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1.  Can Contextualization Increase Understanding During Man-Machine Communication? A Theory-Driven Study 
The Internet offers unlimited possibilities for finding health information. However, the user is often faced with the problem of understanding it. Contextualization has a role to play in enhancing the user’s comprehension. We report on a study which addresses this issue, using a theoretical model of communication whose central theme is that of context. A randomized controlled experimental design was chosen, using as a test-bed the website SeniorGezond we had previously developed. The study was composed of a pre-test, the intervention with the website and a post-test. Participants (n=40) were randomly assigned to exposure or no exposure to contextualization with the website. Results show that contextualization increases understanding for non-knowledgeable users. Furthermore, the participant’s cognitive style was found to be a significant factor on understanding. We also found that participants bring their own contexts such as social context and psychological context to support their understanding.
doi:10.2174/1874431100802010082
PMCID: PMC2669642  PMID: 19415137
Internet; communication; consumer health information; contextualization of information; information retrieval.
2.  Exploring Patients' Views of a Cognitive Behavioral Therapy-Based Website for the Self-Management of Irritable Bowel Syndrome Symptoms 
Background
Cognitive behavioral therapy (CBT) has been shown to have positive effects on the management of irritable bowel syndrome (IBS) symptoms. A factorial pilot randomized placebo-controlled trial (called MIBS) tested the potential effectiveness of a self-management CBT-based website alongside two medications: methylcellulose and mebeverine, and a placebo. The results showed no significant differences in quality of life or symptom severity measures, but enablement and participant’s global assessment of relief was higher in the website groups.
Objective
To conduct a qualitative study nested within this trial, in order to explore patients’ views and experiences of using the CBT-based website to facilitate self-management of IBS.
Methods
Semistructured interviews were carried out with patients who had used the website with one session of nurse support (n=16) or the website alone (n=15) while participating in the MIBS trial. An inductive thematic analysis was conducted.
Results
We identified three types of engagement with the CBT-based website. One group of participants, mostly in the website-only condition, had limited or no engagement with the website. One group engaged with the content and advice on practical lifestyle changes. The final group of participants engaged with the content and advice on psychological aspects related to IBS. Similarities and differences between these three groups are explored.
Conclusions
Teaching self-management techniques through a Web intervention was received positively by most of the participants. Concepts linked to cognitive aspects of CBT appeared to be harder for participants to engage with. Participants who received nurse support rated the cognitive aspects more positively, suggesting that some therapy support alongside the website should be considered. However, the Web format was preferred by some who favored anonymity as well as those who appreciated the accessibility and ease of use of this type of management. Suggestions on how to encourage engagement with Web interventions are discussed.
doi:10.2196/jmir.2672
PMCID: PMC3785978  PMID: 24001787
irritable bowel syndrome; cognitive behaviour therapy; Internet; primary care; qualitative research
3.  Grapheme-color synaesthesia is associated with a distinct cognitive style 
In this study we investigated whether synaesthesia is associated with a particular cognitive style. Cognitive style refers to preferred modes of information processing, such as a verbal style or a visual style. We reasoned that related to the enriched world of experiences created by synaesthesia, its association with enhanced verbal and visual memory, higher imagery and creativity, synaesthetes might show enhanced preference for a verbal as well as for a visual cognitive style compared to non-synaesthetes. In Study 1 we tested a large convenience sample of 1046 participants, who classified themselves as grapheme-color, sound-color, lexical-gustatory, sequence-space, or as non-synaesthetes. To assess cognitive style, we used the revised verbalizer-visualizer questionnaire (VVQ), which involves three independent cognitive style dimensions (verbal style, visual-spatial style, and vivid imagery style). The most important result was that those who reported grapheme-color synaesthesia showed higher ratings on the verbal and vivid imagery style dimensions, but not on the visual-spatial style dimension. In Study 2 we replicated this finding in a laboratory study involving 24 grapheme-color synaesthetes with objectively confirmed synaesthesia and a closely matched control group. Our results indicate that grapheme-color synaesthetes prefer both a verbal and a specific visual cognitive style. We suggest that this enhanced preference, probably together with the greater ease to switch between a verbal and a vivid visual imagery style, may be related to cognitive advantages associated with grapheme color synaesthesia such as enhanced memory performance and creativity.
doi:10.3389/fpsyg.2013.00632
PMCID: PMC3777024  PMID: 24065938
visualizer; verbalizer; imagery; learning style; memory; creativity
4.  Social Presence and Use of Internet-Delivered Interventions: A Multi-Method Approach 
PLoS ONE  2013;8(2):e57067.
Objective
Internet-delivered interventions can effectively change health risk behaviors and their determinants, but adherence to intervention websites once they are accessed is very low. This study tests whether and how social presence elements can increase website use.
