The aim of this study was toexplore positive and negative preferences towards problem-based learning inrelation to personality traits and socio-cultural context. The study was an anonymous andvoluntary cross-sectional survey of medical students (N=449) in hybridproblem-based curricula in Nepal, Norway and North Dakota. Data was collectedon gender, age, year of study, cohabitation and medical school. The PBLPreference Inventory identified students' positive and negative preferences inrelation to problem-based learning; the personality traits were detected by theNEO Five-Factor Inventory. The determinants of the two kinds of preferenceswere analyzed by hierarchical multiple linear regressions.Positive preferences were mostly determined bypersonality; associations were found with the traits Extraversion, Openness toexperience, Conscientiousness and Neuroticism; the first three are related tosociability, curiosity and orderliness, the last, to mental health. Thelearning environments of such curricula may be supportive for some andunnerving for others who score high on Neuroticism. Negative preferences wererather determined by culture, but also, they correlated with Neuroticism andConscientiousness. Negative preferences were lower among females and studentsliving in symmetrical relationships. Some high on Conscientiousness dislikedgroup work, and the negative correlation with Agreeableness indicated that lesssociable students were not predisposed to this kind of learning activity.Preferences related to problem-based learningwere significantly and independently determined both by personality traits andculture. More insights into the nature of students' preferences may guideaspects of curriculum modifications and the daily facilitation of groups.  One was the gap between the goals stated on paper and the achievement in practice of the knowledge, skills and attitudes of medical students. Additionally, the speed of incoming new scientific discoveries, advanced diagnostics, therapeutic technologies, and the availability of medical knowledge via Internet exerted new demands on the health programs.,,The challenge in PBL is to make the small groups function effectively. Understanding the contributing elements to good and goal-oriented group dynamics is therefore relevant. To enhance the breadth of the students' learning and to improve the quality of the physicians of the future, topics such as learning styles,Today, the five-factor model "The Big Five" and the derived inventories are regarded as the most advanced approach to measure personality traits. These inventories have good psychometric properties and have been widely used, and they have proven to be valid and reliable across cultures.In the interactive groups of PBL, students are expected to take more responsibility for their learning. Accordingly, their motivation, attitudes, likes and dislikes, in short, their preferences towards the small group activity will sway the upshot of their work, more so than in lecture or seminar settings. Thus, the students' preferences are likely to be important determinants of the outcome of the PBL work. PBL groups have the potential to provide more than cognitive learning; they may promote team work skills and personal development.To date, measures of medical students' positive and negative preferences or attitudes towards the key features of PBL are found lacking. For this purpose, an inventory originating from Norway was tested and eventually used in an international context in this study. The assumption is that the PBL preferences express student motivation, likes and dislikes or attitudes towards central features of PBL, and that these student preferences are reflected in the quality and outcome of the group work. Furthermore, personality is assumed to be a major contributor to the students' preferences.In addition, socio-cultural factors are assumed to play a role in shaping the PBL preferences. For this reason, representative samples of medical schools from three different continents were sought. Socio-cultural parameters in this study were such as the gender distribution of the medical schools, the pattern of cohabitation of the medical students during their study years, possibly also the age of the students and their year of study, in addition to the medical school itself. Below we present briefly some characteristics of the three medical schools involved in the study. They all have PBL as a central component in the initial years of hybrid curricula, and the student participation in the PBL groups is obligatory.In Nepal (KUSMS), PBL was introduced in 2001. The curriculum consists of four and a half years followed by internship of one year. PBL groups of seven or eight students are held on pre-clinical topics the first two years with one new case every week. The PBL sessions last two hours, and are held three times a week on alternative days. After the PBL session, students are provided two-hours to prepare their learning objectives. At the end of each block, there is a two-hour wrap-up session.In Norway (NTNU), PBL was introduced in 1993. The curriculum lasts six years followed by internship of one and a half years. PBL groups include eight students. In the first two years, PBL groups of two hours duration are held twice a week, while in the third and fourth year, PBL groups meet once a week for three hours. One new case is introduced at every PBL session.In North Dakota (UND), PBL was introduced in 1998. The medical curriculum consists of four years; PBL covers the first two years. Seven or eight students meet for two hours on alternative days, three times weekly. One new patient case study is introduced each week; the case is concluded with a physician-patient wrap-up session at the end of the week.The purpose of this research study was to examine whether there are relationships between personality traits, culture and preferences for a certain approach to medical education, namely hybrid problem-based learning curricula. We have postulated that medical students' likes and dislikes, attitudes or preferences for PBL are not only linked to their personality traits, but also to their socio-cultural context. If these assumptions are confirmed, the findings may be useful for planning, or modification of medical education curricula, and also, they may have the potential to inform PBL tutors about students' contributions to the effectiveness of the small groups. To pursue these notions, our study explored positive and negative PBL preferences in countries as socio-culturally apart as Nepal in Asia, Norway in Europe and North Dakota in North America. The aim of this study was to explore possible links between the students' PBL preferences and personality in the context of diverse socio-cultural backgrounds.This is a cross-sectional survey. In North Dakota and Nepal, the distributed survey was written in English, which is the teaching language at both institutions. At the NTNU, the survey was in Norwegian. In all three locations, one or two classes were approached and asked to participate in an international survey on PBL preferences. Anonymous consent was used, and the students' were free to participate. No student's name was ever registered or associated with the completed questionnaires at any site. On our request, the REC Central Norway  exempted the study from collecting written informed consent due to the anonymous nature of the data collection.Data was collected in 2011 and 2012 from three medical schools: from Kathmandu University School of Medical Sciences (KUSMS), Nepal, 123 students ; Norwegian University of Science and Technology (NTNU), Norway, 229 students ; University of North Dakota School of Medicine and Health Sciences at Grand Forks (UNDSMHS), USA, 97 students , in total, 449 (100%) participants.Data was collected on the medical students' gender, age, cohabitation, medical school and the year of study. Age was used as a continuous variable; though a note was added in the survey to assure anonymity: "You may drop this [item about age] if you find that it may identify you". Fifty-two  students used this response option. The four categories of cohabitation are displayed in This inventory has been developed and administered at NTNU by the first author using reiterative rewordings of the items over several years, always with 2nd year students, until a good fit was achieved by factor analyses with the principal component extraction method and varimax rotation. In PPI, the students are asked to indicate how true each of six items are to them on a scale from 0 to 9; 0 - "Not at all", 2 - "A little", 4 - "Moderately", 6 - "Much", and 8 - "Very much"; the response options 1, 3, 5, 7, 9 could be used to modify their responses up or down.In this study, the PPI was used in English for the first time. Accordingly, the double back translation method was applied in the development of the English version. To ascertain that the inventory in the study had a factor structure that was independent of the location of the respondents, factor analyses with the principal component extraction and varimax rotation was carried out within the sample of each medical school, and also for the total population. The two-factor solution with the same item distribution appeared in the samples from Nepal and North Dakota as in the original Norwegian version, and also in the total sample. The inventory absorbed 63.6% of the total variance (N=449). The two-factor solution absorbed 68.0% in Nepal (N=123), 59.3% in Norway (N=229), and 60.0% in North Dakota (N=97).According to the item content, the first factor of the total population reflected the negative and the second factor positive PBL preferences of the students. The two factors were converted into two separate scores, each consisting of three items. One item had high loadings on both factors; due to the semantic item content and the negative correlation with PBL Negative, it was assigned to the PBL Positive. The mean sum of the non-weighted items no. 3, 5, 6 gave the PBL Negative score (M 3.04 (SD 1.95); Cronbach alpha = 0.65; item-to-sum correlations ranged from 0.72-0.80). Items no. 1, 2, 4 gave the PBL Positive score (M 6.35 (SD 1.27); Cronbach alpha = 0.64; item-to-sum correlations ranged from 0.73-0.80). No item deletion would give a higher Cronbach alpha value for any of the two scores. The two factors and their related scores do not represent a continuum. The correlation between PBL Positive and PBL Negative was negative . For more details about PPI, the item distribution and the related statistics, see Personality traits were captured by the NEO Five-Factor Inventory (NEO-FFI); the short version of 60 items was chosen.The data were analysed in two steps in relation to the PBL Positive and PBL Negative as the dependent