, 1982), and the response rate (Jones, 1993). Therefore, careful planning must precede the development and administration of any questionnaire. This article, providing a summary of some of the issues and techniques to consider when developing and administering a questionnaire, is organized into two main topics: Writing the questions and increasing response rate. Several subtopics are discussed within each of these two main topics, and suggestions for improving questionnaires are made throughout.
Do selective topical beta antagonists for glaucoma have respiratory side effects?
BACKGROUND/AIMS: Topical beta antagonists are prescribed for glaucoma in approximately 500 000 people in the United Kingdom. The authors have previously shown that topical beta antagonists are associated with an excess incidence of airways obstruction. They examined whether selective topical beta antagonists are associated with excess airways obstruction. METHODS: A historical cohort study was performed to determine the incidence of airways obstruction in subjects with no previous history of airways obstruction, following treatment with topical beta antagonists for glaucoma for the period 1993-7. Cases were defined as having received a first prescription of a drug specifically used in the management of airways obstruction. RESULTS: For selective topical beta antagonists 12 of 324 treated subjects developed airways obstruction, compared with 112 of 9094 controls (adjusted hazard rate 3.0 (95% confidence interval (95% CI) 1.6 to 5.4)). For non-selective topical beta antagonists, the corresponding figures were 69 of 2321 subjects compared with the same control group (adjusted hazard rate 2.2 (1.6 to 3.0)). There was no significant difference between groups (p = 0.47, chi(2)), both being associated with a significantly increased risk of airways obstruction. CONCLUSION: Selective topical beta antagonists do appear to have an excess risk of airways obstruction in this population setting and should be subject to the same prescribing caveats as unselective topical beta antagonists.
The interview mode effect on the Center for Epidemiological Studies Depression (CES-D) scale: an item response theory analysis.
BACKGROUND: Evidence of a mode effect has raised concerns about the comparability and validity of self- versus interviewer-administered versions of the Center for Epidemiological Studies Depression (CES-D) scale. Response anonymity has been proposed to explain this effect. However, the factors that contribute to this mode effect are not well understood. We used item response theory (IRT) to examine the nature of the CES-D mode effect. METHODS: A sample of depressed primary care patients from the Partners-in-Care Study were randomized to receive either a phone interview (N=139) or a mail survey (N=139) of the CES-D. We used likelihood ratio tests to identify differentially functioning items in the 2 groups. Category response curves are used to describe these effects. RESULTS: Twelve items manifested differential functioning. Category response curves consistently indicate that phone respondents had a lower probability of endorsing the third of 4 response categories than mail respondents, suggesting a possible cognitive effect. CONCLUSION: Although response anonymity could be important in mode effects observed in surveys of sensitive topics, cognitive factors appear more important to the mode effect in the CES-D.
A randomized comparative study of the effects of oral and topical estrogen therapy on the vaginal vascularization and sexual function in hysterectomized postmenopausal women.
OBJECTIVE: To compare the effects of oral and vaginal estrogen therapy (ET) on the vaginal blood flow and sexual function in postmenopausal women with previous hysterectomy. DESIGN: Fifty-seven women were randomized to receive either oral (0.625 mg of conjugated equine estrogens per tablet; n = 27) or topical (0.625 mg conjugated equine estrogens per 1 g vaginal cream; n = 30) estrogen administered once daily. All women underwent estradiol measurements, urinalysis, pelvic examination, introital color Doppler ultrasonographies, and personal interviews for sexual symptoms using a validated questionnaire before and 3 months after ET. RESULTS: A higher serum level of estradiol was noted in the oral group compared with the topical group after 3 months of ET. There were significant increases in the number of vaginal vessels and the minimum diastole (P < 0.01), and marked decreases of pulsatility index values (P < 0.01) in both groups after ET. Regarding the systolic peak, we found a significant decrease only in the topical group (P < 0.05). Although the post-ET prevalence of anorgasmia decreased significantly in both groups (P < 0.05), changes in other domains, including the rates of low libido and coital frequency, were not statistically significant (P > 0.05). In the topical group, ET improved sexual function on the vaginal dryness and dyspareunia domains in a statistically significant manner (P < 0.05), but this was not the case in the oral group (P > 0.05). However, the efficacy of oral ET for vaginal dryness and dyspareunia reached 80% and 70.6%, respectively. The corresponding figures of the topical ET were 79.2% and 75%. CONCLUSIONS: The results of our study suggest that ET alone in hysterectomized postmenopausal women increases the vaginal blood flow and improves some domains of sexual function, but it may not have an impact on diminished sexual desire or activity. Compared with systemic therapy, topical vaginal preparations are found to correlate with better symptom relief despite the lower serum level of estradiol.
Intraocular pressure effects of multiple doses of drugs applied to glaucomatous monkey eyes.
