Statistics help request: Likert survey, pre/post interventional comparison,
one-time question answering session, multi-dependent variables.
Questions are asked in the end of this post.
Season's Greetings to all.
My name is Georgios, a Greek-Canadian 4th year general medicine resident in
France, working on a small one year "M.D thesis" (not a typical 4-year PhD)
project, which will involve
a Likert type of survey
as concerns a pre/post interventional comparison
based on a one-time question answering session,
using multi-dependent variables.
As this is my first post in the present forum, I hope not to be repeating
issues that have already been covered in messages that I perhaps did not
read.
I have asked a number of specialists for help on this particular issue, and
they have all directed me towards social science statisticians, which are
quite difficult to find where I am located (small town in France).
It is for this reason that I am asking for a contribution from your generous
forum.
PREAMBLE
Contrarily to American and other Anglophone Medical Institutions that provide
medical students with
Empathic Communication Training
that is usually HETERO-evaluated (by patients or specialists),
such a method has yet to be formally used in France during medical training.
Therefore, in the waiting of such formal empathic communication education, I
have created a protocol using some ACRONYM, whereby each letter refers to
some verbal/non-verbal communication element, which will be refered to as
"ITEM".
ITEMS
These "ITEMS" have been "drawn" from a number of PROTOCOLS that have already
been validated in the Anglophone scientific literature. A translation of just
ONE such protocol is not the objective here, and I feel there is no further
need to validate the French terms I have used as "equivalents".
PROTOCOL
The items will be sent out to various health care personnel, in form of a
"PROTOCOL", so that they may become acquainted with their content, and so as
to try applying them during patient visits for a DURATION of approximately
one month.
MAIN HYPOTHESIS and PRIMARY OBJECTIVE (1A)
HYPOTHESIS: Empathic communication has been shown to be in part acquired, by
qualified training.
For those in France with insufficient means for such training, a handy
ACRONYM PROTOCOL, using already validated items, should help
INCREASE awareness and IMPROVE empathic communication with patients.
The PRIMARY OBJECTIVE (1A) will be to test for “change after intervention”
(where nul hypothesis H0 = no change) for each “CONSTANT” variable (“item”)
i.e. reading and applying the Frech Acronym Protocol will eventually lead to
some change in the way the doctor uses the items included therein.
SURVEY
The Survey will have three parts.
Part ONE will ask for general information (age group, status, specialty,
former empathic communication education, willingness to IMPROVE on empathic
communication)...
Part TWO will determine if candidates are INHERENTLY empathic, using some
well known score (DAVIS' Interpersonnal Reactivity Index (IRI) questionnaire)
Part THREE will be the CORE of the survey,
and will contain quaLItative/ORDINATE data that I would prefer not to convert
to quaNTitative/Numerical data.
I would really like to MAINTAIN the ordinal values/scale in terms of RANK
order,
and to use NON-PARAMETRIC statistics(boxplots, medians, quartiles, ranges,
etc.) for any pre/post comparisons.
Here is an example of just one ITEM, presented firstly in "detailed form",
followed by an "abbreviated" version:
ITEM one (e.g. "eye contact")
--(FREQUENCY):
----How OFTEN did/do you use Item ONE ("eye contact")?
----- PRE-- (Never//Sporadically//Sometimes//Almost one time out of two//Very
often//Almost Always//Always//I don't know)
----- POST- (Never//Sporadically//Sometimes//Almost one time out of two//Very
often//Almost Always//Always//I don't know)
--(QUALITY: )
----(How AWARE were/are you in using Item ONE ("eye contact")?)
----- PRE (Always Unconsciously//Mainly Unconsciously//Equally Consciously-
Unconsciously (willingly)//Mainly Consciously (willingly)//
Always Consciously (willingly)//I don't know)
----- POST (Always Unconsciously//Mainly Unconsciously//Equally Consciously-
Unconsciously (willingly)//Mainly Consciously (willingly)//
Always Consciously (willingly)//I don't know)
--(EFFECT [independent of PRE/POST]):
-- (I have witnessed or feel that this item has an effect on patients)
----- (Always Negative// Mainly Negative// No effect whatsoever// Mainly
Positive// Always Positive// I don't know)
ABBREVIATED version or SURVEY PART III
ITEMS are numbered from n=01 (Items O1) to n=n (last item)
Items 01 to n-1: AUTOEVALUATION
I01 (item 01
-I01-F (for FREQUENCY):
--How OFTEN did/do you use Item ONE ("eye contact")?