variables, first by bivariate correlation analyses, thereafter by hierarchical multivariate, linear regression analyses. In the bivariate correlation analyses, Pearson's Chi squared was used between two categorical variables; One Way ANOVA with Scheffe's procedure was applied whenever continuous variables were explored in relation to the categorical variables with three or more response options. Pearson's correlation was used for two continuous variables.In the second step, hierarchical regression analyses were carried out to explore the associations of PBL Positive and PBL Negative as dependent variables. For both, an identical set of independent variables consisting of three blocks were entered: the first covered the socio-cultural variables; the second encompassed the five personality traits, and since there was some overlap between the two preferences, the last block contained the opposite PBL preference. Categorical variables were re-coded into dummy variables.SPSS version 19 was used in all the statistical computations.Gender, age and cohabitation as well as aspects of the medical schools were unevenly distributed between the three medical schools, see In the bivariate correlations with PBL Positive and PBL Negative, no significant gender difference was found. A significant correlation  was found for age with PBL Positive, but not for PBL Negative. PBL Positive was scored higher by those who lived with partners, spouses and/or children. Students from North Dakota scored significantly higher on PBL Positive than those from Nepal and Norway. Students from NTNU scored significantly higher on PBL Negative than those from Nepal and North Dakota. With regard to personality, all traits correlated significantly with the PBL Positive; Neuroticism had a negative correlation. For PBL Negative, only Openness to experience correlated significantly and negatively.In both regression analyses, three identical blocks of independent variables were used in relation to the two preferences. The independent variables of each block are displayed in detail in the tables 3 and 4. When using PBL Positive as the dependent variable, gender, age and cohabitation played no significant role. The medical school in Nepal showed a significant negative correlation. Entering the five personality traits elevated the adjusted RWith PBL Negative as the dependent variable, gender showed a significant negative correlation. Age did not reach significance. Students who lived with fellow students or a partner, spouse and/or children, had significant negative correlations. Moreover, students from Nepal and North Dakota were significantly and negatively correlated with PBL Negative. The first block consisting of the socio-cultural variables appeared with an adjusted value to RThe study shows that personality traits play a major part in determining medical students' positive PBL preferences. The same is true, but to a much lesser extent for the PBL negative preferences where socio-cultural dimensions play a more substantial role. Independent of their whereabouts in the world, the preferences, likes or dislikes of medical students towards PBL are to a significant degree related both to personality and to the cultural context of the medical student. The findings met our main expectations, and they may have relevance for several types of interactive small group learning settings. The findings about the five personality traits and the two PBL preferences seem to point in the same direction. PBL is appreciated by outgoing, curious, sociable and conscientious students, and to some extent, also by some, but not all students high on neuroticism. The most relevant traits for medical education found in other studies have been conscientiousness, extraversion and openness to experience.The gender distribution of the three medical schools plausibly exhibits societal attitudes towards females entering higher education. The students' cohabitation patterns may also reflect societal differences and norms. The higher mean age of students from the US is likely related to the college graduation required before entering medical school. In Norway and Nepal such demands do not exist, and students will normally start at a lower age at medical school. Age played no role in relation to any of the PBL preferences when other factors were corrected for, while the liking of PBL may perhaps increase with the years in PBL learning environments.Negative PBL preference is explained far more by the socio-cultural background of the student. In relation to this preference, the inclusion of the block with personality traits made a minor, yet significant addition to the explained variance. Students from Nepal were less enthusiastic about PBL than students from North Dakota; the non-authoritarian and self-administered learning format of PBL may be culturally unfamiliar to some Nepalese. In PBL curricula, the students' knowledge, self-discipline, and interpersonal skills are continuously exposed to fellow students and tutors. This transparency requires social trust and provides less opportunity to keep a social distance and for hiding one's ways. For most, to be seen and to be socially involved may gratify proximity needs and induce a sense of mutual social commitment. For a few, however, the transparency, the high level of social and academic exposure and the obligations towards the PBL group may be met with reluctance, perhaps even activate paranoid fears, or it may seem intimidating for the socially inhibited. In both cases, PBL may be felt as intrusive and prying. In traditional curricula, students have more "freedom" to hide. They can choose if, how and when they want to learn; they can easily remain unexposed on the backbenches of the lecture halls.Neuroticism has a positive association with both preferences. The trait reflects a general propensity to respond to events, circumstances and challenges with dysphoric affect and apprehension, sometimes even with unjustified suspicion. The social inclusion and interactive nature of PBL groups may offer a supportive environment for some socially insecure students high on Neuroticism; they may relax and feel integrated into the small groups. However, other socially anxious or reticent students may feel uneasy and uncomfortable in the closely-knit PBL groups; they may feel untroubled with more social distance and prefer impersonal learning arenas rather than the small group settings. The two opposite responses to the social proximity of the PBL groups may explain the dual relationship of Neuroticism in relation to the PBL preferences.,,Conscientiousness seems to be a significant predictor of academic success,This study is the first to link students' attitudes or preferences for PBL to personality traits. The findings concur in part with a study that compared students on a traditional lecture-based track with students on a PBL track; those with favourable attitudes towards psychiatry demonstrated more "Openness to experience" and "Agreeableness".,As of yet, personality traits have not been specifically linked to the ideal doctor, but a set of roles has been discussed in this regard.From an ethical point of view, the contention that PBL favours one set of personality traits, may be viewed as discrimination against those who otherwise qualify for admission. However, literature lacks studies indicating that lecture-based teaching enhances personality traits that would be more favourable for physicians. Several studies indicate rather the opposite.,It has been argued that students in their early stages of medical school tend to be more inclined towards being competitive and impersonal.In general, survey data tend to have lower reliability and validity than interview data.The PPI inventory is new and brief; it has been standardized over years on Norwegian medical students in their second study year. This is the first time IPP is used in an international context. The psychometric properties within each country are found to be acceptable, and the preference concepts, i.e., the item structure of PBL Positive and PBL Negative of the two factors, are the same across the three locations. Even so, the generalizability of the findings from this new inventory should be handled with some caution until the item structure and the related preference scores have been tested by further studies in diverse contexts. In this study, the concepts implied by the item distribution of the two preferences did not seem to be confined to any particular culture. The same factor structure or item distribution as found in Norway appeared also in the two other medical schools; essential cross-cultural dimensions of the original version have suggestively been safeguarded by the translation. The Cronbach alpha algorithm makes it difficult to obtain high values for scales with less than 10 items. In this study, the number of items is three. Even so, the internal consistency is acceptable. However, it should be kept in mind that with a low number of items, the scale is more sensitive to misunderstandings. The item-to-sum correlations provide a more adequate picture when the number of items is small; the ranges of the correlations were either good or acceptable. PBL is a heterogeneous concept, as pointed out by some researchers.The strengths of the study lie in the fact that three rather different medical schools and cultures are represented, which helps in the differentiation between personality issues and culture. The number of participants from each site is acceptable; the sample size from each location can be assumed to be fairly representative of their respective classes. The personality measure is solid and well-established with very good psychometric properties and multicultural strengths. The PPI is a new instrument that specifically addresses issues related to PBL, and as such, it may offer new angles for the exploration of small group learning environments. Conceptually, the findings in relation to the two PBL preferences point in the same direction.The reforms of recent decades involving the introduction of PBL into medical curricula are generally associated with expectations of improved cognitive and social learning. So far, the body of research within medical education that has utilized the advances of personality trait research has been rather small. The current study demonstrates reasonable connections between students' PBL preferences and their personality traits. Also, the study emphasizes that negative PBL preferences pose more challenges on the socio-cultural level. In modern society, student participation is commonplace in the shaping of academic curricula. To know the students' positive and negative preferences towards any curriculum may turn out to be helpful in developing educational programs. The findings of the present study may also have implications for the day-to-day facilitation in PBL groups.This study shows that the personality traits extraversion, openness to experience and conscientiousness, but also neuroticism are closely linked to positive preferences for PBL. Some less sociable persons may have compulsive traits and some with mental problems may disfavour PBL. The study does not link personality traits to academic success, but to PBL preferences or student satisfaction. Further investigations of the Big Five traits in relation to PBL and small group learning activities seem relevant for the social and cognitive effectiveness of small groups in academic settings.The authors declare that they have no conflict of interest