The effects of multiple dosing with 0.5% timolol maleate, 2% epinephrine hydrochloride, 4% pilocarpine hydrochloride, 1% vanadate, 1% forskolin (nonproprietary name, colforsin), or 0.5% prostaglandin F2 alpha on intraocular pressure (IOP) were each tested on eight cynomolgus monkey eyes in which glaucoma was induced by photocoagulating the trabecular meshwork with the argon laser. The week prior to drug therapy, baseline IOP measurements were carried out at hourly intervals from 9:30 am to 3:30 pm on three days. One to two days later, therapy was initiated. Each drug was applied topically to both eyes of each monkey twice daily for at least four days. The IOP was measured with a calibrated pneumatonometer at the same hourly intervals on treatment days as on the baseline days. The IOP at each time of day on treatment days was compared with the average baseline IOP measured at the corresponding time of day. Topical application of timolol, epinephrine, pilocarpine, vanadate, and prostaglandin F2 alpha significantly reduced IOP without evidence of tolerance or tachyphylaxis during the course of therapy. Forskolin did not significantly decrease IOP after the second day of treatment.
Personally addressed hand-signed letters increase questionnaire response: a meta-analysis of randomised controlled trials.
BACKGROUND: Postal questionnaires are commonly used to collect data for health studies, but non-response reduces study sample sizes and can introduce bias. Finding ways to increase the proportion of questionnaires returned would improve research quality. We sought to quantify the effect on response when researchers address participants personally by name on letters that accompany questionnaires. METHODS: All randomised controlled trials in a published systematic review that evaluated the effect on response of including participants' names on letters that accompany questionnaires were included. Odds ratios for response were pooled in a random effects meta-analysis and evidence for changes in effects over time was assessed using random effects meta-regression. RESULTS: Fourteen randomised controlled trials were included covering a wide range of topics. Most topics were unrelated to health or social care. The odds of response when including participants' names on letters were increased by one-fifth (pooled OR 1.18, 95% CI 1.03 to 1.34; p = 0.015). When participants' names and hand-written signatures were used in combination, the effect was a more substantial increase in response (OR 1.45, 95% CI 1.27 to 1.66; p < 0.001), corresponding to an absolute increase in the proportion of questionnaires returned of between 4% and 10%, depending on the baseline response rate. There was no evidence that the magnitude of these effects had declined over time. CONCLUSION: This meta-analysis of the best available evidence indicates that researchers using postal questionnaires can increase response by addressing participants by name on cover letters. The effect appears to be enhanced by including hand-written signatures.
Drug metabolism in skin. Comparative activity of the mixed-function oxidases, epoxide hydratase, and glutathione S-transferase in liver and skin of the neonatal rat.
Aryl hydrocarbon hydroxylase (AHH) activity in the skin of neonatal rats was compared to that in epidermis, dermis, and other body tissues. Following topical application of benzo[a]pyrene (BP) or the polychlorinated biphenyl mixture Aroclor 1254 there was induction of AHH in each tissue studied. There was a greater increase in the activity of skin enzyme as compared to other extrahepatic tissues. When whole-organ activity (pmol of 3-OH-BP per min per whole organ) was considered, skin represented 2%, 21%, and 27% or whole body activity in control, BP-treated, and Aroclor 1254-treated animals, respectively. Skin microsomes from control rats exhibited 2, 0.5, 24, and 6% of corresponding liver microsomal AHH, 7-ethoxycoumarin de-ethylase, NADPH-cytochrome c reductase, and epoxide hydratase activities, respectively. Glutathione S-transferase activity in skin cytosol was 15% of the corresponding hepatic activity. Following topical application of Aroclor 1254 there were increases in the activity of AHH and 7-ethoxycoumarin de-ethylase in the skin and the liver. Glutathione S-transferase (40-60%) and epoxide hydratase (83-94%) activities in neonatal rat liver were induced by skin application of Aroclor 1254.
Encouraging out-patients to make the most of their first hospital appointment: to what extent can a written prompt help patients get the information they want?
A randomised controlled study in which a written prompt was sent to new patients to help them make the most of their consultation was conducted amongst patients referred to the dermatology, gynaecology and orthopaedic out-patients clinics at the Royal Free Hospital, London. The impact of the help card on patients' expectations, preparation for and experience of their out-patient consultation are discussed. A help card and letter were sent to a random sample of patients before their appointment to encourage them to prepare and prioritize questions to ask the doctor at the consultation. After their consultation, patients were sent a postal questionnaire to complete at home. Analysis of the questionnaires provided quantitative and qualitative data about patients' information requirements and whether they were fulfilled. The results highlight the difficulties out-patients have in asking questions and discussing topics fully at their initial consultation, even when they have thought of questions in advance. Half the patients who were sent a help card said they got more out of their consultation as a result, yet few statistically significant differences between the help card group and the other patients were found.