Methods
A website about Hepatitis A, B, and C virus infections was used in a preparatory lab-based eye-tracking study assessing whether social presence elements attract participants' attention, because this is a prerequisite for affecting website use. In the following field study, 482 participants representative of the Dutch population were randomized to either a website with or a website without social presence elements. Participants completed a questionnaire of validated measures regarding user perceptions immediately after exposure to the website. Server registrations were used to assess website use.
Results
Participants in the experimental condition focused on the social presence elements, both in terms of frequency (F(1, 98) = 40.34, p<.001) and duration (F(1, 88) = 39.99, p<.001), but did not differ in website use in comparison with the control condition; neither in terms of the number of pages visited (t(456) = 1.44, p = .15), nor in terms of time on the website (t(456) = 0.01, p = .99).
Conclusions
Adding social presence elements did not affect actual use of an intervention website within a public health context. Possible reasons are limited attention for these elements in comparison with the main text and the utilitarian value of intervention websites.
doi:10.1371/journal.pone.0057067
PMCID: PMC3577738  PMID: 23437310
5.  Design and process evaluation of an informative website tailored to breast cancer survivors’ and intimate partners’ post-treatment care needs 
BMC Research Notes  2012;5:548.
Background
On-line provision of information during the transition phase after treatment carries great promise in meeting shortcomings in post-treatment care for breast cancer survivors and their partners. The objectives of this study are to describe the development and process evaluation of a tailored informative website and to assess which characteristics of survivors and partners, participating in the feasibility study, are related to visiting the website.
Methods
The development process included quantitative and qualitative assessments of survivors’ and partners’ care needs and preferences. Participants’ use and evaluation of the website were explored by conducting baseline and post-measurements. During the intervening 10–12 weeks 57 survivors and 28 partners were granted access to the website.
Results
Fifty-seven percent (n=21) of survivors who took part in the post-measurement indicated that they had visited the website. Compared to non-visitors (n=16), they were more likely to have a partner and a higher income, reported higher levels of self-esteem and had completed treatment for a longer period of time. Partners who consulted the on-line information (42%, n=8) were younger and reported lower levels of social support compared to partners who did not visit the website (n=11). Visitors generally evaluated the content and lay-out positively, yet some believed the information was incomplete and impersonal.
Conclusions
The website reached only about half of survivors and partners, yet was mostly well-received. Besides other ways of providing information and support, a website containing clear-cut and tailored information could be a useful tool in post-treatment care provision.
doi:10.1186/1756-0500-5-548
PMCID: PMC3583797  PMID: 23034161
Breast cancer; Partner; Design study; Process evaluation; Internet; Survivorship
6.  Providing Patients Web-based Data to Inform Physician Choice: If You Build It, Will They Come? 
Journal of General Internal Medicine  2007;22(10):1463-1466.
Background
Despite growing emphasis on public reporting of health care quality data, available data are often ignored.
Objective
To evaluate the usefulness of web-based physician-level data for patients choosing a new primary care physician (PCP).
Design
Patients seeking a new PCP (n = 2225) were invited to view web-based information including PCP credentials, personal characteristics, office location and hours, and patient experience scores. Patient experience scores included validated measures of interpersonal quality, appointment access, care coordination, health promotion, and patient recommendations of the PCP. After viewing the website, participants indicated their preferred PCP and completed a study questionnaire.
Results
Of the invited participants, 17% visited the website (n = 382). Patient experience scores were cited most frequently as important to physician choice (51%). Among these measures, patients’ highest priorities were interpersonal quality (37%) and patient recommendations of the PCP (41%). For patients citing these priorities, the odds of choosing a highly scored physician after viewing the data was nearly 10 times that of choosing such a physician by chance (odds ratio (OR) = 9.52 and 9.71, respectively).
Conclusions
Targeting patients known to be making a health care decision appears to promote the use of performance data. Patients particularly valued data concerning other patients’ experiences and, after viewing the data, made choices well-aligned with their priorities.
doi:10.1007/s11606-007-0278-1
PMCID: PMC2305859  PMID: 17653810
health care decision-making; physician performance measures; public reporting; patient care experience measures
7.  Evaluation of Active Transition, a Website-Delivered Physical Activity Intervention for University Students: Pilot Study 
JMIR Research Protocols  2013;2(1):e16.
Background
While physical activity in individuals tends to decline steadily with age, there are certain periods where this decline occurs more rapidly, such as during early adulthood. Interventions aimed at attenuating the declines in physical activity during this transition period appear warranted.
Objective
The purpose of the study was to test the feasibility and efficacy of a theoretically informed, website-delivered physical activity intervention aimed at students entering university.
Methods
Using a quasi-experimental design, 65 participants (44 females; mean age 18.51, SD 0.91) were assigned to either an intervention (receiving website access plus weekly prompts) or comparison condition (receiving unprompted website access only), completing questionnaires at baseline and follow-up 8 weeks later. The intervention website, “Active Transition”, was specifically designed to target students’ physical activity cognitions and self-regulatory skills.
