Why a Safe but Challenging Environment Is Important

Medical Decision Making http://mdm. sagepub. com/ Do Patient Decision Aids Meet Effectiveness Criteria of the International Patient Decision Aid Standards Collaboration? A Systematic Review and Meta-analysis Annette M. O'Connor, Carol Bennett, Dawn Stacey, Michael J. Barry, Nananda F. Col, Karen B. Eden, Vikki Entwistle, Valerie Fiset, Margaret Holmes-Rovner, Sara Khangura, Hilary Llewellyn-Thomas and David Rovner Med Decis Making published online 14 September 2007 DOI: 10. 1177/0272989X07307319.   A more recent version of this article was published on – Oct 5, 2007 Published by: http://www. sagepublications. com On behalf of: Society for Medical Decision Making Additional services and information for Medical Decision Making can be found at: Email Alerts: http://mdm. sagepub. com/cgi/alerts Subscriptions: http://mdm. sagepub. com/subscriptions Reprints: http://www. sagepub. com/journalsReprints. nav Permissions: http://www. sagepub. com/journalsPermissions. nav Version of Re cord – Oct 5, 2007 ;; OnlineFirst Version of Record – Sep 14, 2007 What is This? Downloaded from mdm. sagepub. com by guest on July 22, 2012 Med Decis Making OnlineFirst, published on September 14, 2007 as doi:10. 1177/0272989X07307319 Do Patient Decision Aids Meet Effectiveness Criteria of the International Patient Decision Aid Standards Collaboration? A Systematic Review and Meta-analysis Annette M. O’Connor, RN, PhD, Carol Bennett, MSc, Dawn Stacey, RN, PhD, Michael J. Barry, MD, Nananda F. Col, MD, MPH, MPP, Karen B. Eden, PhD, Vikki Entwistle, PhD, Valerie Fiset, MScN, Margaret Holmes-Rovner, PhD, Sara Khangura, Hilary Llewellyn-Thomas, PhD, David Rovner, MD Objective. Related article: Explain the Post 16 Options 2017 To describe the extent to which patient decision aids (PtDAs) meet effectiveness standards of the International Patient Decision Aids Collaboration (IPDAS). Data sources. Five electronic databases (to July 2006) and personal contacts (to December 2006). Results. Among 55 randomized controlled trials, 38 (69%) used at least 1 measure that mapped onto an IPDAS effectiveness criterion. Measures of decision quality were knowledge scores (27 trials), accurate risk perceptions (12 trials), and value congruence with the chosen option (3 trials). PtDAs improved knowledge scores relative to usual care (weighted mean difference [WMD] = 15. %, 95% confidence interval [CI] = 11. 7 to 18. 7); detailed PtDAs were somewhat more effective than simpler PtDAs (WMD = 4. 6%, 95% CI = 3. 0 to 6. 2). PtDAs with probabilities improved accurate risk perceptions relative to those without probabilities (relative risk = 1. 6, 95% CI = 1. 4 to 1. 9). Relative to simpler PtDAs, detailed PtDAs improved value cong ruence with the chosen option. Only 2 of 6 IPDAS decision process criteria were measured: feeling informed (15 trials) and feeling clear about values (13 trials). PtDAs improved these process measures relative to usual care (feeling uninformed WMD = –8. , 95% CI = –11. 9 to –4. 8; unclear values WMD = –6. 3, 95% CI = –10. 0 to –2. 7). There was no difference in process measures when detailed and simple PtDAs were compared. Conclusions. PtDAs improve decision quality and the decision process’s measures of feeling informed and clear about values; however, the size of the effect varies across studies. Several IPDAS decision process measures have not been used. Future trials need to use a minimum data set of IPDAS evaluation measures. The degree of detail PtDAs require for positive effects on IPDAS criteria should be explored. Key words: decision support techniques; patient education; patient participation; randomized controlled trials. (Med Decis Making 2007;XX:xx–xx) Received 23 July 2007 from the Ottawa Health Research Institute, Canada (AMO, SK, CB); University of Ottawa, Canada (AMO, DS); Massachusetts General Hospital, Boston (MJB); Maine Medical Center, Portland, Maine (NFC); Oregon Health and Science University, Portland (KBE); Social Dimensions of Health Institute, Dundee, UK (VE); Algonquin College, Ottawa, Canada (VF); Michigan State University, East Lansing (MH-R, DR); and Dartmouth Medical School, Hanover, New Hampshire (HL-T). Financial support for this study was provided by a group grant of the Canadian Institutes of Health Research. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, and writing and publishing the report. Address correspondence to Annette M. O’Connor, RN, PhD, University of Ottawa, Ottawa Health Research Institute, 1053 Carling Avenue, ASB, Ottawa, Ontario, Canada K1Y 4E9; e-mail: [email  protected] ca. DOI: 10. 1177/0272989X07307319 P atient decision aids (PtDAs) are adjuncts to counseling that explain options, clarify personal values for the benefits versus harms, and guide patients in deliberation and communication. With the rapid proliferation of these tools, the International Patient Decision Aids Collaboration (IPDAS) has reached agreement on criteria for judging the quality of PtDAs. 1 IPDAS is a network of more than 100 researchers, practitioners, patients, and policy makers from 14 countries. These collaborators developed a checklist of criteria that payers, patients, practitioners, developers, and researchers can use to assess PtDAs they encounter. The criteria address 3 domains of quality: clinical content, the development process, and effectiveness. 554 †¢ MEDICAL DECISION MAKING/MON–MON 2007 Downloaded from mdm. sagepub. com by guest on July 22, 2012 Copyright 2007 by Society for Medical Decision Making.DECISION AIDS â€Å"EFFECTIVENESS CRITERIA OF DECISION AIDS†This article addresses the 3rd domain, the evaluation of PtDAs’ effectiveness in fostering a high-quality decision process and a high-quality choice. Over the past decade, there has been considerable debate about the definition of a good decision when there is no single best therapeutic action and choices depend on how patients value benefits versus harms. 