Medical students' and tutors' experiences of directed and self-directed learning programs in evidence-based medicine: a qualitative evaluation accompanying a randomized controlled trial

This qualitative study aims to interpret the results of a randomized controlled trial comparing two educational programs (directed learning and self-directed learning) in evidence-based medicine (EBM) for medical students at the University of Oslo from 2002 to 2003. There is currently very little comparative educational research in this field. In the trial, no statistically significant differences between the study groups were shown for any outcomes considered (EBM knowledge, skills, and attitudes). Further analysis suggests that main reason for the negative trial results was that the majority of students learned equally effectively, whichever program they received, although implementation of the educational programs was not complete because of varying attendance. This study illustrates a stepwise evaluation model that might be useful in evaluating other socially complex interventions.     

On value-judgements and ethics in health technology assessment

The widespread application of technology in health care has imposed a broad range of challenges. The field of health technology assessment (HTA) is developed in order to face some of these challenges. However, this strategy has not been as successful as one could hope. One of the reasons for this is that social and ethical considerations have not been integrated in the HTA process. Nowadays however, such considerations have been included in many HTAs. Still, the conclusions and recommendations of the HTAs are not followed. The reason for this may be that the methods for integrating ethics for HTA are not sufficiently developed, or that they are not adequate. This article presents a supplementary approach to the ethical inquiry in HTA. It is argued that a value analysis is crucial in order to address the ethical issues of health care technology in a fruitful way and to make viable decisions about such technology.

Against the De Minimis Principle

According to the class of de minimis decision principles, risks can be ignored (or at least treated very differently from other risks) if the risk is sufficiently small. In this article, we argue that a de minimis threshold has no place in a normative theory of decision making, because the application of the principle will either recommend ignoring risks that should not be ignored (e.g., the sure death of a person) or it cannot be used by ordinary bounded and information-constrained agents.     

Principal stratum strategy: Potential role in drug development

A randomized trial allows estimation of the causal effect of an intervention compared to a control in the overall population and in subpopulations defined by baseline characteristics. Often, however, clinical questions also arise regarding the treatment effect in subpopulations of patients, which would experience clinical or disease related events post-randomization. Events that occur after treatment initiation and potentially affect the interpretation or the existence of the measurements are called intercurrent events in the ICH E9(R1) guideline. If the intercurrent event is a consequence of treatment, randomization alone is no longer sufficient to meaningfully estimate the treatment effect. Analyses comparing the subgroups of patients without the intercurrent events for intervention and control will not estimate a causal effect. This is well known, but post-hoc analyses of this kind are commonly performed in drug development. An alternative approach is the principal stratum strategy, which classifies subjects according to their potential occurrence of an intercurrent event on both study arms. We illustrate with examples that questions formulated through principal strata occur naturally in drug development and argue that approaching these questions with the ICH E9(R1) estimand framework has the potential to lead to more transparent assumptions as well as more adequate analyses and conclusions. In addition, we provide an overview of assumptions required for estimation of effects in principal strata. Most of these assumptions are unverifiable and should hence be based on solid scientific understanding. Sensitivity analyses are needed to assess robustness of conclusions.     

A Measure of Dependence Between Two Compositions

We consider the problem of describing the correlation between two compositions. Using a bicompositional Dirichlet distribution, we calculate a joint correlation coefficient, based on the concept of information gain, between two compositions. Numerical values of the joint correlation coefficient are calculated for compositions of two and three components, respectively. We also present an estimator of the joint correlation coefficient for a sample from a bicompositional Dirichlet distribution. Two confidence intervals are presented and we examine their empirical confidence coefficients using a Monte Carlo study. Finally, we apply the estimator to a data set analysing the joint correlation between the 1967 and 1997, and the 1977 and 1997 compositions of the government gross domestic product for the 50 states of the USA and the District of Columbia.     

Role of National Divorce Rates in Moderating the Association Between Marriage Duration and Body Mass Index

The aim of this study was to investigate the moderating effects of the national divorce rate on the association between body weight and marriage duration. Previous studies argued that a high divorce rate at country level reduces the body weight of married people because of an increased risk of a return to the marriage market. To examine the association in question, this study used retrospective data from 14,083 middle-aged individuals in Europe. For women the divorce rate, the percentage change, and the trend of change did not moderate the positive association between body mass index and marriage duration. In contrast, for men a high divorce rate and a steady decline over time positively moderated the relation between body mass index and marriage duration.     

The Physical Housing Environment and Subjective Well-Being Among Older People Using Long-Term Care Services in Japan

Abstract

For older people using long-term care services, the conditions of their life-space may be critical. The relationships between the physical housing environment and aspects of health were examined among older people in Japan (aged 65+ years, N?=?1,928) by multivariable logistic regression analysis, adjusting for sociodemographic characteristics. Lack of safety, low access to emergency assistance, low or high indoor temperature, poor sanitary conditions, and state of home disrepair were significantly associated with negative aspects of health among people with low activities of daily living (ADL) independence. Home care service providers and policymakers need to consider the importance of appropriate environmental conditions for the most vulnerable groups.     

A comprehensive workplace intervention and its outcome with regard to lifestyle, health and sick leave: the AHA study

This study is a prospective multicentre cohort study entitled Work and Health in the Processing and Engineering Industries, the AHA Study (AHA is the Swedish abbreviation for the study). Four large workplaces in Sweden participated during the years from 2000 to 2003. The present report has two objectives: (1) to present a comprehensive occupational health intervention programme and (2) to evaluate this programme with a focus on lifestyle (smoking and exercise), health related quality of life (HRQoL) and sick leave. Interventions were provided on an individual and group level, including evidence-based methods for four health/focus areas (individual level) and a group intervention based on a survey-feedback methodology. The analyses in this report were exclusively employed at an organizational level. The proportion of smokers decreased at three companies and the course of the HRQoL was advantageous at two of the companies as compared to a gainfully employed reference group. A significant decrease in sick leave was revealed at one company, whereas a break in an ascending sick-leave trend appeared at a second company as compared to their respective corporate groups. This comprehensive workplace intervention programme appears to have had positive effects on smoking habits, HRQoL and sick leave.     

Personality factors predicting changes in shift work tolerance: A longitudinal study among nurses working rotating shifts

Abstract

The aim of the present study was to investigate the relationship between personality factors (hardiness, morningness, flexibility, and languidity) and longitudinal changes on different measures of shift work tolerance (fatigue, sleepiness, anxiety and depression) over one year among nurses working rotating shifts. A total of 642 female Norwegian nurses working in a rotating three-shift schedule participated in the study. The cohort was established by age-stratified selection among members of the Norwegian Nurses Association in 2008. Questionnaires were administered in 2008/2009 (T1) and in 2009/2010 (T2). The results showed that hardiness was negatively related to fatigue, anxiety and depression at T2 when controlling for the scores on these constructs at T1. Morningness was not related to any indicators of shift work tolerance at T2 when controlling for shift work tolerance at T1. Flexibility was negatively related to anxiety at T2 when controlling for anxiety at T1. Languidity was positively related to sleepiness and fatigue at T2 when controlling for sleepiness and fatigue at T1. The findings indicate that personality factors, especially hardiness, can predict changes related to shift work tolerance over a period of one year.