Results
Intervention usage was low, with only 47% (18/38) of participants assigned to the intervention condition logging into the website 2 or more times. Among the broader student sample, there were significant declines in students’ physical activity behaviors (F 1,63=18.10, P<.001), attitudes (F 1,62=55.19, P<.001), and perceived behavioral control (F 1,62 =17.56, P<.001). In comparisons between intervention users (29/65, individuals logging in 2 or more times) and non-users (36/65, individuals logging in once or not at all), there was a significant interaction effect for intervention usage and time on perceived behavioral control (F 1,62=5.13, P=.03).
Conclusions
Poor intervention usage suggests that future efforts need to incorporate innovative strategies to increase intervention uptake and better engage the student population. The findings, however, suggest that a website-delivered intervention aimed at this critical life stage may have positive impact on students’ physical activity cognitions. Future studies with more rigorous sampling designs are required.
doi:10.2196/resprot.2099
PMCID: PMC3650928  PMID: 23649858
physical activity; efficacy trial; Internet-based intervention; university students
8.  Factors influencing use of an e-health website in a community sample of older adults 
Objective
The use of the internet as a source of health information and link to healthcare services has raised concerns about the ability of consumers, especially vulnerable populations such as older adults, to access these applications. This study examined the influence of training on the ability of adults (aged 45+ years) to use the Medicare.gov website to solve problems related to health management. The influence of computer experience and cognitive abilities on performance was also examined.
Design
Seventy-one participants, aged 47–92, were randomized into a Multimedia training, Unimodal training, or Cold Start condition and completed three healthcare management problems.
Measurement and analyses
Computer/internet experience was measured via questionnaire, and cognitive abilities were assessed using standard neuropsychological tests. Performance metrics included measures of navigation, accuracy and efficiency. Data were analyzed using analysis of variance, χ2 and regression techniques.
Results
The data indicate that there was no difference among the three conditions on measures of accuracy, efficiency, or navigation. However, results of the regression analyses showed that, overall, people who received training performed better on the tasks, as evidenced by greater accuracy and efficiency. Performance was also significantly influenced by prior computer experience and cognitive abilities. Participants with more computer experience and higher cognitive abilities performed better.
Conclusions
The findings indicate that training, experience, and abilities are important when using complex health websites. However, training alone is not sufficient. The complexity of web content needs to be considered to ensure successful use of these websites by those with lower abilities.
doi:10.1136/amiajnl-2012-000876
PMCID: PMC3638176  PMID: 22802269
Older adults; e-health; training
9.  Return of Incidental Findings in Genomic Medicine: Measuring What Patients Value 
Purpose
Little is known about factors that influence patients’ preferences for the return of incidental findings from genome sequencing. This study identified attributes of incidental findings that were important to patients and developed a discrete choice experiment (DCE) instrument to quantify patient preferences.
Methods
An initial set of key attributes and attribute levels was developed from a literature review and in consultation with experts. The attributes’ salience and communication were refined using focus group methodology (N=12) and cognitive interviews (N=6) with patients who had received conventional genetic testing for familial colorectal cancer or polyposis syndromes. The attributes and levels used in the hypothetical choices presented to participants were identified using validated experimental design techniques.
Results
The final DCE instrument incorporates the following attributes and levels: lifetime risk of disease (5%, 40%, 70%); disease treatability (medical, lifestyle, none); disease severity (mild, moderate, severe); carrier status (yes, no); drug response likelihood (high, moderate, none), and test cost ($250, $425, $1000, $1900).
Conclusion
Patient preferences for incidental genomic findings are likely influenced by a complex set of diverse attributes. Quantification of patient preferences can inform patient-provider communication by highlighting the attributes of incidental findings that matter most to patients and warrant further discussion.
doi:10.1038/gim.2013.63
PMCID: PMC3823641  PMID: 23722871
10.  Delivering interventions for depression by using the internet: randomised controlled trial 
BMJ : British Medical Journal  2004;328(7434):265.
Objective To evaluate the efficacy of two internet interventions for community-dwelling individuals with symptoms of depression—a psychoeducation website offering information about depression and an interactive website offering cognitive behaviour therapy.
Design Randomised controlled trial.
Setting Internet users in the community, in Canberra, Australia.
Participants 525 individuals with increased depressive symptoms recruited by survey and randomly allocated to a website offering information about depression (n = 166) or a cognitive behaviour therapy website (n = 182), or a control intervention using an attention placebo (n = 178).
Main outcome measures Change in depression, dysfunctional thoughts; knowledge of medical, psychological, and lifestyle treatments; and knowledge of cognitive behaviour therapy.