2–6 To select criteria for decision quality, IPDAS participants were asked to identify â€Å"the things that you would nee d to observe in order to say that after using a patient decision aid, the way the decision was made was good and the choice that was made was good. IPDAS endorsed the following criteria for establishing that a decision aid is effective: †¢ Decision quality: The PtDA improves the match between the chosen option and the features that matter most to the informed patient. †¢ Decision processes leading to decision quality: The PtDA helps patients to recognize that a decision needs to be made, know options and their features, understand that values affect the decision, be clear about the option features that matter most, discuss values with their practitioner, and become involved in preferred ways. Our study objectives were 1) to describe the number and types of measures used in randomized controlled trials (RCTs) that correspond to IPDAS criteria for effectiveness and 2) to determine the extent to which RCTs of PtDAs meet these new IPDAS criteria for effectiveness. METHODS We have been updating the Cochrane Review of decision aids since the late 1990s. 7–9 This review differed from previous reviews by focusing on the new IPDAS criteria. Moreover, we used a new systematic review software, TrialStat SRS, to manage the search and data extraction; therefore, our search, screen, and data extraction were redone completely. Data sources included 1) electronic databases to July 2006 (MEDLINE, PsycINFO, CINAHL, and EMBASE), 2) Cochrane Controlled Trials Register (2006, issue 2), and 3) contact with known developers and evaluators to December 2006. The search strategy is described in the appendix. The search was not restricted on the basis of language. PtDAs were defined as interventions designed to help people make specific, deliberated choices among options (including the status quo) by providing information about the options and outcomes (e. . , benefits, DECISION AIDS: PAST, PRESENT, AND FUTURE harms) in sufficient detail that an individual could judge their value implicitly. Patient decision aids may also include information about the clinical condition, outcome probabilities tailored to personal risk factors, an explicit values clarification exercise (e. g. , a relevance chart, utility assessments of probable outcome states, a weigh scale), descriptions of others’ experiences, and guidance in the steps of decision making and communicating with others. This definition excludes interventions focused solely on lifestyle changes, hypothetical situations, clinical trial entry, or general advanced directives; education programs not geared to a specific decision; and interventions designed to promote adherence to a recommended option or to elicit passive informed consent. In the current review, we also excluded studies whose PtDAs were not available for inspection to catalogue their elements according to the new IPDAS domains. As a consequence, a few studies reported in the previous reviews were not included. We included published RCTs comparing 1) PtDAs to usual-care controls or 2) detailed PtDAs to simpler ones (which may not have the level of detail or may not contain all of the IPDAS elements). Participants were deciding about screening or treatment options for themselves, for a child, or for an incapacitated significant other. Two reviewers independently screened each study (CB, SK, DS, AMO, VF), extracted data (CB, SK), and assessed study quality (C. B. , S. K. ) using standardized forms, including the Jadad scale. 0 Inconsistencies were resolved by consensus. Trial results were described individually. Metaanalysis was used for decision quality and for decision process measures because these effects were expected to be independent of the type of decision. Meta-analysis was performed only on those outcomes with similar types of measures. Review Manager 4. 211 was used to estimate a weighted treatment effect (with 95% confidence intervals [CIs]), defined as weighted mean differences ( WMDs) for continuous measures and pooled relative risks (RRs) for dichotomous outcomes. The data used in each meta-analysis can be viewed in the online supplement available at http://mdm. sagepub. com/cgi/ content/full/Volume/Issue/Page#/DC1. All data were analyzed with a DerSimonian and Laird12 random effects model because of the diverse nature of the trials. Forest plots were used to assess and display potential heterogeneity, and funnel plots were used to explore publication bias. Because of statistically significant heterogeneity for most of the outcomes, we performed post hoc subanalyses to explore the potential causes of heterogeneity. Heterogeneity was explored according 555 Downloaded from mdm. sagepub. com by guest on July 22, 2012 O’CONNOR AND OTHERS to the following factors: type of decision (treatment versus screening), type of media of decision aid (video/ computer versus audio booklet/pamphlet), and a possible ceiling effect based on good usual-care scores (removal of studies with lower knowledge and realistic risk perception scores; removal of studies with higher decisional conflict scores for subscales feeling uninformed and unclear values). We analyzed the effects of removing the biggest outlier(s) defined by visual inspection of the forest plots. In addition, a post hoc analysis was performed to examine the effect of 1) excluding trials of low methodological quality and 2) excluding trials that were outliers and contributed to heterogeneity.RESULTSOf the 22,778 unique citations obtained in the review, we identified 1293 as relevant by title and then screened those abstracts (see