---I01-F PRE (i = 1 (Never) to i = 7 (Always), and where i=0 for "I don't
know"=
---I01-F POST (j = 1(Never) to j = 7 (Always), and where j=0 for "I don't
know")
-I01-Q (for QUALITY):
--(How AWARE were/are you in using Item ONE ("eye contact")?)
---I01-Q PRE (m = 1 (Always Unconsciously) to m = 5 (Always Consciously
[willingly]) and where m=0 for "I don't know")
---I01-Q POST (n = 1 (Always Unconsciously) to n = 5 (Always Consciously
[willingly]) and where n=0 for "I don't know")
-I01-E (for EFFECT [independent of PRE/POST]):
-- (I have witnessed or feel that this item has an effect on patients)
-I01-E GLOBAL: (q= 1 (Always Negative) to q= 5 (Always Positive) and where
q=0 for "I don't know")
Item n: indirect HETERO (patient) EVALUATION (of doctor)
spontaneous patient appreciation:
+-I n - F (for FREQUENCY):
--How OFTEN did your patients spontaneously express their appreciation
concerning your communication skills?
---I n - F PRE (i = 1 (Never) to i = 7 (Always), and where i=0 for "I don't
know"=
---I n -F POST (j = 1(Never) to j = 7 (Always), and where j=0 for "I don't
know")
QUESTIONS to the FORUM
Q01) What would be the best way to compare I01 i to j, so as to obtain some
(non)-parametric statistic along with some "significance score"?
Q02) What would be the best way to compare I01 m to n?
In my humble opinion, I can do some sort of "difference", Post minus Pre, and
create "categories", and then show what percentage of ALL candidates
eventually fall in each category (I don't know anwers will be excluded)
- - examples of "change" categories, perhaps 13 in all (ranging from minus 6
to positive 6):
- - - radical negative change: j minus i = minus 6;
- - - no change at all (j minus i = 0);
- - - radical positive change: j minus i = 6;
Histogram:
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
(Pre-Post Difference Categories
Score +++(-6 )++(-5 )++(-4 )....( 0 ).... ++(+4 )++(+5 )++(+6 )++
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Percent++( % )++( % )++( % )...( % ) .... ++( % )++( % )++( % )++
(per categry)
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Q03) Although these differences could be expressed graphically (as in the
histogram suggested above), is there some non-parametric statistic that could
be used?
Q04) The same questions apply to Item I01-Q (for QUALITY)
Q05) - Remark: I01-E (for EFFECT [independent of PRE/POST]) will determnine
the "usefulness" of various items, so as to perhaps underline the more
IMPORTANT ones.
Q06) Is there some way to "CONNECT" "i to m" AND "j to n" (i.e. BOTH "pre" to
BOTH "post" subcategories), so as to create a "unique" study statistic, that
will take into account "frequency and quality" of use, in SIMULTANEOUS
manner?
Q07) - Remark:
The survey is administered only ONCE, after the INTERVENTION (application of
a protocol) has taken place.
The candidates are asked to answer both, PRE and POST intervention questions
at the same time. One possible bias would be their incapicity to distinguish
the difference.
If, however, the items had been revealed in an initial phase
(either just before or just after reading the protocol),
it is not certain how "generously" the candidates would auto-evaluate
themeselves, thus rendering a "second, POST-phase" evaluation less
"homogeneous" adnd, by consequence, biase.
Is it a serious methodological problem to inquire on PRE and POST
interventional effects SIMULTANEOUSLY?
Q08)
Is there some way of encoding categories used
- in part on (empathy score)
- as well as in part two (age, specialty, etc subcategories)
so as to find any corelations with
- categories (subcategories) of part three?
Q09)
What would be the best/easiest software to use, capable of producing box
plots and histograms from any such correlations?
I wish to thank all those who have read through this long post, and wish
everyone a peaceful and joyous Christmas (and other festivity) season, all in
good health.
Georgios