Results Intention to treat analyses indicated that information about depression and interventions that used cognitive behaviour therapy and were delivered via the internet were more effective than a credible control intervention in reducing symptoms of depression in a community sample. For the intervention that delivered cognitive behaviour therapy the reduction in score on the depression scale of the Center for Epidemiologic Studies was 3.2 (95% confidence interval 0.9 to 5.4). For the “depression literacy” site (BluePages), the reduction was 3.0 (95% confidence interval 0.6 to 5.2). Cognitive behaviour therapy (MoodGYM) reduced dysfunctional thinking and increased knowledge of cognitive behaviour therapy. Depression literacy (BluePages) significantly improved participants' understanding of effective evidence based treatments for depression (P < 0.05).
Conclusions Both cognitive behaviour therapy and psychoeducation delivered via the internet are effective in reducing symptoms of depression.
doi:10.1136/bmj.37945.566632.EE
PMCID: PMC324455  PMID: 14742346
11.  Are women ready for the new cervical screening protocol in England? A systematic review and qualitative synthesis of views about human papillomavirus testing 
British Journal of Cancer  2012;107(2):243-254.
Background:
A new protocol for human papillomavirus (HPV) testing within the UK cervical screening programme commenced in April 2011, creating new patient experiences. This is the first review to synthesise a substantial body of international evidence of women's information needs, views and preferences regarding HPV testing. We aimed to inform the development of educational materials to promote informed choice, reduce anxiety and improve disease control.
Methods:
We searched 12 bibliographic databases. Two reviewers independently screened papers and assessed study quality; disagreements were resolved by discussion. Results were extracted verbatim and authors' findings treated as primary data. Studies were synthesised collaboratively using framework methods.
Results:
We synthesised findings from 17 studies. Women had overwhelmingly negative concerns; an HPV diagnosis was daunting, had associated problems of disclosure of a sexually transmitted infection (STI), impacted on relationships and provoked fear of stigmatisation. Nevertheless, many thought HPV testing could be a preferable alternative to repeat cytology. Knowledge was poor; women struggled to interpret limited information in the context of existing knowledge about STIs and cervical cancer.
Conclusion:
Women are likely to be poorly informed, have limited understanding and many unanswered questions. This could increase anxiety and reduce ability to make informed choices, presenting a substantial challenge for those who design and provide information.
doi:10.1038/bjc.2012.256
PMCID: PMC3394982  PMID: 22699825
human papillomavirus; cervical screening; cervical cancer; systematic review
12.  Building blocks for meta-synthesis: data integration tables for summarising, mapping, and synthesising evidence on interventions for communicating with health consumers 
Background
Systematic reviews have developed into a powerful method for summarising and synthesising evidence. The rise in systematic reviews creates a methodological opportunity and associated challenges and this is seen in the development of overviews, or reviews of systematic reviews. One of these challenges is how to summarise evidence from systematic reviews of complex interventions for inclusion in an overview. Interventions for communicating with and involving consumers in their care are frequently complex. In this article we outline a method for preparing data integration tables to enable review-level synthesis of the evidence on interventions for communication and participation in health.
Methods and Results
Systematic reviews published by the Cochrane Consumers and Communication Review Group were utilised as the basis from which to develop linked steps for data extraction, evidence assessment and synthesis. The resulting output is called a data integration table. Four steps were undertaken in designing the data integration tables: first, relevant information for a comprehensive picture of the characteristics of the review was identified from each review, extracted and summarised. Second, results for the outcomes of the review were assessed and translated to standardised evidence statements. Third, outcomes and evidence statements were mapped into an outcome taxonomy that we developed, using language specific to the field of interventions for communication and participation. Fourth, the implications of the review were assessed after the mapping step clarified the level of evidence available for each intervention.
Conclusion
The data integration tables represent building blocks for constructing overviews of review-level evidence and for the conduct of meta-synthesis. Individually, each table aims to improve the consistency of reporting on the features and effects of interventions for communication and participation; provides a broad assessment of the strength of evidence derived from different methods of analysis; indicates a degree of certainty with results; and reports outcomes and gaps in the evidence in a consistent and coherent way. In addition, individual tables can serve as a valuable tool for accurate dissemination of large amounts of complex information on communication and participation to professionals as well as to members of the public.