Figure 1). Of these, 130 citations were retrieved for full-text review. Sixty-four studies were excluded for the following reasons: the study was not focused on making a choice (n = 33), the study was not an RCT (n = 14), the decision support intervention did not meet the definition of a PtDA (n = 8), the study involved a hypothetical situation (n = 6), and no outcome data were provided (n = 3). In all, 55 eligible trials (66 references) were found for duplicate data extraction and analysis. The 55 published RCTs evaluating individual PtDAs13–78 used 51 different PtDAs that focused on 23 different screening or treatment topics (see Table 1). Among the 51 different PtDAs, the elements most frequently included were information about the options and outcomes in sufficient detail to judge their value implicitly (100% by definition), information about the clinical condition (98%), outcome probabilities (84%), examples of others’ experiences (59%), explicit values clarification exercises (55%), and guidance in the steps of decision making (47%). Quality ratings in the trials ranged from 0/5 to 3/5. All studies lost 2 points because patients or practitioners could not be blinded to the intervention. As shown in Table 2, 38 of the 55 trials (69%) reported at least 1 outcome that could be mapped onto an IPDAS criterion for effectiveness; 33 (60%) measured some aspect of decision quality, and 15 (27%) measured a decision process leading to decision quality. Decision Quality As noted above, the definition of decision quality has 2 elements: the extent to which decisions are 556 †¢ MEDICAL DECISION MAKING/MON–MON 2007 informed and based on personal values. Trials used 3 measures corresponding to this definition: knowledge test results, accuracy of risk perceptions, and value congruence with chosen option. Knowledge. Twenty-seven of the 55 studies examined the effects of PtDAs on knowledge; 18 of these compared PtDAs to usual care, and 9 compared PtDAs with more or less detail. The studies’ knowledge tests were based on information contained in the PtDA, thereby establishing content validity. The proportion of accurate responses was transformed to a percentage scale ranging from 0% (no correct responses) to 100% (perfectly accurate responses). In the comparison of PtDAs to usual care15,16,18,26,28,29, 31,36,39,41,43,48,50,64,65,69,73,78 (Figure 2), PtDAs had higher average knowledge scores (WMD = 15. 2%, 95% CI = 11. 7, 18. 7). The 9 studies comparing detailed with simpler PtDAs22,24,30,35,54,60,61,63,66 (Figure 3) showed a smaller effect (WMD = 4. 6%, 95% CI = 3. 0, 6. 2). Accurate risk perceptions. Eleven of 55 studies examined the effects of including probabilities of PtDAs on the accuracy of patients’ perceived probabilities of outcomes. 4,28,41,43–45,54,63,73,74,77 Eight studies measured perceived probabilities as percentages,24,28,43–45,54,73,74 and 3 gauged probabilities in words. 41,63. 77 Perceived outcome probabilities were classified as accurate according to the percentage of individuals whose judgments corresponded to the scientific evidence about the chances of an outcome for similar people. In 4 of 5 studies that elicited perceived probabilities for multiple outcomes,24,44,54,60 the propo rtion of realistic expectations was averaged; in the remaining study,43 the most conservative result was chosen for meta-analysis. People who received a detailed PtDA with descriptions of outcomes and probabilities were more likely to have accurate risk perceptions than those who did not receive this information; the pooled RR of having accurate risk perceptions was 1. 6 (95% CI = 1. 4, 1. 9; Figure 4). The pooled relative risk for probabilities described in words was 1. 3 (95% CI = 1. 1, 1. 5). The pooled relative risk for probabilities described as numbers was 1. 8 (95% CI = 1. 4, 2. 3). Value congruence with chosen option. Four of 55 studies measured value congruence with the chosen option; however, Lerman and others41 did not calculate differences between interventions. The 3 trials comparing interventions were similar in that they 1) focused on the decision to take menopausal hormone replacement therapy (HRT) and 2) compared 2 active interventions. However, these trials used different measures of value (text continued on p 565) Downloaded from mdm. sagepub. com by guest on July 22, 2012 DECISION AIDS â€Å"EFFECTIVENESS CRITERIA OF DECISION AIDS† 2,778 unique citations identified for initial screening (screening based on review of the title) 1,293 potentially relevant citations identified and screened (based on review of the abastract) for retrieval 130 citations retrieved for full-text review 64 excluded: study not focused on making a choice (n = 33); study was not RCT (n = 14); decision support intervention did not meet the definition of a PtDA (n = 8); study involved a hypothetical situatio n (n = 6); no outcome data provided (n = 2); protocol only (n = 1) 5 eligible trials (66 references) for duplicate data extraction Data entry & RCT meta- analysis Figure 1 Flowchart of the procedural steps in the systematic review. RCT = randomized controlled trial; PtDA = patient decision aid. DECISION AIDS: PAST, PRESENT, AND FUTURE Downloaded from mdm. sagepub. com by guest on July 22, 2012 557 Table 1 Elements in DAs Characteristics of 55 Trials Included in the Systematic Review of Patient Decision Aids 558 Number of Enrollees in Intervention + Comparison: Options Considered Quality Rating (Jadad) Others’ Experiences Comparison of Most and Least Intensive Intervention Options and Clinical Outcomes Problem Explicit Outcome Values Probability Clarification Guidance in Steps of DM Source, Year, Location Auvinen and others13,14 2004, Finland 3/5 1/5 2/5 3/5 2/5 2/5 — X — X X X — — X X X — — X — X X — — X X — — X — X — — — X — — X X X — X — — — X — — — — — X — — — X — — — X — — — — — — — — X — — Barry and others15 1997, United States Bekker and others,16,17 2004, United Kingdom Bernstein and others18 1998, United States Pamphlet PtDA Standard care by clinical guideline Interactive videodisc PtDA Usual care Decision analysis plus consultation Usual care Video PtDA Usual care Clancy and others19 1988, United States 30 + 30 men: prostate cancer treatment 67 + 61 women: HRT 1/5 — X X X X X X X X X — X X X X X 103 + 100 men: prostate cancer treatment 104 + 123 men: benign prostate hypertrophy treatment 59 + 58 women: prenatal diagnostic screening for Down syndrome 65 + 53 patients: ischemic heart disease treatment 753 + 263 physicians: hepatitis B vaccine Davison and Degner20 1997, Canada Deschamps and others21 2004, Canada 3/5 — X X X — X — X — X — — — X — X — X — X — X — — — X — — — X — X Downloaded from mdm. sagepub. com by guest on July 22, 2012 Deyo and others22 2000; Phelan and others23 2001, United States 2/5 Dodin and others24 2001, Canada 50 + 47 adults: colon cancer screening 3/5 2/5 3/5 143 + 144 parents: infant polio vaccine schedules 112 + 114 men: PSA testing 190 + 203 patients: herniated disc or spinal stenosis treatment 52 + 49 women: HRT Pamphlet + decision analysis PtDA Usual care Written materials, PtDA, and audiotape of consultation Usual care Audiotape and booklet Pharmacist consultation Interactive videodisc PtDA Simple PtDA pamphlet Audiotape booklet PtDA Simple PtDA pamphlet Dolan and Frisina25 2002, United States Dunn and others26 1998, United States Frosch and others27 2003, United States — X — X X X X X X X — X — X X — — — — — — X — X X — — — — — Computer: analytic hierarchy process and pamphlet PtDA Usual care Video and pamphlet PtDA Usual care Video PtDA Internet presentation mirroring content of video continued) Gattellari and Ward28 2003, Australia 3/5 3/5 3/5 X X — X — X — X X — X X — X — X X — — X — — — — — X X — — — X — — X — — — X — X â⠂¬â€ X — X — X X X X X X — X — X — X — — — — — X — — — — — X — X — X — X — X — X — — — — — 140 + 140 men: PSA testing 86 + 50 women: breast cancer surgery 1/5 126 + 122 men: PSA testing Gattellari and Ward29 2005, Australia Goel and others30 2001, Canada Green and others31 2001, United States 3/5 CD-ROM PtDA plus counseling Genetic counseling Pamphlet PtDA Usual care Pamphlet PtDA General information leaflet Pamphlet PtDA General information leaflet Audiotape and booklet PtDA Simple PtDA pamphlet CD-ROM PtDA plus counseling Usual care Green and others32,33 2004, United States 0/5 2/5 Herrera and others34 1983, United States Hunter and others35 2005, Canada 3/5 3/5 2/5 3/5 Audiotape and booklet PtDA Usual care Audiotape and booklet Individual genetic counseling Decision board PtDA Usual care Video plus booklet PtDA Usual care Booklet PtDA Personal risk profile X — X — X — X — X X X — 2/5 X X X — X — X X X — X X X — X X 9 + 14 higher risk women: breast cancer genetic testing 106 + 105 higher risk women: breast cancer genetic testing 56 + 47 parent(s): circumcision of male newborns 116 + 126 women: prenatal diagnostic testing X — X — X X X — X X X — X X — — X — X — X — X — X — — — Downloaded from m dm. sagepub. com by guest on July 22, 2012 Johnson and others36 2006, United States Kennedy and others37 2002, United Kingdom Lalonde and others38 2006, Canada — — X — X — X — X — X — — — — — X — X — X — X — X — X — (continued) Laupacis and others39 2006, Canada 2/5 Legare and others40 2003, Canada 122 + 164 women: breast cancer genetic testing 100 + 101 women: prenatal diagnostic testing 1/5 32 + 35 patients: dental surgery 300 + 298 women: menorrhagia treatment 13 + 13 patients: cardiovascular health treatment 60 + 60 patients: preoperative autologous blood donation 97 + 87 women: HRT erman and others41 1997, United States Leung and others42 2004, China Audiotape booklet PtDA Simple pamphlet PtDA Discussion PtDA and counseling Usual care wait list control Interactive multimedia PtDA Video and pamphlet 559 Table 1 Elements in DAs continued) 560 Number of Enrollees in Intervention + Comparison: Options Considered Quality Rating (Jadad) Others’ Experiences Comparison of Most and Least Intensive Intervention Options and Clinical Outcomes Problem Explicit Outcome Values Probability Clarification Guidance in Steps of DM Source, Year, Location Man-Son-Hing and others43 1999, Canada — X X X X — — — 3/5 1/5 2/5 X X X X X X — X — X — X — X — X — X — X — X — X — X — — — X — X 3/5 Audiotape and booklet PtDA Usual care X X X X X — X — X — — — — — — X — X — X — — — — — — McAlister and others44 2005, Canada McBride and others45,46 2002, United States Miller and others47 2005, United States 139 + 148 aspirin users in atrial fibrillation trial: move to warfarin 219 + 215 patients: antithrombotic therapy 289 + 292 women: HRT 279 women: BRCA1 BRCA2 gene testing Montgomery and others48,49 2003, United Kingdom 52 + 55 + 51 + 59 adults: hypertension treatment 3/5 Downloaded from mdm. sagepub. com by guest on July 22, 2012 Morgan and others50 2000, Canada 3/5 3/5 — X — X — X — X X — X — X — X — X X — X — X — X — — — — — — — — — — X — — X — X — X — — — — — — — — — — X — Murray and others51 2001, United Kingdom 3/5 2/5 Murray and others52 2001, United Kingdom Myers and others53 2005, United States 121 + 121 men: PSA testing 120 + 120 patients: ischemic heart disease treatment 57 + 55 men: benign prostate hypertrophy treatment 102 + 102 women: HRT Audiotape and booklet PtDA Usual care Pamphlet PtDA Usual care Discussion PtDA and general information pamphlets General information pamphlets Decision analysis PtDA Video and booklet PtDA Decision analysis, video and booklet PtDA Standard care Interactive videodisc PtDA Usual care Interactive videodisc PtDA Usual care O’Connor and others54 1998, Canada 81 + 84 women: HRT 1/5 X X X X X — X — X — X — Interactive