Accurate measurement of health inequities is indispensable to track progress or to identify needs for health equity policy interventions. A key empirical task is to measure the extent to which observed inequality in health – a difference in health – is inequitable. Empirically operationalizing definitions of health inequity has generated an important question not considered in the conceptual literature on health inequity. Empirical analysis can explain only a portion of observed health inequality. This paper demonstrates that the treatment of unexplained inequality is not only a methodological but ethical question and that the answer to the ethical question – whether unexplained health inequality is unfair – determines the appropriate standardization method for health inequity analysis and can lead to potentially divergent estimates of health inequity.We use the American sample of the 2002–03 Joint Canada/United States Survey of Health and measure health by the Health Utilities Index (HUI). We model variation in the observed HUI by demographic, socioeconomic, health behaviour, and health care variables using Ordinary Least Squares. We estimate unfair HUI by standardizing fairness, removing the fair component from the observed HUI. We consider health inequality due to factors amenable to policy intervention as unfair. We contrast estimates of inequity using two fairness-standardization methods: direct  and indirect . We use the Gini coefficient to quantify inequity.Our analysis shows that about 75% of the variation in the observed HUI is unexplained by the model. The direct standardization results in a smaller inequity estimate  than the indirect standardization .The choice of the fairness-standardization method is ethical and influences the empirical health inequity results considerably. More debate and analysis is necessary regarding which treatment of the unexplained inequality has the stronger foundation in equity considerations.The online version of this article (doi:10.1186/s12939-015-0138-2) contains supplementary material, which is available to authorized users. Inequalities and inequities in health care and health outcomes continue to be in the center stage of health policy in many jurisdictions. Accurate measurement of inequalities and inequities is indispensable to track progress or to identify needs for policy interventions ,2. RegulTo date, no single, agreed-up definition of health inequities exists. Alternative definitions of health inequity can be distinguished by the sources of health inequality each classified as ethically acceptable and unacceptable. For example, Braveman and Gruskin define health equity as “the absence of systematic disparities in health … between social groups who have different levels of underlying social advantage/disadvantage” Given that the ultimate focus of policy concern is health inequities, a key empirical task is to measure the extent to which observed inequality in health is inequitable. This requires an integration of the conceptual and empirical literatures on health inequity ,5,11,12.The goal of this paper is to demonstrate that the answer to the ethical question – whether unexplained health inequality is unfair – determines the choice of the standardization method and can lead to potentially divergent estimates of health inequity. In the next section, we explain how this question arises in the assessment of health inequities and articulate how answers to this question lead to particular methodological choices. We then demonstrate the importance of this ethical question empirically using the Joint Canada/United States Survey of Health (JCUSH) , which iThe issue of unexplained health inequality arises in an effort to be transparent and explicit about the definition of health inequity when empirically measuring health inequity. Measuring health inequity requires individual-level data to model variation in health at the individual level. Assuming that we have such individual-level health survey data, we begin by quantifying the amount of inequality in the distribution of observed health across individuals. We can use a univariate inequality index . This provides a measure of the total amount of health inequality in the population.unfair health across individuals in the population, that is, unfair health inequality. Unfair health, however, is not directly observable. To estimate it from observed health, we first model variation in health. The goal is to statistically explain as much variation in health as possible with the data at hand. This enables us to partition variation in health into that attributable to factors considered fair, or legitimate, sources of variation, and that attributable to factors considered unfair, or non-legitimate, source of variation. In other words, to define health inequities we need to look at causes of health inequalities [To measure health inequity, we must quantify the distribution of ualities .As an example, let us consider a popular definition of health inequity, policy amenability, which argues that health inequality due to factors amenable to policy intervention is unfair . We clasClassifications like that in Table fairness-standardization. This leaves us with only inequality due to unfair sources. Fairness-standardization is similar to age-standardization in epidemiological studies, which removes the influence of age when estimating mortality rates, but in this context, standardization removes the influence of all legitimate sources of inequality. Consequently, the standardization generates the inequitable distribution of health in the population. The amount of inequity is then quantified by applying the same inequality index as above to this distribution of unfair health. Despite the use of the same mathematical index, the measure here is an index of inequity, as opposed to simply inequality, as it quantifies the distribution of unfair health.Having classified each variable, we then remove the influence of the fair component – legitimate variables according to a chosen definition of health inequity – on the observed health through For fairness-standardization, two methods are available: direct and indirect. As we show below, the choice of the standardization method is closely connected to ethical judgments regarding unexplained inequality.Both direct and indirect standardization methods are based on the notion that the observed health consists of legitimate, illegitimate, and unexplained components:Using the direct standardization method, we predict unfair health directly by allowing only the illegitimate variables alone to influence the predictions. To do so, we purge the influence of legitimate variables by setting the value of these variables constant (expressed with the bar in the equation) during the prediction and ignore the unexplained component:As is clear, this produces a distribution in which the only source of variation in predicted levels of health arises from variation across individuals in illegitimate factors.Using the indirect standardization, we first predict fair health by allowing only the legitimate variables to influence the predictions. To do so, we purge the influence of illegitimate variables  and ignore the unexplained component:We then calculate unfair health by subtracting the estimate of fair health from the observed health and adding the mean health of the population:This addition of the mean health of the population is conventional  and ensuFor both standardization methods, we can choose any values at which to hold the relevant variables constant (legitimate variables for direct standardization and illegitimate for indirect standardization). But the choice reflects an ethical and policy judgment regarding the reference attributes by which we assess health inequity. For example, for the definition of policy amenability discussed above, we can hold each relevant variable at the category to which policies might reasonably aim , or we could set the level to the healthiest category in the population . Whether we should assess health inequity against a modest or ambitious goal depends on which differences in health we consider as unfair and what reference we consider as an appropriate policy goal. Just as the legitimate-illegitimate classification of variables, the choice of reference values can generate debate. For the purpose of this paper, which compares the two standardization methods, we set reference values equal to the modest goals as an example.Importantly for the focus of this paper, notice that the unfair health estimated by the direct standardization does not include the unexplained component while the unfair health estimated by the indirect standardization does. The larger the unexplained component is, the greater the discrepancy is between unfair health estimated by these two standardization methods.Notice further that the choice of the standardization methods implies ethical judgments: using the direct standardization, we regard unexplained variation in inequality as ethically acceptable, and using the indirect standardization, we regard it as unfair. Although this issue has been raised in the health economics literature ,11,12, tWe estimate health inequity using the 2002–03 Joint Canada/United States Survey of Health (JCUSH), a cross-sectional population health survey jointly conducted by Statistics Canada and the U.S. National Center for Health Statistics . The JCUFor simplicity and the ease of exposition, in this paper we present the results for the American sample only. The analysis using the Canadian sample yielded the same key methodological findings (available from the authors upon request). The original American sample of the JCUSH is 5,183 (response rate: 50.2%). We exclude observations with missing values , except income (19.8%), for which we create “income missing” category. We also exclude 48 observations with scores of the Health Utilities Index (HUI), our measure of health, less than or equal to zero. The final sample size for our analysis is 4,328.We