doi:10.1186/1471-2288-9-16
PMCID: PMC2678150  PMID: 19261177
13.  Interactive E-learning module in pharmacology: a pilot project at a rural medical college in India 
Many medical educators are experimenting with innovative ways of E-learning. E-learning provides opportunities to students for self-directed learning in addition to other advantages. In this study, we designed and evaluated an interactive E-learning module in pharmacology for effectiveness, acceptability and feasibility, with the aim of promoting active learning in this fact-filled subject. A quasi-experimental single-group pre-test/post-test study was conducted with fourth-semester students of the second professionals course (II MBBS), selected using non-probability convenience sampling method. An E-learning module in endocrine pharmacology was designed to comprise three units of interactive PowerPoint presentations. The pre-validated presentations were uploaded on the website according to a predefined schedule and the 42 registered students were encouraged to self-learning using these interactive presentations. Cognitive gain was assessed using an online pre- and post-test for each unit. Students’ perceptions were recorded using an online feedback questionnaire on a 5-point Likert scale. Finally, focused group discussion was conducted to further explore students’ views on E-learning activity. Significant attrition was observed during the E-learning activity. Of the 42 registered students, only 16 students completed the entire E-learning module. The summed average score of all three units (entire module) was increased significantly from 38.42 % (summed average pre-test score: 11.56/30 ± 2.90) to 66.46 % (summed average post-test score: 19.94/30 ± 6.13). The class-average normalized gain for the entire module was 0.4542 (45.42). The students accepted this E-learning activity well as they perceived it to be innovative, convenient, flexible and useful. The average rating was between 4 (agree) and 5 (strongly agree). The interactive E-learning module in pharmacology was moderately effective and well perceived by the students. The simple, cost-effective and readily available Microsoft PowerPoint tool appealed to medical educators to use this kind of simple E-learning technology blended with traditional teaching to encourage active learning among students especially in a rural setup is attractive.
doi:10.1007/s40037-013-0081-0
PMCID: PMC3890000  PMID: 24072666
E-learning; Pharmacology; Active learning; Self-learning; PowerPoint
14.  The acceptability of urinary LCR testing for Chlamydia trachomatis among participants in a probability sample survey of sexual attitudes and lifestyles 
Sexually Transmitted Infections  2001;77(3):194-198.
websiteextra
A table detailing response rates appears on the STI website.
www.sextransinf.com
Objectives: To examine the factors that influence respondents' willingness to participate in urinary testing for Chlamydia trachomatis in a general population feasibility survey of sexual attitudes and lifestyles.
Methods: 199 sexually experienced, 18–44 year old participants, recruited as part of a larger (n=901) methodological study of sexual attitudes and lifestyles, were invited to provide a urine sample for chlamydial infection testing using ligase chain reaction (LCR) techniques. Analysis of the survey data and in-depth qualitative interviews were undertaken to explore the factors that influenced participants' decisions to participate.
Results: 143/199 (72%) participants agreed to provide a urine sample. The likelihood of providing a urine sample was reduced if other individuals were present in the home at the time of interview (OR 0.42, 95% confidence interval 0.20–0.90, p=0.03). Trust and rapport with the interviewer, understanding the aims of the test, sense of obligation, and perceived importance of the test were identified as additional influencing factors in the in-depth interviews.
Conclusions: Survey respondents' uncertainty or embarrassment at participating in urine testing can be overcome if they are well informed, motivated by the potential health gain, and briefed by trained and confident interviewers.
Key Words: screening; chlamydia; sexually transmitted diseases; survey; sexual behaviour
doi:10.1136/sti.77.3.194
PMCID: PMC1744322  PMID: 11402228
15.  Development of StopAdvisor 
ABSTRACT
Reviews of internet-based behaviour-change interventions have shown that they can be effective but there is considerable heterogeneity and effect sizes are generally small. In order to advance science and technology in this area, it is essential to be able to build on principles and evidence of behaviour change in an incremental manner. We report the development of an interactive smoking cessation website, StopAdvisor, designed to be attractive and effective across the social spectrum. It was informed by a broad motivational theory (PRIME), empirical evidence, web-design expertise, and user-testing. The intervention was developed using an open-source web-development platform, ‘LifeGuide’, designed to facilitate optimisation and collaboration. We identified 19 theoretical propositions, 33 evidence- or theory-based behaviour change techniques, 26 web-design principles and nine principles from user-testing. These were synthesised to create the website, ‘StopAdvisor’ (see http://www.lifeguideonline.org/player/play/stopadvisordemonstration). The systematic and transparent application of theory, evidence, web-design expertise and user-testing within an open-source development platform can provide a basis for multi-phase optimisation contributing to an ‘incremental technology’ of behaviour change.
doi:10.1007/s13142-012-0135-6
PMCID: PMC3717907  PMID: 24073123
Smoking cessation intervention; Internet-based; Website; Theory-based
16.  An empirical comparison of methods for analyzing correlated data from a discrete choice survey to elicit patient preference for colorectal cancer screening 
Background
A discrete choice experiment (DCE) is a preference survey which asks participants to make a choice among product portfolios comparing the key product characteristics by performing several choice tasks. Analyzing DCE data needs to account for within-participant correlation because choices from the same participant are likely to be similar. In this study, we empirically compared some commonly-used statistical methods for analyzing DCE data while accounting for within-participant correlation based on a survey of patient preference for colorectal cancer (CRC) screening tests conducted in Hamilton, Ontario, Canada in 2002.