videodisc PtDA Usual care Discussion PtDA and general information pamphlet General information pamphlet Audiotape and booklet PtDA Simple PtDA pamphlet O’Connor and others55 1999, Canada 3/5 X X X X X X 1/5 3/5 0/5 — X — X — X — X — X — — — — — — — X — — X X X X X X — X X X X X — — — X 16 + 17 women: osteoporosis treatment 384 + 384 men: PSA testing 37 + 37 patients: dental orthognathic surgery 3/5 3/5 X X X — X — X — X — — — — — — — — X — X 101 +100 women: HRT Oakley and Walley56 2006, United Kingdom Partin and others57 2004, Canada Phillips and others58 1995, United States Pignone and others59 2000, United States Audiotape and booklet PtDA DA without explicit values clarification Audiotape and booklet PtDA Usual care Video PtDA Usual care Video imaging of facial reconstruction PtDA Usual care Video PtDA Usual care — — — X Rostom and others60 2002, Canada X X X X X X — X X X X X X X X X — X — — — 125 + 124 adults: colon cancer screening 25 + 26 women: HRT X X X X — — — — — — — — — — X X — — — — — 83 + 89 women: HRT 1/5 Computer PtDA with testing + feedback regarding knowledge Audiotape with booklet Lecture with personal decision exercise PtDA Simple PtDA pamphlet Booklet PtDA Simple PtDA pamphlet Booklet PtDA Usual care Rothert and others61 1997; Holmes-Rovner and others62 1999, United States Schapira63 2000, United States 1/5 2/5 Downloaded from mdm. sagepub. com by guest on July 22, 2012 Schwartz and others64 2001, United States 2/5 Booklet PtDA Usual care Shorten and others65 2005, Australia X — X — X — X — — — X — Street and others66 1995, United States 1/5 22 + 135 men: prostate cancer screening 191 + 190 Ashkenazi Jewish women: breast cancer genetic testing 85 + 84 pregnant women: birthing options after previous cesarean delivery 30 + 30 women: breast cancer surgery Interactive multimedia PtDA Simple PtDA X X X X — — — — X — X — (continued) 561 562 Table 1 Elements in DAs (continued) Source, Year, Locat ion Number of Enrollees in Intervention + Comparison: Options Considered Quality Rating (Jadad) Comparison of Most and Least Intensive Intervention Options and Clinical Outcomes Problem Explicit Outcome Values Probability Clarification Others’ Experiences Guidance in Steps of DM VanRoosmalen and others67,68 2004, the Netherlands X X — X — X — X — X — X — X — X X — — X — X — X — — X — — X — X — X — X — X — X — X X X X — — — — — — — — — — — — — X — 44 + 44 women with BRCA1/2 mutation: prophylactic surgery 3/5 X X X X — — X — — — — — — — X — — — — — X X — — — — — — — — — — — — — — Volk and others69,70 1999, United States 3/5 3/5 3/5 80 + 80 men: prostate cancer screening Vuorma and others71,72 2003, Finland Video and brochure PtDA with decision analysis Same video and brochure PtDA pamphlet Video with pam phlet PtDA Usual care Booklet PtDA Usual care Whelan and others73 2003, Canada 3/5 2/5 184 + 179 women: menorrhagia treatment 82 + 93 women: breast cancer chemotherapy Downloaded from mdm. sagepub. com by guest on July 22, 2012 Whelan and others74 2004, Canada Wolf and others75,76 1996, United States 1/5 2/5 Script PtDA Usual care Pamphlet PtDA Usual care 94 + 107 women: breast cancer surgery 103 + 102 men: prostate cancer screening Decision board PtDA and booklet Usual care with booklet Decision board PtDA Usual care Script PtDA Usual care Wolf and Schorling77 2000, United States Wong and others78 2006, United States 266 + 133 seniors: colon cancer screening 162 + 164 women: pregnancy termination Note: DM = decision making; PtDA = patient decision aid; HRT = hormone replacement therapy; PSA = prostate-specific antigen. Table 2 Cumulative Studies Still in 2007 Review Reporting Outcome in Each Cochrane Review Update Year % n/N Lead Author 15 50 18 Trials Measuring Outcomes That Map onto the International Patient Decision Aid Standards (IPDAS) Criteria Outcome Decision quality 2007 1999 2003 15 27 2/13 8/30 49 27/55 Knowledge scores 999 2003 54 57 7/13 17/30 Realistic expectations, accurate risk perceptions Barry, Morgan, Bernstein, Lerman,41 Rothert,61 O’Connor,54 Street66 As above plus Schwartz,64 Man-Son-Hing,43 Volk,69 Dunn,26 Green,31 Goel,30 Shapira,63 Rostom,60 Phelan,23 Dodin24 As above plus Bekker,16 Gattellari,28 Johnson,36 Whelan,73 Shorten,65 Montgomery,48 Gattellari,29 Laupacis,39 Wong,78 Hunter35 OConnor,54 Lerman41 As above plus Wolf,77 McB ride,45 Man-Son-Hing,43 Rostom,60 Shapira,63 Dodin24 As above plus Whelan,74 Whelan,73 McAlister,44 Gattellari28 Value congruence with chosen option Decisional Conflict Scale (DCS) 2007 1999 2003 2007 1999 2003 2007 80 2007 1999 2003 2007 1999 2003 57 15 30 27 15 33 24 15/55 2/13 10/30 13/55 2/13 9/30 17/30 Downloaded from mdm. sagepub. com by guest on July 22, 2012 22 0 10 5 15 30 12/55 0/13 3/30 3/55 2/13 9/30 Decision process leading to decision quality Feeling informed, subscale of the DCS Feeling clear about values, subscale of DCS O’Connor,55 Holmes-Rovner,62 Dodin24 As above OConnor,54 Morgan50 As above plus Murray,51 Murray,52 Dolan,25 Man-Son-Hing,43 Dodin,24 Goel,30 OConnor55 As above plus Montgomery,48 Shorten,65 Laupacis,39 Whelan,74 McAlister,44 Lalonde,38 Legare,40 Hunter35 O’Connor,54 Morgan50 As above plus Murray,51 Murray,52 Dolan,25 Man-Son-Hing,43 Dodin,24 Goel,30 OConnor55 As above plus Montgomery,48 Laupacis,39 McAlister,44 Wong,78 Bekker,16 Lalonde38 O’Connor,54 Morgan50 As above plus Murray,51 Murray,52 Dolan,25 Man-Son-Hing,43 Dodin,24 Goel,30 OConnor55 As above plus Montgomery,48 Laupacis,39 McAlister,44 Lalonde38 Note: Trials included in 1999 and 2003 but not in 2007 are Davison and others (measuring feeling informed, clear values); Maisels and others,81 Michie and others82 (measuring knowledge scores), and Thornton and others. 