measure health by the Health Utilities Index Mark 3 (HUI), a well validated and widely used generic health-related quality of life measure . The HUIWe use a number of attributes known to be associated with health and available from the JCUSH: demographic status, health behaviour, socioeconomic status, and health care system factors, including the availability of basic health care, quality of health care, and health care insurance. We tested for interactions among these variables and retained the interaction terms between smoking and income and between body mass index (BMI) and education, which remain statistically significant at the 5% level in the final model.We use the Gini coefficient to quantify health inequality and inequity ,20. The The analysis proceeds with the following three steps. First, we estimate the magnitude of inequality in the observed HUI across individuals using the Gini coefficient. Second, we model variation in the observed HUI. Third, based on the definition of policy amenability, as discussed above, and using the direct and indirect standardization methods, we estimate unfair HUI for each individual and quantify the magnitude of inequity using the Gini coefficient. In both standardization methods, we hold relevant variable at the category to which policies might reasonably aim , it spikes at 1.0 , and it is left-skewed. Researchers have recommended a number of alternative statistical methods to empirically model the distribution of HUI, including Ordinary Least Squares (OLS), Tobit, censored least absolute deviation (CLAD), two-part models, and latent class models, with no consensus regarding the best approach -26. In tWe weight all analyses using the sample weights provided by the JCUSH. To estimate variance accounting for the JCUSH’s complex survey design, we use the balanced repeated replication methods with balanced repeated replication weights provided by Statistics Canada and the US National Center for Health Statistics. We consider p<0.05 as statistically significant. We use Stata 11 for all analyses ,28.Sample characteristics and the average HUI across subgroups mostly follow expected patterns Table . The ave2: 0.258, Table The fit of our model is comparable to other work describing the variation in the HUI  and of 0.086 (the indirect standardization) translate into the expected mean differences in the HUI of 0.101 and 0.166, respectively, between two randomly selected persons. These HUI values are more than three times larger than the minimally policy relevant difference of the HUI, 0.030.Figure In the context of the empirical assessments of health inequities, this paper investigated the empirical importance of the ethical question of whether unexplained health inequality is unfair. The classification of unexplained inequality as fair or unfair is closely connected to the choice of the fairness-standardization methods, a critical step for the measurement of health inequities. As the analysis of the US component of the JCUSH showed, this choice can substantially influence the empirical results regarding how much health inequity exists in the population and the proportion of observed health inequality that is inequitable. We obtained the same results in analyses using the Canadian sample of the JCUSH and using a different definition of health inequity, equal opportunity for health (results not shown).The question of how best to treat unexplained health inequality deserves more extensive consideration in the assessment of health inequities than it currently does. Both direct and indirect fairness-standardization methods are technically valid but can produce different health inequity information and imply different ethical stances in regard to unexplained variation. An analogy here may be the choice between direct and indirect age-standardization methods in epidemiological studies . Both ofAlthough unexplained health inequality is not an issue for those who subscribe to the view that all health inequalities are inequitable , it is an unavoidable issue for empirical analysts who do distinguish between pure health inequality and health inequity. Currently available data and modeling techniques enable analysts to explain only a relatively small portion of observed variation in health at the individual level. Because the issue of unexplained inequality only arises in empirical work, it has rarely been paid attention to in the conceptual discussion regarding definitions of health inequity. Still, some work in the recent detailed philosophical analysis of health inequity by philosophers, economists, and ethicists provides a hint as to how to consider the ethical significance of unexplained inequality.To examine the ethical significance of unexplained inequality, it is useful to recognize that unexplained variation – residuals in a regression context – consists of two types of variation: variation systematically related to unobserved factors and random variation. The issue of unmeasured systematic variation stems from methodological limitations. Improved data, such as longitudinal data with a rich array of variables capturing individuals’ life history, and improved modeling techniques can reduce unmeasured systematic variation. As soon as unmeasured systematic variation becomes observed systematic variation, the question goes back to a familiar, on-going debate regarding definitions of health inequity, that is, which sources of health inequality are ethically unacceptable.To assess the ethical significance of random variation, the philosophical literature distinguishes “brute luck” – unfortunate events from which even sensible persons suffer, such as being hit by lightning during the commute with no warning, or suffering from a genetic disease by chance (often referred to as genetic lottery) – and “option luck” – unfortunate events associated with voluntary risks, such as being hit by lightning while playing golf with a plenty of warning or getting injured during voluntary bungee jumping -34. The Advances in data, modeling techniques, and philosophical arguments are ongoing processes, and the measurement and monitoring of health inequities for effective policy making cannot wait for their perfection. Three proposals are available for the treatment of unexplained health inequality in the current imperfect world that still urges policy making. First, Bago d’Uva, Jones, and van Doorslaer  recommenFinally, Garcia-Gomez and colleagues  empiricaMost of this emerging empirical work and its authors’ insight in into the importance of ethical discussion are of considerable significance for public health and health policy. Given potentially serious policy implications of the issue of unexplained health inequality, analysts should at least make their methodological choices explicit and report both results from both standardization methods whenever they can. Moving beyond this pragmatic solution, however, analysts need to spur more debate and analysis regarding which treatment of the unexplained inequality has the stronger foundation in equity considerations.aThe choice of the standardization methods would become even more ethically relevant if we used a non-linear model for the HUI. This means that, in a sense, our results using a linear model provide conservative estimates of the importance of this choice. We would like to thank an anonymous reviewer for pointing this out.


The integrated treatment of first episode psychosis has been shown to improve functionality and negative symptoms in previous studies. In this paper, we describe a study of integrated treatment  versus treatment as usual, comparing results at baseline with those at 6-month re-assessment (at the end of the study) for these patients, and online training of professionals to provide this complementary treatment, with the following objectives: 1) to compare the efficacy of individual psychoeducation as add-on treatment versus treatment as usual in improving psychotic and mood symptoms; 2) to compare adherence to medication, functioning, insight, social response, quality of life, and brain-derived neurotrophic factor, between both groups; and 3) to analyse the efficacy of online training of psychotherapists.This is a single-blind randomised clinical trial including patients with first episode psychosis from hospitals across Spain, randomly assigned to either a control group with pharmacotherapy and regular sessions with their psychiatrist  or an intervention group with integrated care including treatment as usual plus a psychoeducational intervention (14 sessions). Training for professionals involved at each participating centre was provided by the coordinating centre  through video conferences. Patients are evaluated with an extensive battery of tests assessing clinical and sociodemographic characteristics , and EuroQoL questionnaire), and brain-derived neurotrophic factor levels are measured in peripheral blood at baseline and at 6 months. The statistical analysis, including bivariate analysis, linear and logistic regression models, will be performed using SPSS.This is an innovative study that includes the assessment of an integrated intervention for patients with first episode psychosis provided by professionals who are trained online, potentially making it possible to offer the intervention to more patients.NCT01783457 clinical trials.gov. Date of registration in primary registry 23 January 2013. The definitions of the words psychotic and psychosis  refer toA recent meta-analysis indicated that the factors that best predict the occurrence of relapses are failure to adhere to treatment, persistent substance abuse disorders, negative comments from caregivers and poor premorbid adjustment . With reRegarding the types of treatment for patients with first episode psychosis, a review concluded that early psychosocial interventions adjunctive to pharmacotherapy may contribute to patient symptomatic and functional recovery . VariousOn the other hand, it has been shown that disciplines, such as cognitive behavioural therapy, that have a shortage of formally trained clinicians could benefit from online learning . In partThis study hopes to shed light on these issues, with an improved methodology; it is a pragmatic trial - that is, there is no selection of a specific type of patients - and the aim is to assess the effectiveness of individual psychoeducation as well as the remote training of therapists.The primary objective of this study is to assess the efficacy of a psychoeducation programme in improving the symptomatology of patients; namely the positive, negative, and general symptoms of psychosis, measured using the Positive and Negative Syndrome Scale (PANSS), State-Trait Anxiety Inventory (STAI), and Hamilton Rating Scale for Depression (HRSD).The secondary