Methods
A two-stage DCE design was used to investigate the impact of six attributes on participants' preferences for CRC screening test and willingness to undertake the test. We compared six models for clustered binary outcomes (logistic and probit regressions using cluster-robust standard error (SE), random-effects and generalized estimating equation approaches) and three models for clustered nominal outcomes (multinomial logistic and probit regressions with cluster-robust SE and random-effects multinomial logistic model). We also fitted a bivariate probit model with cluster-robust SE treating the choices from two stages as two correlated binary outcomes. The rank of relative importance between attributes and the estimates of β coefficient within attributes were used to assess the model robustness.
Results
In total 468 participants with each completing 10 choices were analyzed. Similar results were reported for the rank of relative importance and β coefficients across models for stage-one data on evaluating participants' preferences for the test. The six attributes ranked from high to low as follows: cost, specificity, process, sensitivity, preparation and pain. However, the results differed across models for stage-two data on evaluating participants' willingness to undertake the tests. Little within-patient correlation (ICC ≈ 0) was found in stage-one data, but substantial within-patient correlation existed (ICC = 0.659) in stage-two data.
Conclusions
When small clustering effect presented in DCE data, results remained robust across statistical models. However, results varied when larger clustering effect presented. Therefore, it is important to assess the robustness of the estimates via sensitivity analysis using different models for analyzing clustered data from DCE studies.
doi:10.1186/1471-2288-12-15
PMCID: PMC3306749  PMID: 22348526
Discrete choice experiment; Intra-class correlation; Statistical model; Patient preference
17.  Thou shalt versus thou shalt not: a meta-synthesis of GPs' attitudes to clinical practice guidelines 
Background
GPs' adherence to clinical practice guidelines is variable. Barriers to guideline implementation have been identified but qualitative studies have not been synthesised to explore what underpins these attitudes.
Aim
To explore and synthesise qualitative research on GPs' attitudes to and experiences with clinical practice guidelines.
Design of study
Systematic review and meta-synthesis of qualitative studies.
Method
PubMed, CINAHL, EMBASE, Social Science Citation Index, and Science Citation Index were used as data sources, and independent data extraction was carried out. Discrepancies were resolved by consensus. Initial thematic analysis was conducted, followed by interpretative synthesis.
Results
Seventeen studies met the inclusion criteria. Five were excluded following quality appraisal. Twelve papers were synthesised which reported research in the UK, US, Canada, and the Netherlands, and covered different clinical guideline topics. Six themes were identified: questioning the guidelines, GPs' experience, preserving the doctor–patient relationship, professional responsibility, practical issues, and guideline format. Comparative analysis and synthesis revealed that GPs' reasons for not following guidelines differed according to whether the guideline in question was prescriptive, in that it encouraged a certain type of behaviour or treatment, or proscriptive, in that it discouraged certain treatments or behaviours.
Conclusion
Previous analyses of guidelines have focused on professional attitudes and organisational barriers to adherence. This synthesis suggests that the purpose of the guideline, whether its aims are prescriptive or proscriptive, may influence if and how guidelines are received and implemented.
PMCID: PMC2084137  PMID: 18252073
attitudes of health personnel; general practice; guideline adherence; guidelines; meta-synthesis; qualitative research
18.  What words and where? Applying usability testing techniques to name a new live reference service 
Objective: A user-focused design approach was taken to develop a new “live reference” service at the Health Sciences Library, University of Saskatchewan. The name of the service, the placement of the links, and the design of a graphical button were seen as key elements in creating service awareness and its subsequent use.
Methods: To ensure library users recognized and understood the label for the new service, selected library users were given an opportunity to choose a phrase that would best describe the service. The top two preferred phrases were then placed on the library Web pages as text and graphic images for further testing. Some pages had links in multiple locations to determine which placement worked best. Task-based usability testing was carried out with participants who were unaware of the new service. Participants were observed as they completed seven Website tasks arranged in increasing levels of difficulty to see whether they would notice the live reference service and seek assistance.
Results: The high level of recognition and use of the service indicate that the label name and link placement were effective with library Website users.
Conclusions: Using user-centered design methodology helped ensure that the new live reference service was visible and used and demonstrated the effectiveness of the user-centered design approach for adding new services to an existing Website.
PMCID: PMC385303  PMID: 15098051
19.  Transforming Dissatisfaction with Services into Self-Determination: A Social Psychological Perspective on Community Program Effectiveness 
Journal of applied social psychology  2009;39(8):1835-1859.