83 These authors were eliminated because we were unable to verify what was in their decision aid to meet the IPDAS definition of a decision aid. 563 O’CONNOR AND OTHERS Study or subcategory y Bekker 2004 Gattellari 2003 Johnson 2006 Whelan 2003 Schwartz 2001 Man-Son-Hing 1999 Morgan 2000 Shorten 2005 Montgomery 2003 Gattellari 2005 Laupacis 2006 Volk 1999 Lerman 1997 Barry 1997 Wong 2006 Bernstein 1998 Dunn 1998 Green 2001 N Decision Aid Mean (SD) 74. 00(14. 50) 50. 00(18. 40) 92. 60(11. 00) 80. 20(14. 40) 65. 71(14. 29) 75. 91(15. 72) 76. 00(32. 04) 75. 33(15. 00) 75. 00(17. 00) 57. 20(21. 30) 83. 00(19. 50) 48. 00(22. 40) 68. 90(19. 00) 75. 00(45. 00) 85. 00(26. 70) 83. 00(16. 00) 83. 67(23. 13) 95. 00(7. 00) N Usual Care Mean (SD) 71. 50(16. 00) 45. 00(15. 90) 85. 20(15. 60) 71. 70(13. 30) 57. 14(15. 71) 66. 46(16. 07) 62. 00(32. 04) 60. 53(17. 07) 60. 00(18. 00) 42. 20(16. 70) 67. 40(17. 00) 31. 00(18. 30) 49. 00(21. 70) 54. 00(45. 00) 60. 00(21. 70) 58. 00(16. 00) 55. 53(22. 80) 65. 00(21. 00) W MD (random) 95% CI W eight % 5. 68 6. 3 5. 49 6. 16 6. 41 6. 24 4. 61 6. 04 5. 43 6. 03 5. 32 5. 50 6. 00 3. 84 5. 81 5. 61 5. 83 3. 97 100. 00 W MD (random) 95% CI 2. 50 [-3. 31, 8. 31] 5. 00 [0. 39, 9. 61] 7. 40 [0. 98, 13. 82] 8. 50 [4. 37, 12. 63] 8. 57 [5. 55, 11. 59] 9. 45 [5. 68, 13. 22] 14. 00 [4. 81, 23. 19] 14. 80 [10. 23, 19. 37] 15. 00 [8. 39, 21. 61] 15. 00 [10. 40, 19. 60] 15. 60 [8. 64, 22. 56 ] 17. 00 [10. 61, 23. 39] 19. 90 [15. 17, 24. 63] 21. 00 [9. 25, 32. 75] 25. 00 [19. 60, 30. 40] 25. 00 [18. 95, 31. 05] 28. 14 [22. 83, 33. 45] 30. 00 [18. 71, 41. 29] 15. 22 [11. 71, 18. 73] 50 106 32 82 191 137 90 99 50 131 53 78 122 104 154 61 143 29 6 108 35 93 190 136 97 92 58 136 53 80 164 123 159 48 144 14 Total (95% CI) 1712 1786 Test for heterogeneity: ? 2 = 130. 32, df = 17 (P ; 0 . 00001), I? = 87. 0% Test for overall effect: Z = 8. 50 (P ; 0. 00001) -50 Favors Usual Care 0 50 Favors Decision Aid Figure 2 Effect of patient decision aids on patients’ mean scores on knowledge tests: decision aid versus usual care. WMD = weighted mean difference; CI = confidence interval. Study N Goel 2001 Rothert / H-Rovner O'Connor 1998-RCT Hunter 2005 Schapira 2000 Street 1995 Rostom 2002 Deyo / Phelan Dodin 2001 Total 77 83 81 116 122 30 25 41 52 627 Detailed DA Mean (SD) 81. 67(11. 1) 86. 79(11. 34) 75. 00(20. 00) 64. 53(19. 61) 83. 33(12. 78) 82. 60(11. 60) 93. 80(9. 00) 71. 76 (17. 06) 71. 04(15. 45) N Simple DA Mean (SD) 80. 00(12. 22) 83. 75(11. 54) 71. 00(21. 00) 60. 13(19. 00) 78. 33(15. 00) 76. 40(13. 80) 87. 10(11. 80) 62. 35(23. 53) 61. 20(17. 90) WMD (random) 95% CI Weight % 14. 31 21. 90 6. 62 10. 92 22. 45 6. 23 7. 85 3. 67 6. 06 100. 00 WMD (random) 95% CI 1. 67 [-2. 59, 5. 93] 3. 04 [-0. 40, 6. 48] 4. 00 [-2. 26, 10. 26] 4. 40 [-0. 47, 9. 27] 5. 00 [1. 60, 8. 40] 6. 20 [-0. 25, 12. 65] 6. 70 [0. 95, 12. 45] 9. 41 [1. 00, 17. 82] 9. 84 [3. 30, 16. 38] 4. 63 [3. 02, 6. 24] 48 87 84 126 135 30 26 49 49 634 Test for heterogeneity: ? 2 = 7. 18, df = 8 (P = 0. 52 ), I? = 0% Test for overall effect: Z = 5. 63 (P < 0. 00001) -50 Favours Simple 0 50 Favours Detailed Figure 3 Effect of patient decision aids (DAs) on patients’ mean scores on knowledge tests: detailed versus simple decision aids. WMD = weighted mean difference; CI = confidence interval. 564 †¢ MEDICAL DECISION MAKING/SEP–OCT 2007 Downloaded from mdm. sagepub. com by guest on July 22, 2012 DECISION AIDS â€Å"EFFECTIVENESS CRITERIA OF DECISION AIDS† Study or subcategory y Decision Aid n/N 90/122 189/266 73/94 109/265 82/122 33/52 58/81 47/82 70/187 88/139 57/106 1516 Usual Care n/N 108/164 72/133 62/107 82/274 62/135 21/49 39/84 34/92 27/165 40/148 11/108 1459 RR (random) 95% CI W eight % 11. 11 10. 83 10. 55 10. 01 10. 16 7. 66 9. 45 8. 54 7. 54 9. 04 5. 12 100. 00 RR (random) 95% CI 1. 12 [0. 96, 1. 31] 1. 31 [1. 10, 1. 56] 1. 34 [1. 10, 1. 63] 1. 37 [1. 09, 1. 73] 1. 46 [1. 17, 1. 83] 1. 48 [1. 01, 2. 17] 1. 54 [1. 18, 2. 02] 1. 55 [1. 12, 2. 15] 2. 29 [1. 55, 3. 38] 2. 34 [1. 75, 3. 14] 5. 28 [2. 93, 9. 50] 1. 61 [1. 35, 1. 92] Lerman 1997 Wolf 2000 Whelan 2004 McBride 2002 Schapira 2000 Dodin 2001 O'Connor 1998-RCT Whelan 2003 McAlister 2005 Man-Son-Hing 1999 Gattellari 2003 Total (95% CI) Total events: 896 (Decision Aid), 558 (Usual Care) Test for heterogeneity: ? 2 = 52. 06, df = 10 (P ; 0. 00001), I? = 80. 8% Test for overall effect: Z = 5. 34 (P ; 0. 00001) 0. 1 0. 2 0. 5 1 Favours Usual Care 2 5 10 Favours Decision Aid Figure 4 Effect of patient decision aids on the proportion of patients classified as having accurate risk perceptions. RR = relative risk; CI = confidence interval. congruence. Holmes-Rovner and others62 measured the correlation between the subjective expected value of hormones and women’s likelihood of taking HRT, converted here to the percentage of variance in likelihood explained by alues. Dodin and others24 measured the percentage of variance in decisions explained by values. O’Connor and others55 used logistic regression to estimate the percentage agreement between values and choice. PtDAs improved value congruence with the chosen option in 2 of 3 studies. In the trial by Dodin and others,24 24% of the variance in HRT decisions wa s explained by personal values when a detailed PtDA with explicit values clarification was used; in contrast, 14% of the variance in decisions was explained when a simpler PtDA was used (P = 0. 003). In the study by Holmes-Rovner and others,62 the percentage of variance in the likelihood of choosing HRT that was explained by women’s expected values was greater when a more detailed PtDA was used (13%–14%) than when a simpler PtDA was used (0. 09%–2%). O’Connor and others55 found that the addition of an explicit values clarification exercise in a PtDA did not improve agreement between values and the chosen option. However, in the subgroup of women who chose HRT, women who used the PtDA with explicit values clarification DECISION AIDS: PAST, PRESENT, AND FUTURE ad a trend toward better agreement (40%) than did those who used an identical PtDA without explicit values clarification (0%, P = 0. 