outcomes of interest are patient functioning  scale, Functioning Assessment Short Test (FAST)), adherence , insight ), social response ), quality of life  and the EuroQoL questionnaire), and brain-derived neurotrophic factor (BDNF) level.We also want to analyse the efficacy of online training of psychotherapists.In this paper, we describe in detail the study design, patient selection and evaluation, the programme of psychoeducation under study, and training of professionals. It is an intervention study of integrated treatment for patients with first episode psychosis, with the innovation that the participating therapists will receive remote training.We registered this single-blind randomised clinical trial in 2013 (identifier NCT01783457). Patients with a first episode of psychosis between 2010 and 2014 are to be included and randomly assigned to one of two treatment groups: the control group, receiving pharmacotherapy together with regular sessions with a psychiatrist , and the intervention group receiving integrated treatment, namely treatment as usual plus a psychoeducational intervention (12 main sessions and 2 booster sessions). A first psychotic episode was defined as the first time a patient displayed positive psychotic symptoms of delusions and/or hallucinations.We are recruiting patients from five psychiatric centres  that agreed to take part in the e-learning project. In all centres, the clinicians recruit subjects who show psychotic symptoms for the first time, and who meet the inclusion criteria (listed below). To obtain 90% power to detect differences in the means at the 5% level of significance, we have estimated that we need to enrol 130 patients in each group (study group and controls) .The treatment is being supervised by one clinician (PV) trained by a highly experienced clinician at the University Hospital of Álava (SB), while the evaluations in all centres are conducted by other clinicians blind to patient allocation.Diagnostic and Statistical Manual of Mental Disorders 4th edition text revised (DSM-IV-TR) criteria for one of the following within the previous 5 years: schizophreniform disorder, schizoaffective disorder, brief psychotic disorder, delusional disorder, non-specified psychotic disorder, bipolar disorder with psychotic symptoms, or major depressive disorder with psychotic symptoms. In addition to giving informed consent, they must also be between 18 and 45 years old and speak good Spanish.For patients to be included, they must have experienced a first episode of psychosis. All those included must have met Subjects with mental retardation, organic brain disorders or the presence of any comorbid condition that could hinder communication, or drug abuse as a primary diagnosis, were excluded.th World Medical Association General Assemble, Fortaleza, Brazil, 2013). The study and protocol were approved by the Clinical Research Ethics Committee of each participating health centre . Before inclusion, all patients are required to sign an informed consent form that includes a specific section covering genetic testing .The study is conducted in compliance with local regulations and internationally established principles of the Declaration of Helsinki ; the person in charge of the assessments is blind to this process.For all participants, the pharmacological treatment used is that which patients have been prescribed by their psychiatrists, independent of their participation in the study.Data are collected on the wide range of clinical and demographic variables detailed below and are entered on a data collection form. All the patients are assessed at baseline and have been or will be assessed at 6 months after inclusion in the study, which corresponds to the end of the psychoeducational programme in the case of the intervention group.Data are collected on age, sex, level of education, living arrangements and employment status.Participants’ symptoms are assessed using the PANSS . This inTrait and state anxiety are measured using the STAI . This inPatients’ social anxiety is assessed using the LSAS , and itsIn addition, in relation to symptoms, we record information on the number of relapses and hospital admissions (psychotic episodes) and the dates on which they occur for 2 years follow-up, the psychopharmacotherapy administered, family history of mental health problems, and record of substance use both before and after the intervention.Patient insight into their illness is measured using SUMD . This scPrognosis is explored using the Strauss and Carpenter Prognostic Scale –36, an iThe overall function of patients is rated using a Spanish version of the GAF scale. This scale is recommended for Axis V in the multiaxial system of DSM-IV-TR  and is bFunctional status is also assessed using FAST . This isAdherence is estimated using the Morisky Medication Adherence Scale . This inThe quality of life is measured using two instruments. First, the World Health Organization Quality of Life WHOQOL-BREF questionnaire  was usedSecond, the EuroQoL questionnaire  was usedAll the instruments used have demonstrated adequate psychometric properties and have been used in many other studies. Interviews are conducted by clinicians who have good inter-rater reliability for the scales used .To investigate BDNF in peripheral blood, blood samples are collected in the morning . Plasma BDNF levels are measured using a BDNF Sandwich enzyme-linked immunosorbent assay kit , according to the manufacturer’s instructions. Blood cells are immediately separated from the plasma and processed. Standard curves are constructed using plasma duplicates. The absorption at 450 nm is measured with a Synergy HT microplate reader .The coordinating group carried out the training of the therapists in the participating centres, via teleconferencing (WebEx Training Center). The course consisted of 12 modules and 2 booster sessions, corresponding to the 14 sessions of the psychoeducational programme, and all the participating groups received the same theoretical content. Once all the materials had been provided and explained, participating groups were asked to perform a task with certain objectives, each group having to complete this before starting the following module.In addition, all the therapists participating in the online training had to prepare a case study with theoretical and practical elements and correctly complete a task under the supervision of a psychotherapist with extensive experience in the field of psychoeducation, before they themselves carried out the psychoeducational intervention with the patients. As well as providing written support material, we attempted to ensure the correct integration of knowledge presented by giving feedback, correcting answers participants gave during sessions, and correcting hypothetical cases presented. At the end of each module, all the therapists were required to complete a form recording the learning objectives covered in the module and testing their knowledge of theoretical and practical aspects of the psychoeducation programme.The psychoeducational programme has 14 1-hour sessions (12 main sessions and 2 booster sessions), fortnightly, for a period of 6 months, focused on improving patient insight into their illness, treatment adherence, prodromal identification, early intervention to prevent relapses, healthy lifestyles, techniques for managing anxiety, social skills and problem solving.What is a first episode of psychosis?The challenge and importance of insight into vulnerabilitySymptom recognitionPrevention of relapses: protective and risk factorsWhat can I do if I note the symptoms emerging again?Treatment adherenceHealthy lifestyles: sleep and sexualityHealthy lifestyles: substance useAnxiety management techniques (I)Anxiety management techniques (II)Social skills: assertiveness techniquesProblem-solving techniquesThe programme includes the following sessions:We have checked the completeness of the training with respect to the administration of the sessions both in terms of content and their structure. The psychoeducational sessions are run with the same interval between sessions in all the centres. Further, the therapists give the psychoeducational intervention to all patients in the same way and provide the same information, enhancing the reliability of the study.If patients report any personal, social, work-related or family problems during the sessions, they are to be helped using cognitive behavioural techniques (psychotherapeutic intervention). Lastly, if patients have any question regarding what they are taught during the sessions, or about their condition, they can call a telephone helpline in working hours (between 08.00 and 15.00 from Monday to Friday). The aim of this service is to facilitate patient access to information and address any questions they might have.Treatment as usual refers to the treatment that is routinely provided to patients with first episode psychosis on the Spanish National Health Service. It consists of ambulatory psychopharmacotherapy with regular sessions with an assigned psychiatrist, corresponding to a personalised psychiatric approach to their management.We used Gridsam, the central database of the Spanish research network for mental health (CIBERSAM). This database facilitates the merging of large amounts of data and access to the records.2-tests for categorical variables and the Student’s t-test or Mann Whitney U test for quantitative variables. Within-group changes in symptomatology and functioning during treatment will be examined using paired t-tests.Comparisons of baseline characteristics of the sample will be made with χUnivariate analyses of covariance will be conducted to investigate differences between groups. For this, the independent variable is the group assignment (integrated treatment versus control) and the dependent variable is the respective clinical or functional outcome score post-treatment. Recurrence-free curve analysis will be performed using Kaplan–Meyer survival analysis to analyse the relapses in the groups during the follow-up. This analysis will be performed on an intention-to-treat basis, with patients being analysed in the treatment group to which they were randomised.In addition, a logistic regression model will be used to analyse the association between clinical variables. Finally, we will also build a logistic regression model to explore factors associated with changes in variables during follow-up.The outcomes will be reported with 95% confidence intervals. All data will be analysed using SPSS . On the other hand, this is the first study in our setting assessing this type of therapy and this type of innovative training with a rigorous methodology (structure and content).We have not completed patient recruitment at the time of submission.