Communication between general practitioners and consultants: what should their letters contain?
OBJECTIVE: To canvass the views of all general practitioners and consultants working in Newcastle upon Tyne on the content of referral letters and replies, the feasibility of standardising certain aspects of referral letters, and the use of communications data for audit purposes. DESIGN: A postal questionnaire was sent to all general practitioners and consultants in Newcastle upon Tyne in May 1991. Questions were asked about the clinical and administrative content of letters, the utility of standard categories to state the reason for referral, the idea of using letters for feedback purposes, and communications as a potential topic for professionally led audit. SETTING: Area served by Newcastle upon Tyne Family Health Services Authority and District Health Authority. RESULTS: Replies were received from 274 (77%) doctors (115 general practitioners and 159 consultants). A majority (225; 82%) were in favour of items defined as "always important" forming a minimum requirement for referral letters and for consultants' replies. Using standardised categories to state the reason for referral was not endorsed: 102 (89%) general practitioners and 132 (83%) consultants preferred referrers to use their own words. Using referral communications to provide feedback was less popular with consultants (54; 34%) than general practitioners (72; 63%). Finally, a majority of doctors (179; 65%) were in favour of using written communications as a topic for professionally led audit. CONCLUSIONS: A high degree of consensus exists among clinicians about the content of referral communications. Although doctors may still reject the concept of standardised communications, they have unambiguously endorsed a standard for communication that they can aspire to, and they are prepared to use it as a yardstick for their actual performance.
T- and B-cell ontogeny: an alternative teaching method: T- and B-cell ontogeny game.
BACKGROUND AND PURPOSES: The game proposed herein stimulates logical thinking and the memorization of complex subject matters in the biomedical field, especially in excessively theoretical disciplines. METHODS: The game consists of an illustrated board with numbered squares, pawns, dice, and a sheet containing questions about the topic. It is played by groups of 6 students and 1 previously trained monitor. The numbered squares correspond to questions about the topic. The player who gets to the last square first wins the game. The validity of the game was tested by means of a questionnaire that was answered by students before and after the game, with a later comparison of the students' grades. RESULTS: The overall results were positive, and test grades significantly increased after the game. CONCLUSIONS: The game enhances learning of difficult topics and fosters the relationship between students, monitors, and professor, thus facilitating the clarification of points that arose during the study.
Patient empowerment via 'pushed' delivery of Personalised Healthcare educational content over the internet.
We present an Internet-based Personalised Healthcare Information (PHI) dissemination system. Information personalisation is guided by the individual's current health profile as recorded in his/her EMR. A PHI package is composed by intelligently selecting and synthesizing various topic-specific documents, each corresponding to some health parameter noted in the EMR. To ensure medical consistency, constraint satisfaction techniques are employed during the information selection phase. The resultant PHI package--covering both long-term and immediate health-maintenance requirements--can be pro-actively pushed to the individual via email, thereby ensuring the timely availability of situation-specific health maintenance information. The featured work is in line with the Malaysian Multimedia Super Corridor Telemedicine initiative and can serve as a test-bed to evaluate the effectiveness of PHI, system design and operational considerations for larger-scale deployment.
Suicide notes of the older adult.
Although not true in all countries, older adults are the developmental age group at highest risk for death by suicide in the United States. Our knowledge of suicide in the elderly is, however, limited. The psychological characteristics for suicide cannot be attributed primarily or even solely to being old. One avenue to understanding this complicated act in the elderly is suicide notes. Despite their limitations, suicide notes contain special revelations of the human mind and there is much one can learn from them about suicide in the older adult. This paper outlines the sparse literature on the topic of suicide notes of the older adult and then presents the author's own life-span research related to the elderly. The research indicated that long-term instability was critical in understanding suicide in the older adult. However, indirect expressions (e.g., ambivalence, unconscious implications) were much less frequently observed in the notes of the elderly than other adults. The research also found that older males often wrote about painful problems in their interpersonal relations in their final letters and this pain was significant in making their final decision. Future research, specifically regarding a protocol analysis based on a review of the research on suicide in the elderly, will be discussed.
Opinions of dental consultants on the standard of referral letters in dentistry.
AIM: To ascertain the views of dental consultants on the relative importance of a range of topics relevant to specialist referral. SUBJECTS: 200 randomly selected dental consultants working in the UK in 1995. MAIN OUTCOME MEASURES: Data items which referral letters should contain; standard of referral letters; appropriate reasons for referral; how referrals could be improved; should restrictions be placed on specialist referrals. RESULTS: 161 replies were received. Overall there was only slight variation between specialities with regard to data items, appropriateness of referral and standard of referral letter. The perceived standard of referral letters was adequate or better on 76% of occasions; 21% were deemed to be of a poor standard; 2% were described as appalling. CONCLUSIONS: A Section 63 course on how to refer competently could be of benefit. Consultants were generally not in favour of restricting referrals to them.