06). Decision Processes Leading to Decision Quality There were no trials evaluating the extent to which PtDAs helped patients to recognize that a decision needs to be made, understand that values affect the decision, and discuss values with their practitioner. Althoug h 8 trials evaluated effects on patient participation, none focused on helping patients become involved in preferred ways. Some studies measured patients’ self-reports about feeling informed and clear about personal values. The measures used to evaluate these 2 criteria were 2 subscales of the Decisional Conflict Scale (DCS). The DCS is reliable, discriminates between those who make or delay decisions, is sensitive to change, and discriminates between different decision support interventions. 54,79 The scores are standardized to range from 0 (no decisional conflict) to 100 points (extreme decisional conflict). Scores of 25 or lower are associated with follow through with decisions, whereas scores that exceed 38 are associated with delay in decision making. 54 When PtDAs are compared with usual care, 565 Downloaded from mdm. agepub. com by guest on July 22, 2012 O’CONNOR AND OTHERS Study or subcategory y Decision Aid N Mean (SD) 22. 17(9. 47) 27. 56(10. 51) 16. 25(13. 75) 29. 93(17. 26) 15. 75(13. 00) 20. 00(21. 50) 15. 75(13. 25) 15. 00(12. 50) 21. 67(15. 83) 32. 50(15. 00) Usual Care N Mean (SD) 58 45 54 93 37 94 148 215 159 56 959 49. 14(25. 40) 38. 88(20. 02) 27. 25(15. 00) 38. 89(22. 53) 24. 50(21. 25) 27. 50(21. 50) 21. 00(14. 75) 20. 00(15. 00) 25. 83(19. 17) 31. 67(14. 17) WMD (random) 95% CI Weight % 8. 64 9. 09 10. 03 9. 73 7. 93 9. 28 11. 82 12. 25 11. 33 9. 90 100. 00 WMD (random) 95% CI -26. 97 [-34. 1, -19. 93] -11. 32 [-17. 83, -4. 81] -11. 00 [-16. 43, -5. 57] -8. 96 [-14. 73, -3. 19] -8. 75 [-16. 67, -0. 83] -7. 50 [-13. 79, -1. 21] -5. 25 [-8. 49, -2. 01] -5. 00 [-7. 60, -2. 40] -4. 16 [-8. 05, -0. 27] 0. 83 [-4. 74, 6. 40] -8. 35 [-11. 89, -4. 80] 02 Uninformed Subscale Montgomery 2003 50 Murray BPH 2001 52 Laupacis 2006 54 Murray HRT 2001 93 Dolan 2002 41 Morgan 2000 86 Man-Son-Hing 1999 139 McAlister 2005 219 Wong 2006 154 Bekker 2004 50 Subtotal (95% CI) 938 Test for heterogeneity: 48. 12, df = 9 (P ; 0. 00001), I? = 81. 3% Test for overall effect: Z = 4. 61 (P ; 0. 0001) -50 0 Favours Decision Aid 50 Favours Usual Care ?2 = Figure 5 Effect of patient decision aids on patients’ scores on the Uninformed subscale of the Decisional Conflict Scale: d ecision aid versus usual care. WMD = weighted mean difference; CI = confidence interval. Study or subcategory y Detailed DA N Mean (SD) 22. 50(17. 50) 17. 50(12. 50) 20. 75(10. 75) 22. 50(17. 50) 38. 25(12. 00) Simple DA N Mean (SD) 84 49 45 100 12 27. 50(20. 00) 22. 25(14. 75) 24. 00(16. 00) 20. 00(17. 50) 31. 25(10. 75) W MD (random) 95% CI W eight % 20. 52 21. 72 22. 00 23. 42 12. 34 100. 00 W MD (random) 95% CI -5. 0 [-10. 73, 0. 73] -4. 75 [-10. 10, 0. 60] -3. 25 [-8. 51, 2. 01] 2. 50 [-2. 34, 7. 34] 7. 00 [-2. 12, 16. 12] -1. 32 [-5. 27, 2. 62] 02 Uninformed Subscale O'Connor 1998-RCT 81 Dodin 2001 52 Goel 2001 76 O'Connor Wells 1999 101 Lalonde 2006 12 Subtotal (95% CI) 322 290 Test for heterogeneity: ? 2 = 9. 24, df = 4 (P = 0. 06), I? = 56. 7% Test for overall effect: Z = 0. 66 (P = 0. 51) -50 0 Favours Detailed DA 50 Favours Simple DA Figure 6 Effect of patient decision aids on patients’ scores on the Uninformed subscale of the Decisional Conflict Scale: detailed ve rsus simple decision aid (DA). WMD = weighted mean difference; CI = confidence interval. a negative score indicates a reduction in decisional conflict, which is in favor of the PtDA. In our review, 15 trials used the DCS subscale for feeling informed and 13 trials used the DCS subscale for feeling clear about values. Because this DCS subscale measures self-reported comfort with knowledge and not actual knowledge, we elected to consider it a process measure and to reserve the gold standard of objective knowledge tests in assessing decision quality. The WMD in feeling uninformed about options, benefits, and harms was –8. (95% CI = –11. 9 to –4. 8) in the 10 trials16,25,39,43,44,48,50–52,78 that compared the PtDAs to usual care (Figure 5). The 5 trials that compared detailed with simpler PtDAs24,30,38,54,55 had a WMD in feeling uninformed of –1. 3 (95% CI = –5. 3 to 2. 6; Figure 6). Eight trials comparing PtDA to usual care25,39,43,44,48,50–52 had a WMD of –6. 3 (95% CI = –10. 0, –2. 7) for feeling clear about values (Figure 7). Five trials compared detailed to simpler PtDAs. 24,30,38,54,55 For these trials, the WMD in feeling clear about values was –1. 1 (95% CI = –4. 8 to 2. ; Figure 8). 566 †¢ MEDICAL DECISION MAKING/MON–MON 2007 Downloaded from mdm. sagepub. com by guest on July 22, 2012 DECISION AIDS â€Å"EFFECTIVENESS CRITERIA OF DECISION AIDS† Study or sub-category Decision Aid N Mean (SD) 50 54 41 82 53 139 219 86 724 28. 50(12. 50) 18. 75(16. 50) 19. 75(15. 75) 37. 50(15. 00) 35. 38(12. 33) 16. 25(12. 50) 15. 00(12. 50) 30. 00(3. 25) Usual Care N Mean (SD) 58 55 37 84 45 148 215 94 736 51. 29(25. 73) 30. 00(17. 00) 29. 25(24. 00) 42. 85(16. 57) 40. 56(16. 44) 19. 00(14. 75) 17. 50(15. 00) 30. 00(3. 25) WMD (random) 95% CI Weight % 9. 8 11. 11 8. 15 12. 88 11. 64 14. 75 15. 30 16. 40 100. 00 WMD (random) 95% CI -22. 79 [-30. 26, -15. 32] -11. 25 [-17. 54, -4. 96] -9. 50 [-18. 61, -0. 39] -5. 35 [-10. 16, -0. 54] -5. 18 [-11. 02, 0. 66] -2. 75 [-5. 91, 0. 41] -2. 50 [-5. 10, 0. 10] 0. 00 [-0. 95, 0. 95] -6. 33 [-9. 98, -2. 69] 03 Unclear Values Subscale Montgomery 2003 Laupacis 2006 Dolan 2002 Murray HRT 2001 Murray BPH 2001 Man-Son-Hing 1999 McAlister 2005 Morgan 2000 Subtotal (95% CI) Test for heterogeneity: 57. 