Background. The use of coercion within the psychiatric services is problematic and raises a range of ethical, legal, and clinical questions. “Physical restraint” is an emergency procedure used in psychiatric hospitals to control patients that pose an imminent physical danger. We wished to review the literature published in scientific peer-reviewed journals describing studies on the use of physical restraint in Norway, in order to identify the current state of knowledge and directions for future research. Design. The databases PubMed, PsycINFO, CINAHL, Web of Science, and Embase were searched for studies relating to physical restraint (including holding) in Norwegian psychiatric hospitals, supplemented with hand searches. Results. 28 studies were included. Most of the studies were on rates of restraint, but there were also some studies on perceptions of patients and staff, case studies, and ethnographic studies. There was only one intervention study. There are differences in use between wards and institutions, which in part may be explained by differences in patient populations. Staff appear to be less negative to the use of restraint than patients. Conclusions. The studies that were identified were primarily concerned with rates of use and with patients' and staff's perspectives. More interventional studies are needed to move the field forward. The use of coercion within the psychiatric services is problematic and raises a range of ethical, legal, and clinical questions , 2. PhysIn Norway, physical restraint (including holding) may be used as an emergency intervention, with the purpose of increasing the safety of the patient in question and/or fellow patients and staff or avoiding significant damage to buildings and objects , 7. The The use of physical restraint is challenging from both a clinical viewpoint and an ethical viewpoint. Subjecting patients to physical restraint carries a risk of physical and psychological harm to patients; staff may be physically harmed when restraining patients, and it may harm the provider-patient relationship and further treatment , 11. MorIn recent years, there has in Europe and the US, as well as in other parts of the world, been an increasing focus on the need to reduce coercion within the psychiatric services , 11, andA literature search of relevant electronic databases, including PubMed, PsycINFO (Ovid), Embase (Ovid), Web of Science, and CINAHL (EBSCO), was performed to identify relevant articles. The search was carried out in September 2015. The search terms used were various combinations of psychiatry, Norway, physical restraint, mechanical restraint, and holding. The search terms were in English, as Norwegian scientists typically publish in English to reach a wider audience. There are a very small number of Norwegian scientific peer-reviewed journals that might publish relevant articles in the Norwegian language, such as the Journal of the Norwegian Medical Association. However, these journals typically provide English abstracts that are indexed in one or more of the databases that were searched. Hand searches were done of the reference lists of those articles that were identified as relevant to the study. The details of the search process can be found in A total of 365 articles were identified in the initial electronic search. Hand searching of the references of articles gave an additional 13 potentially relevant articles. The titles and abstracts of the publications were screened for relevance, reducing the number to 102. When duplicates were removed, 38 articles remained, and these were read in full and considered against the inclusion and exclusion criteria (see below). This gave the final 28 articles that were included in the review see .All articles published in peer-reviewed journals carried out with data from Norway and involving the use of physical restraint  within adult psychiatric hospitals were considered for inclusion. Articles not specifically mentioning restraint or that examined coercion only as a general concept were excluded. Studies only involving municipal services, nursing homes, and services for the intellectually disabled were excluded. Studies without data from Norway were excluded, as were studies that did not include primary empirical data . Surveys on rates of use of restraint in Norway that had not been published in peer-reviewed journals were not included in the review, but some have nevertheless been mentioned in Discussion.The 28 included articles were grouped into five different categories according to their study purposes and methods used. The key findings in each article in the different categories were condensed and the common findings in the various categories were identified.The 28 articles were categorized according to their study purposes and methods used see . 27 arti21 of the studies followed a quantitative methodology. Seven articles had a qualitative design, that is, in-depth interviews , case stThe following categorization was devised: (1) studies examining patients' perceptions of physical restraint, (2) studies examining staff's perceptions of physical restraint by means of questionnaires, (3) studies examining the rates of use of physical restraint and factors that influence such rates; these studies were typically reviews of protocols and/or medical records at one or more departments at one or more hospitals, (4) studies examining the effects of interventions on reducing physical restraint, (5) case studies of individual patients subjected to physical restraint, and (6) ethnographic studies.Three studies were identified –14 that In one study , 19 patiFour studies –18 examiA study based on questionnaires from 85 staff at one psychiatric hospital found that patients' assault, acting-out, and self-harming were given as most important reasons for physical restraint. 80% of staff believed that physical restraint was used appropriately, and 94% believed that it did not influence patients' recovery . In a stThese studies were typically reviews of protocols and/or medical records at one or more departments at one or more hospitals. With one exception , all theOne study from 1983 of a forensic psychiatric hospital found that the use of restraint had been reduced dramatically from more than 15,000 patient days in 1977 to only 1.5 patient days in the first third of 1981 , in an eLinaker et al. , examiniKnutzen et al. , in a reIn a study of records of 306 patients who had been subjected to physical restraint, Knutzen et al.  found thThe only intervention study identified was by Sørgaard, who used three interventions: patients' engagement in the formulation of treatment plans, patient and staff evaluations, and renegotiations of treatment plans .Sørgaard  found thThree case studies were identified –34. ThesAll of the studies warned against physical complications that may arise as a consequence of attempting to restrain a patient or actually restraining a patient. Hem and coworkers , 33 founThree studies had an ethnographic approach. One involved observation and interviews with five patients and six nurses of an open seclusion unit , while tA central finding in the study by Hem et al.  was thatA main finding of this review was that half of the included articles (14 of 28) were on rates and factors that influenced rates, especially patient-related factors, such as patients' sex, age, ethnicity, diagnoses, level of aggression, legal status, and duration of stay. A few studies described the importance of organizational or staff-related factors on rates of restraint, including staff-patient ratios, ward size, and staff education levels. Despite this being the category with the highest number of articles, the differences in samples, study designs, and outcomes make it challenging to aggregate the findings. Methodological challenges of this kind have also been highlighted by researchers assessing data from other countries –40.In the present review, one study  found thFour studies were concerned with staff perceptions. Overall, the studies suggested that staff believed that restraint was carried out correctly, although there were some differences in opinion between different groups of staff. There were also some differences in opinion as to when physical restraint should be used. Three studies dealt with patients' perceptions. The studies suggested that the patients felt that restraint could have been avoided and most patients reacted negatively to the experience. There were also three ethnographic studies, in part describing staff and patient perceptions, underlining the negative experience of patients to this intervention. Three articles presented cases discussed in the relevant literature, emphasizing physical complications that may arise in connection with the use of restraints or holding .A main finding in this review was that nearly all the identified studies on restraint in Norwegian adult psychiatric hospitals were observational, with only one exception. While there have been several interventional projects with the aim to reduce restraint, these appear not to have been published in peer-reviewed and indexed journals. A next step in the development of the research in this field of research in Norway would be increasing the number of interventional studies and ensuring that they follow needed scientific rigour in order to allow their publication in scientific journals. Researchers in other countries have also pointed to the need to increase the number of high quality intervention studies in this field , 49, andThe present review showed that there was some variation in the quality of the identified studies, and intervention studies were almost nonexistent. While it might be challenging to carry out intervention studies in this field , there iThe number of studies used in the present review is relatively small as the number of studies in this field is still quite limited. While it is likely that the search captured nearly all the relevant studies that have been published in peer-reviewed journals, there is a possibility that some studies published in journals not indexed by the databases might have been missed.The studies that were identified were primarily concerned with patients' and staff's perspectives and rates of use. There is a need for interventional studies with stronger designs.