A field study of supported employment for adults with mental illness (N=174) provided an experimental test of cognitive dissonance theory. We predicted that most work-interested individuals randomly assigned to a non-preferred program would reject services and lower their work aspirations. However, individuals who chose to pursue employment through a non-preferred program were expected to resolve this dissonance through favorable service evaluations and strong efforts to succeed at work. Significant work interest-by-service preference interactions supported these predictions. Over two years, participants interested in employment who obtained work through a non-preferred program stayed employed a median of 362 days versus 108 days for those assigned to a preferred program, and participants who obtained work through a non-preferred program had higher service satisfaction.
doi:10.1111/j.1559-1816.2009.00506.x
PMCID: PMC2796807  PMID: 20037662
20.  Divergent Selection and the Evolution of Signal Traits and Mating Preferences 
PLoS Biology  2005;3(11):e368.
Mating preferences are common in natural populations, and their divergence among populations is considered an important source of reproductive isolation during speciation. Although mechanisms for the divergence of mating preferences have received substantial theoretical treatment, complementary experimental tests are lacking. We conducted a laboratory evolution experiment, using the fruit fly Drosophila serrata, to explore the role of divergent selection between environments in the evolution of female mating preferences. Replicate populations of D. serrata were derived from a common ancestor and propagated in one of three resource environments: two novel environments and the ancestral laboratory environment. Adaptation to both novel environments involved changes in cuticular hydrocarbons, traits that predict mating success in these populations. Furthermore, female mating preferences for these cuticular hydrocarbons also diverged among populations. A component of this divergence occurred among treatment environments, accounting for at least 17.4% of the among-population divergence in linear mating preferences and 17.2% of the among-population divergence in nonlinear mating preferences. The divergence of mating preferences in correlation with environment is consistent with the classic by-product model of speciation in which premating isolation evolves as a side effect of divergent selection adapting populations to their different environments.
Experimentally manipulating the resource environment of Drosophila serrata reveals that mating preferences can evolve, at least in part, as a result of environmentally-based divergent natural selection.
doi:10.1371/journal.pbio.0030368
PMCID: PMC1262626  PMID: 16231971
21.  Older Home-Care Patients' Preferred Approaches to Depression Care 
The purpose of this pilot study was to explore the approaches to depression care preferred by older home-care patients and examine characteristics associated with those preferences. Twenty-eight long-term home-care patients, ages 62 to 95, were interviewed. Patients ranked their depression care preferences and provided rationale for their responses. Results indicated prayer was preferred by the highest percentage of patients (50%). Comparing patients with and without depression experience, prayer was preferred by the latter group. The results highlight the importance of addressing patient preferences during care planning to improve participation in geriatric depression care management.
PMCID: PMC3672860  PMID: 18714602
22.  Risk Information Exposure and Direct to Consumer Genetic Testing for BRCA Mutations among Women with a Personal or Family History of Breast or Ovarian Cancer 
Background
Direct to consumer (DTC) BRCA testing may expand access to genetic testing and enhance cancer prevention efforts. However, it is not know if current DTC websites provide adequate risk information for informed medical decision-making.
Methods
284 women with a personal or family history of breast/ovarian cancer were randomly assigned to view a “mock” DTC commercial website (control condition: CC, n=93) or the same “mock” website that included information on the potential risks of obtaining genetic testing online. Risk information was framed two ways: risk information attributed to expert sources (ES, n=98) and unattributed risk information (URI, n=93). Participants completed an online survey. Endpoints were intentions to get BRCA testing, testing site preference and beliefs about DTC BRCA testing.
Results
Sample characteristics: mean age 39 (range 18–70), 82% white, mean education 3 yrs. college. Women exposed to risk information had lower intentions to get BRCA testing than women in the CC (adjusted odds ratio (OR) 0.48; 95% confidence interval (CI) 0.26–0.87, p=0.016), less positive beliefs about online BRCA testing (adjusted OR 0.48; 95% 0.27–0.86, p=0.014). Women in the ES condition were more likely to prefer clinic based testing than women in the CC (adjusted OR 2.05; 95% CI 1.07–3.90, p=0.030).
Conclusion
Exposing women to information on the potential risks of online BRCA testing altered their intentions, beliefs and preferences for BRCA testing. Policy makers may want to consider content and framing of risk information on DTC websites as they formulate regulation for this rapidly growing industry.
doi:10.1158/1055-9965.EPI-08-0825
PMCID: PMC2963112  PMID: 19318436
communication; direct to consumer; BRCA; informed consent; cancer
23.  Selective information seeking: can consumers' avoidance of evidence-based information on colorectal cancer screening be explained by the theory of cognitive dissonance? 
Background: Evidence-based patient information (EBPI) is a prerequisite for informed decision-making. However, presentation of EBPI may lead to irrational reactions causing avoidance, minimisation and devaluation of the information.
Objective: To explore whether the theory of cognitive dissonance is applicable to medical decision-making and useful to explain these phenomena.
Setting and participants: 261 volunteers from Hamburg (157 women), ≥50 years old without diagnosis of colorectal cancer.