Topical capsaicin in the management of HIV-associated peripheral neuropathy.
Distal symmetrical peripheral neuropathy (DSPN) is a particularly distressing pain syndrome associated with human immunodeficiency virus (HIV) disease. Capsaicin has been found to be effective in relieving pain associated with other neuropathic pain syndromes, and is mentioned as a possible topical adjuvant analgesic for the relief of DSPN. This multicenter, controlled, randomized, double-masked clinical trial studied patients with HIV-associated DSPN and compared measures of pain intensity, pain relief, sensory perception, quality of life, mood, and function for patients who received topical capsaicin to the corresponding measures for patients who received the vehicle only. Twenty-six subjects were enrolled in the study. At the end of 1 week, subjects receiving capsaicin tended to report higher current pain scores than did subjects receiving the vehicle (Mann-Whitney test; P = 0.042). The dropout rate was higher for the capsaicin group (67%) than for the vehicle group (18%) (chi 2 test of association; P = 0.014). There were no other statistically significant differences between the capsaicin and vehicle groups with respect to current pain, worst pain, pain relief, sensory perception, quality of life, mood, or function at study entry or at any time during the 4-week trial. These results suggest capsaicin is ineffective in relieving pain associated with HIV-associated DSPN.
Qualitative evaluation of a form for standardized information exchange between orthopedic surgeons and occupational physicians.
BACKGROUND: Both occupational physicians and orthopedic surgeons can be involved in the management of work relevant musculoskeletal disorders. These physicians hardly communicate with each other and this might lead to different advice to the patient. Therefore, we evaluated a standardized information exchange form for the exchange of relevant information between the orthopedic surgeon and the occupational physician. The main goals of this qualitative study are to evaluate whether the form improved information exchange, whether the form gave relevant information, and to generate ideas to further improve this information exchange. METHODS: The information exchange form was developed in two consensus meetings with five orthopedic surgeons and five occupational physicians. To evaluate the information exchange form, a qualitative evaluation was set up. Structured telephone interviews were undertaken with the patients, interviews with the physicians were face-to-face and semi-structured, based on a topic list. These interviews were recorded and literally transcribed. Each interview was analyzed separately in Atlas-Ti. RESULTS: The form was used for 8 patients, 7 patients agreed to participate in the qualitative evaluation. All three orthopedic surgeons involved and three of the six involved occupational physicians agreed to be interviewed. The form was transferred to 4 occupational physicians, the other 3 patients recovered before they visited the occupational physician. The information on the form was regarded to be useful. All orthopedic surgeons agreed that the occupational physician should take the initiative. Most physicians felt that the form should not be filled out for each patient visiting an orthopedic surgeon, but only for those patients who do not recover as expected. Orthopedic surgeons suggested that a copy of the medical information provided to the general practitioner could also be provided to occupational physicians. CONCLUSION: The information exchange form was regarded to be useful and could be used in practice. The occupational physician should take the initiative for using this form and most physicians felt the information should only be exchanged for patients who do not recover as expected. That means that the advantage of giving information early in the treatment is lost.
Improving social adjustment in children with attention-deficit/hyperactivity disorder.
OBJECTIVE: To determine if sending motivational letters would improve peer relations in children with social maladjustment and attention-deficit/hyperactivity disorder (ADHD). DESIGN: From a consecutive sample, a case series was followed up for 2 years. SETTING: Primary care, private physician, office-based practice. PATIENTS: Ninety-five children diagnosed as having ADHD by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria made up the consecutive sample. Twenty-one children qualified with a comorbid social maladjustment disorder with baseline t scores of 1.5 SDs or greater above the mean on the asocial domain of the Conners' Teacher Rating Scale. Seventeen children completed the study. There were no significant differences between these patients and those who did not complete the study (P = .55 for baseline score differences and P = .85 for age). INTERVENTIONS: In addition to conventional therapy for ADHD when children achieved a goal, such as an improved report card or better conduct, a personal letter about their success was mailed to them. Letters averaged 5 per student per year. MAIN OUTCOME MEASURES: The asocial domain of the Conners' Teacher Rating Scale was repeated during the next 2 school years for comparison. Statistical analysis was by a repeated-measures analysis of variance and Helmert contrasts. RESULTS: Of 17 students who completed the study, 16 improved on the Conners' Teacher Rating Scale asocial domain, and the results were statistically significant (P<.001). CONCLUSIONS: Difficulties with peer relations are commonly seen in children with ADHD. Sending motivational letters correlated with improved social adjustment in these children. The data suggest that busy practitioners might consider incorporating this successful, and time-efficient, intervention into their ADHD treatment regimens.
Freedom vs fairness. The need for a rational system of evaluation of medical trainees.
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