For the first time, a national survey of adults in Canada posed questions on charitable giving for HIV and AIDS. The objective of this analysis was to explore the behaviour and attitudes of this population in terms of charitable giving.In 2011, individuals in Canada 16 years of age or older were recruited for a survey from an online panel supplemented by random digit dial telephone interviewing. The margin of error was +/−2.1 percentage points (95%). Chi-square tests were used to detect bivariate associations. A multivariate logistic regression model was fit to compare those who had donated to HIV and AIDS in the past 12 months with those who had donated to other disease or illness charities.2,139 participated. 82.5% had donated to a charitable cause in the past 12 months. 22.2% had ever donated to HIV and AIDS, with 7.8% doing so in the past 12 months. Individuals who had donated to HIV and AIDS versus other disease or illness charities tended to be younger (p<0.05), single (p<0.005), more highly educated (p<0.001) and to self-identify as a member of a sexual minority group (p<0.001). Multivariate analysis revealed individuals who self-identified as a member of a sexual minority group were significantly much more likely to have donated to HIV and AIDS than to other disease or illness charities in the past 12 months .Despite a generally philanthropic orientation, relatively few respondents had ever been involved in charitable giving for HIV and AIDS. Those who had could be understood relationally as individuals at closer social proximity to HIV and AIDS such as members of sexual minority groups. For more than three decades, Public Health practitioners in Canada have tracked the incidence, prevalence and factors associated with the Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). During this time, researchers, non-governmental and governmental organizations, health care and service providers, community stakeholders and others have worked together to generate knowledge and to develop and deliver an array of programs and services designed to raise public awareness. In the absence of a cure, the main focus of Canada's Public Health response remains the prevention of the transmission of HIV, the reduction of stigma and discrimination, and the increase of the length and quality of life of people living with HIV and AIDS (PLHIV).Despite these efforts, in Canada, the number of new HIV infections continues to increase. With advances in treatment, and declines in HIV-related mortality, the number of PLHIV also is increasing. Canada's HIV epidemic is concentrated rather than generalized. That is, among specific sub-populations , the prevalence of HIV is substantial enough and concentrated enough that it leads to continuing HIV transmission and infection within these sub-populations. . Given that Canada's HIV epidemic is concentrated, research and prevention efforts tend to strategically target sub-populations deemed most vulnerable to HIV infection, rather than the general public A blueprint document for Canada's response to HIV recognized the importance of tracking and understanding the public's view of HIV to ensure that ongoing government support as well as private and corporate donations for HIV continue and/or are increased In 2011 university researchers conducted a survey of the general public with regard to issues relevant to HIV. The survey included questions related to knowledge and awareness of HIV and other infections, knowledge about specific issues related to HIV and AIDS including modes of infection, perceptions on seriousness and curability, treatments, attitudes towards people living with HIV and AIDS, level of comfort around HIV and AIDS, knowledge of people who had died of AIDS, availability and frequency of HIV testing, information-seeking behaviour, criminal prosecution of HIV non-disclosure, perceived effectiveness of condoms, number of primary and casual sexual partners and charitable giving for HIV and AIDS While a substantial literature exists on charitable giving While the majority of Canadians made financial donations, a minority accounted for most of the dollars donated. The top 25% of donors  accounted for 82% of the total value of donations. Those who gave the most were more likely than others to be older, report higher household income, more formal education, to be married or widowed, and to be religiously active. Although donors with higher household income tended to donate larger amounts, those with lower income tended to donate more as a percentage of total income othering arguably continues to impact on altruism and charitable giving for HIV and AIDS Eveland & Crutchfield (2007) describe how in the early years of the HIV epidemic, funding for HIV and AIDS service organizations tended to be informal, personal, and centred around the social and political networks of those most affected The aim of this analysis is to better understand the characteristics of people in Canada who donate to Public Health causes like HIV and AIDS.The study received ethics approval from the University of Toronto Research Ethics Board.The survey was conducted in Canada's two official languages, English and French, and administered in all of Canada's provinces and territories. Individuals who were 16 years of age or older and living in Canada at the time of data collection were eligible to participate. All respondents were recruited via random digit dialing and surveyed using a mixed-mode methodology for data collection. This consisted of telephone and online panel components. The mode of interviewing employed for any given respondent was based upon their choice as well as the availability of respondents to panel interviewers. At the core of the mixed-methodology process was a sampling frame based on probability theory where all elements of the target population had an equal chance of being selected into the sample. At the first stage of recruitment, a sample was randomly generated from a dual landline-cell phone sample frame. The sample was loaded into an Interactive Voice Response system (IVR). The IVR system made an initial call and up to three repeat calls before numbers were retired from the sample. The IVR surveying incorporated a recorded script questionnaire which allowed for consistency across individuals. Respondents provided their answers to the recorded questions by pressing the appropriate buttons on their telephone keypad and the system recorded their responses into a survey database. Once respondents had completed the general questions, they were asked if they would like to participate in additional surveys with the panel. If so, they moved to the next stage of the recruitment process: live interviewer confirmation. At this second stage of the recruitment process, the interviewer introduced the respondent to the panel's compensation scheme, recorded basic demographic data  and provided the respondent with a choice to participate by telephone or over the Internet. Email addresses were confirmed in real time during the conversation for those indicating a preference for online survey completion.The survey contained questions regarding demographics and a range of HIV knowledge, attitudes and behaviours. Specific to this analysis were questions exploring respondents' patterns of past charitable giving to causes including HIV and AIDS, intentions for future charitable giving, attitudes towards private sector philanthropic activities and the role of governments in funding and continuing to fund HIV and AIDS research. Questions about respondents' charitable giving history were asked only of those who indicated that they had donated to charity in the past 12 months. Given the sensitive nature of the survey and inclusion of questions not previously asked, the study was pre-tested among a sample of 100 respondents.Data were analyzed with Stata/IC 13.1. Following best practices as outlined by Public Works and Government Services Canada 2,139 respondents completed the survey. Overall, the un-weighted sample closely reflected the actual distribution of Canadians in terms of key variables such as gender, age and province/territory (as per the Canadian Census 2011) In our study, the mode of survey-administration (online or telephone) was contingent upon a respondent's choice and the ability of panel interviewers to access respondents at a given time and location. Telephone became the mode employed to survey harder-to-reach individuals within the randomly recruited panel. This resulted in demographic variation by mode. Compared to the online self-administered mode, those who completed by telephone were more likely to be women, single, heterosexual , over age 60, earn less than $40,000, and report high school education or less.83% of survey respondents reported that they had donated to any charity in the past 12 months. Women were marginally more likely to donate compared to men (84% versus 81%). The proportion donating in the past 12 months tended to increase with age, education, being employed in the past 12 months, greater reported household income, and reported religious affiliation (data not shown).Of those who had donated in the past 12 months, respondents were most likely to donate to organizations that were seeking a cure or treatment for specific diseases and illnesses (62%). Substantial proportions also donated to charities assisting children and youth (51%), disaster relief organizations (42%) and hospitals (32%). When those who had made a donation to a disease or illness charity in the past 12 months were probed on the specific disease or illness, a small cluster of charities tended to be the beneficiaries of these donations. Among this cluster, cancer-based charities were almost universal among donors (96%). Additionally, 45% identified heart and stroke as the disease or illness to which they had donated in the past 12 months, 21% had donated to multiple sclerosis (MS), and 20% to diabetes (data not shown).Of the respondents who had donated to any disease or illness charity in the past 12 months, 22% reported having donated to HIV and AIDS. Bivariate analysis shows that among these individuals, ever having donated to HIV and AIDS was significantly associated with age, education, household earning, marital status, and self-identifying as a sexual minority .Of those who had donated to a disease or illness charity in the past 12 months, individuals more likely to have ever donated to HIV and AIDS included women (58%) versus men (42%); those who were 40–59 years of age (39%) or over 60 years of age (27%) compared to those 25–39 years of age (24%) or those between 16–24 years of age (11%); those with some college or a college degree (31%) or some university or a university degree (31%) compared to those with a graduate or professional degree (21%), or those with less than a high school education (17%). In addition, individuals who described themselves as belonging to a sexual minority were more likely to report donating to HIV in the past year .While 22% of respondents reported ever having donated to HIV and AIDS, 8% of respondents indicated donating to HIV and AIDS in the past 12 months. Individuals who had donated to HIV and AIDS versus other disease or illness charities in the past 12 months were more likely to be younger, have less education, lower household income, be single and be a member of a sexual minority . ComparaA multivariate logistic regression model was fit to compare those who had donated to HIV and AIDS with those who had donated to any other disease or illness in the past 12 months . The finOverall, survey respondents believed it was government's responsibility to continue to fund HIV and AIDS research (58% believed this to a large extent and 36% believed this to a moderate extent) . A majorThis analysis reveals that Canadians are a charitable people, with a majority of survey respondents having donated to a charitable cause in the past 12 