Design and variables: Within an experiment we simulated information seeking on colorectal cancer screening. Consumers’ attitudes towards screening were surveyed using a rating scale from -5 (participate in no way) to +5 (participate unconditionally) (independent variable). Using a cover story, participants were asked to sort 5 article headlines according to their reading preferences. The headlines simulated the pro to contra variety of contents to be found in print media about colorectal cancer screening. The dependent variable was the sequence of article headlines.
Results: Participants were very much in favour of screening with scores for faecal occult blood test of 4.0 (0.1) and for colonoscopy 3.3 (0.1). According to our hypothesis we found statistically significant positive correlations between the stimuli in favour of screening and attitudes and significant negative correlations between the stimuli against screening and attitudes.
Conclusion: The theory of cognitive dissonance is applicable to medical decision-making. It may explain some phenomena of irrational reactions to evidence-based patient information.
PMCID: PMC2703235  PMID: 19675713
evidence-based patient information; cognitive dissonance; information seeking
24.  Mutation-Based Learning to Improve Student Autonomy and Scientific Inquiry Skills in a Large Genetics Laboratory Course 
CBE Life Sciences Education  2013;12(3):460-470.
The innovative mutation-based learning approach (MBL) was created to encourage students to propose redesigns of teacher-designed experiments and to then conduct both teacher-designed and student-designed experiments for comparison. The MBL approach improves students autonomy and scientific inquiry skills.
Laboratory education can play a vital role in developing a learner's autonomy and scientific inquiry skills. In an innovative, mutation-based learning (MBL) approach, students were instructed to redesign a teacher-designed standard experimental protocol by a “mutation” method in a molecular genetics laboratory course. Students could choose to delete, add, reverse, or replace certain steps of the standard protocol to explore questions of interest to them in a given experimental scenario. They wrote experimental proposals to address their rationales and hypotheses for the “mutations”; conducted experiments in parallel, according to both standard and mutated protocols; and then compared and analyzed results to write individual lab reports. Various autonomy-supportive measures were provided in the entire experimental process. Analyses of student work and feedback suggest that students using the MBL approach 1) spend more time discussing experiments, 2) use more scientific inquiry skills, and 3) find the increased autonomy afforded by MBL more enjoyable than do students following regimented instructions in a conventional “cookbook”-style laboratory. Furthermore, the MBL approach does not incur an obvious increase in labor and financial costs, which makes it feasible for easy adaptation and implementation in a large class.
doi:10.1187/cbe.12-09-0168
PMCID: PMC3763013  PMID: 24006394
25.  Role of Cognitive Testing in the Development of the CAHPS® Hospital Survey 
Health Services Research  2005;40(6 Pt 2):2037-2056.
Objective
To describe how cognitive testing results were used to inform the modification and selection of items for the Consumer Assessment of Health Providers and Systems (CAHPS®) Hospital Survey pilot test instrument.
Data Sources
Cognitive interviews were conducted on 31 subjects in two rounds of testing: in December 2002–January 2003 and in February 2003. In both rounds, interviews were conducted in northern California, southern California, Massachusetts, and North Carolina.
Study Design
A common protocol served as the basis for cognitive testing activities in each round. This protocol was modified to enable testing of the items as interviewer-administered and self-administered items and to allow members of each of three research teams to use their preferred cognitive research tools.
Data Collection/Extraction Methods
Each research team independently summarized, documented, and reported their findings. Item-specific and general issues were noted. The results were reviewed and discussed by senior staff from each research team after each round of testing, to inform the acceptance, modification, or elimination of candidate items.
Principal Findings
Many candidate items required modification because respondents lacked the information required to answer them, respondents failed to understand them consistently, the items were not measuring the constructs they were intended to measure, the items were based on erroneous assumptions about what respondents wanted or experienced during their hospitalization, or the items were asking respondents to make distinctions that were too fine for them to make. Cognitive interviewing enabled the detection of these problems; an understanding of the etiology of the problem informed item revisions. However, for some constructs, the revisions proved to be inadequate. Accordingly, items could not be developed to provide acceptable measures of certain constructs such as shared decision making, coordination of care, and delays in the admissions process.
Conclusions
Cognitive testing is the most direct way of finding out whether respondents understand questions consistently, have the information needed to answer the questions, and can use the response alternatives provided to describe their experiences or their opinions accurately. Many of the candidate questions failed to meet these standards. Cognitive testing only evaluates the way in which respondents understand and answer questions. Although it does not directly assess the validity of the answers, it is a reasonable premise that cognitive problems will seriously compromise validity and reliability.
doi:10.1111/j.1475-6773.2005.00472.x
PMCID: PMC1361243  PMID: 16316437
Survey research and questionnaire design; hospitals; cognitive interviewing; CAHPS; patient assessment/satisfaction

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