months. Donations were directed primarily to charities seeking treatment or a cure for diseases and illnesses, although significant proportions of Canadians reported donations to charities assisting children, to disaster relief agencies, to charities dealing with poverty and homelessness and to hospitals. Smaller proportions of this donor group reported donations to charities that addressed international development, the environment and universities or other educational institutions.Cancer charities were, by far, the most frequent beneficiaries of respondents' donations from those who donated to illness or disease charities. Indeed, almost all respondents reported that they had ever made a donation to a cancer organization. Just under one-in-ten of those who had made a donation to an organization focused on a disease or illness reported donations to organizations focused specifically on HIV and AIDS in the past 12 months, with just over one-in-five ever having made a donation to HIV and AIDS.In a cross-national comparison of national campaigns for charitable causes in the Netherlands, Spain, Sweden, and the United States undertaken between 1950 and 2011, van Leeuwen and Wiepking (2012) compared potential determinants of success, namely perceived characteristics of recipients, characteristics of the donor, and structural characteristics of national campaigns In our study, while reports of donations specifically to HIV and AIDS were relatively few, almost half of those who had never made a donation to HIV and AIDS indicated a willingness to do so in the future, although those who indicated they were “very likely” to consider making such a donation were a small minority. Nevertheless, the findings reflect an important potential opportunity to broaden charitable giving to HIV and AIDS through the identification and recruitment of donors from the substantial pool of those who would consider giving to HIV and AIDS.The findings suggest the study population strongly believed that governments have a responsibility to fund HIV and AIDS research. In addition, there was a belief that the private sector has a role to play in donating to HIV and AIDS also. These findings reflect a public expectation that governments continue to fund HIV and AIDS activities, supplemented by the private sector, and by individuals.The literature on charitable giving highlights, how, across North America, a key concern for non-profit organizations raising charitable donations is to determine ways to enhance empathy in segmented groups of potential donors and appeal to each donor group on their level In order to maintain and increase charitable giving for HIV and AIDS, it will be important for Public Health, and agencies serving it, to provide accurate and reliable information regarding HIV and AIDS as the available evidence indicates that more accurate knowledge on HIV and AIDS is associated with more empathetic and altruistic attitudes toward PLHIV, and by extension may be more associated with overall charitable giving to causes related to HIV and AIDS.While the findings reported in this paper help shed light on the charitable giving of people in Canada towards HIV and AIDS, they do so under several caveats. First, there exists a well-documented sampling bias between surveys that ask about charitable giving and survey response In an analysis of the impact of data collection method Boyle, Lewis and Tefft (2009) reflect how the increasing popularity of cell phone only or cell phone mainly households can impact the coverage bias in landline-oriented survey research While the individuals who were recruited to participate in our study were located within Canada, the questions upon which the analysis in this paper is based did not explicitly indicate that only charitable donations to causes in Canada were to be included. Therefore, we cannot be sure what proportion of our respondents donated to causes in Canada versus causes outside of Canada. While questions posed to respondents indicated the type of charities individuals had donated to, questions were not included that sought information on specific charities. Future research would be advised to explore further the nature of the causes that people in Canada donate to, including the internationalization of philanthropy, and patterns of donating to specific causes or charities particularly as they relate to charitable activities over an individual's life course.The findings reported here are based on cross-sectional survey research, which carries with it a number of limitations


Malnutrition is evident in 30% to 90% of patients with cancer at some point during their disease course . Significant weight loss (> 10% of body weight) increases the risk of morbidity and mortality in individuals with cancer . At diagnosis, at least one third of patients exhibit weight loss of > 5%, but this number is significantly higher in those with advanced disease . Along with this weight loss, there are also changes in protein and albumin status that indicate progressive deterioration of nutritional status and propensity for cachexia . Thus, it is important to recognize those patients who are at risk for malnutrition or who are already malnourished at diagnosis.In an outpatient private practice, a dietitian or nutritionist may not be available for nutrition counseling; thus, this important step becomes an essential component of the oncology advanced practitioner’s role. In this article, an intervention developed at a suburban outpatient practice to address the problem of malnutrition in lung cancer patients is described. A synopsis of the screening and counseling program is given.At the first office visit, newly diagnosed lung cancer patients were approached to participate in the pilot study. Seven patients  consented to participate. One participant had stage II disease, three had stage III disease, and three had stage IV disease. Participants ranged in age from 45 to 83 years and all were either current (six patients) or former (one patient) smokers. Six of the participants had a diagnosis of non–small cell lung cancer and one had small-cell lung cancer.During the first visit, baseline bloodwork was ordered: complete blood cell (CBC) count with differential, comprehensive metabolic panel, and C-reactive protein (CRP). The CRP was added because evidence shows that there is elevation of the acute proinflammatory humoral response in patients who are at risk for malnutrition and cachexia . Each patient made an appointment for an individualized counseling session during the next week.Each individualized nutrition counseling session with the patient and family members included an explanation of the nutrition screening, setting of individual goals for the intervention, bloodwork review, explanation and completion of required screening tools, and discussion of nutrition information. During the first session, the project goal was explained to the patient and family members as being the successful screening for nutritional deficiencies, the evaluation of any deficiencies, and the provision of counseling and support during therapy to mitigate any deficiencies. The patient and family members also shared their goals for study participation. See Figure 1 for a flow chart depicting the components of the first individualized nutrition counseling session.Nutrition of the Cancer Patient: Special Population Series, was distributed. This series of pamphlets focuses on cancer patients in active treatment and is broken down into understanding the side effects of therapy, treating them at home, and avoiding the complications in the future. Information sheets with suggestions on increasing caloric intake through shakes and protein-rich foods were distributed and reviewed. During the session, the patient completed the Scored Patient-Generated Subjective Global Assessment (PG-SGA) tool .The baseline bloodwork review highlighted areas of concern. In particular, the CBC and other indices that are important in evaluating for nutrition deficiencies  were explained to the patient and family members. The nurse practitioner investigator discussed albumin and its role as an indicator of nutrition status. The patient’s CRP level was noted, and its significance as it pertains to nutrition was explained. A pamphlet on nutrition information from the American Institute for Cancer Research (2007), entitled The PG-SGA tool evolved from the Subjective Global Assessment, which was first used in the 1980s to determine a hospitalized patient’s nutrition status . In 1996, the PG-SGA tool was modified, by Faith Ottery at Fox Chase Cancer Center, to reflect the particular concerns related to oncology patients. The instrument has a 98% specificity and an 82% sensitivity. The top section is completed by the patient and/or family member with regard to weight changes, amount of food intake, symptoms caused by cancer or therapy, and current activity level. In the lung cancer study, the nurse practitioner investigator completed the remainder of the tool. The worksheet is made up of categories that score for weight loss, criteria or condition (other comorbidities), metabolic stress, physical examination, and global assessment. The investigator’s and patient’s scores are combined to obtain an overall assessment score. The patient and/or family member also completed a quality-of-life tool for the study, but this is outside the scope of this article and will not be discussed.This counseling process was repeated 6 and 12 weeks after starting therapy and coincided with follow-up scans for determination of response to therapy. The patients and their family members were also given the nurse practitioner investigator’s contact information for any questions that might arise between counseling sessions.Based on analysis of aggregate data from phone conversations with patients and family members, results from the pilot study indicate that the patients and their family members felt that both undergoing individualized counseling and being assigned a designated contact person were beneficial.There was a correlation between CRP level and physical well-being. Patients with a higher CRP level, indicating greater inflammation, reported lower scores for physical well-being and vice versa. The serum albumin levels ranged from 2.4 to 4.6 mg/L, with a mean of 3.657 mg/L and a standard deviation of 0.76. In all cases, serum albumin levels either remained stable or rose during the 12 weeks of the study.Recorded patient contacts to the nurse practitioner investigator were high in the first and last intervals. There was a direct correlation between PG-SGA score, or nutrition status, and the number of telephone questions. These data indicated that even though nutrition scores did improve over time, the participants felt that having the contact person as a resource was a positive experience. Due to the patients’ acuity and the study duration, there were only seven participants, one of whom died before completing the study. Thus, it is difficult to generalize the findings from this pilot study.Monitoring the nutrition status of oncology patients is vital to their continued well-being. Oncology advanced practitioners play a unique role, which allows them to screen and counsel these patients during their treatment. The pilot study results discussed in this article describe positive effects from an intervention conducted by an advanced practice clinician in an outpatient clinic setting. Because patients are frequently in the office for an appointment, it is an easy way to maintain contact and manage any side effects from treatment before they can cause major problems. However, further research is needed on the best way to empower these complicated patients with the information and tools necessary to sustain their nutrition during the disease process. As advanced practitioners, we need to do our part to collect this evidence and incorporate it into our practice patterns.