71, df = 7 (P ; 0. 0 0001), I? = 87. 9% Test for overall effect: Z = 3. 40 (P = 0. 007) -50 Favours Decision Aid 0 50 Favours Usual Care ?2 = Figure 7 Effect of patient decision aids on patients’ scores on the Unclear Values subscale of the Decisional Conflict Scale: decision aid versus usual care. WMD = weighted mean difference; CI = confidence interval. Study or sub-category y Detailed DA N Mean (SD) 81 77 52 12 97 25. 00(17. 50) 24. 00(12. 50) 25. 00(13. 75) 39. 50(10. 75) 22. 50(15. 00) N 84 45 49 12 100 Simple DA Mean (SD) 32. 50(17. 50) 25. 75(15. 75) 24. 75(13. 50) 37. 50(13. 00) 20. 00(15. 00) W MD (random) 95% CI W eight % 21. 23 21. 09 21. 32 10. 94 25. 42 100. 0 W MD (random) 95% CI -7. 50 [-12. 84, -2. 16] -1. 75 [-7. 13, 3. 63] 0. 25 [-5. 07, 5. 57] 2. 00 [-7. 54, 11. 54] 2. 50 [-1. 69, 6. 69] -1. 05 [-4. 81, 2. 70] O'Connor 1998-RCT Goel 2001 Dodin 2001 Lalonde 2006 O'Connor Wells 1999 Subtotal (95% CI) 319 290 Test for heterogeneity: ? 2 = 9. 02, df = 4 (P = 0. 06 ), I? = 55. 7% Test for overall effect: Z = 0. 55 (P = 0. 58) -50 0 Favours Detailed DA 50 Favours Simple DA Figure 8 Effect of patient decision aids on patients’ scores on the Unclear Values subscale of the Decisional Conflict Scale: detailed versus simple decision aid (DA). WMD = weighted mean difference; CI = confidence interval. Post hoc Analysis Effects of study quality. To examine the effect of possible bias from including trials of low methodological quality, the 13 trials15,21,31,34. 41,45,54,56,58,61,63,66,77 with Jadad scores of 0 or 1 were excluded from the analysis. Overall, the results remained the same. There was a significant improvement in knowledge scores for the comparison of PtDAs to usual-care controls (WMD = 14. 0%, 95% CI = 2. 4, 8. 6) and for the comparison of detailed to simpler PtDAs (WMD = 5. 5%, 95% CI = 2. 4, 8. 6). The proportion of patients having accurate risk perceptions was greater for patients receiving PtDAs with information on outcome probabilities (RR = 2. 0, 95% CI = 1. 4, 2. 8). Publication bias. There were too few studies to explore potential publication bias for all of the outcomes, with the exception of knowledge for the comparison of PtDAs to usual care. The funnel plot for this outcome (Figure 9) points to the absence of smaller negative studies. DECISION AIDS: PAST, PRESENT, AND FUTURE Downloaded from mdm. sagepub. com by guest on July 22, 2012 567 O’CONNOR AND OTHERS Comparison: 01 Decision Aids versus Usual Care Outcome: 0 07 Knowledge: Decision Aids vs Usual Care SE(WMD) 2 4 6 8 -100 -50 0 50 100 WMD (fixed) Figure 9 Funnel plot of all 18 randomized controlled trials comparing patient decision aids to usual care (knowledge). WMD = weighted mean difference. Heterogeneity. There was statistically significant heterogeneity when PtDAs were compared with usual care for 4 outcomes: knowledge test scores, realistic risk perceptions, feeling uninformed, and feeling unclear regarding personal values (Table 3). It should be noted that the heterogeneity of the effect was not in the direction but in the size. When we explored the potential factors contributing to heterogeneity (Table 3), we found that none of the factors eliminated heterogeneity for the outcomes of knowledge scores. When grouped into treatment and screening decisions, the WMD for knowledge scores was slightly higher for the treatment group (16. 6% v. 13. 1%), but there was still statistically significant heterogeneity. For the outcomes of accurate risk perceptions, heterogeneity was not significant when we removed 3 studies with lower accurate risk perception scores in the usual-care control group (P = 0. ). 28,43,44 For the outcome of feeling uninformed, heterogeneity was no longer significant with 1) removal of 3 studies with higher uninformed scores in the usual-care control group (P = 0. 11), 2) inclusion of only audio booklet/ pamphlet decision aids (P = 0. 06), and 3) removal of an outlier48 (P = 0. 06). None of the factors eliminated heterogeneity for the outcomes of unclear values scores. DISCUSSION The majority o f trials report on at least 1 IPDAS effectiveness measure, predominately knowledge test scores. Of those reporting IPDAS measures, we found that PtDAs were superior to usual practices in 568 †¢ MEDICAL DECISION MAKING/SEP–OCT 2007 meeting the new IPDAS standards 1) for decision quality and 2) for 2 process measures (feeling informed and feeling clear about personal values). Detailed PtDAs had superior effects over simpler PtDAs on value congruence with the chosen option and on accurate risk perceptions but not on knowledge test scores or on self-reports about feeling informed and feeling clear about values. We also identified the gaps in the use of measures of effectiveness endorsed by IPDAS, notably, value congruence with the chosen option and most of the decision process measures. There are some study limitations. Study quality ratings of all trials included in the review were low because they all lost 2 points for lack of blinding. Although not an a priori exclusion criterion for this review, in the future, we may consider using study quality ratings for the selection of included trials. The conclusions of this review are limited by 1) inadequate power to detect important differences in effectiveness in subgroups and 2) the wide variability in the decision contexts, the elements within the PtDAs, the type of comparison interventions, the targeted outcomes, and the evaluation procedures. This article focuses solely on measures of effectiveness, not harms. The small number of studies for most outcomes did not allow for analysis of publication bias because of the failure to publish negative studies. Moreover, there may have been publication bias because of failure to report all negative findings in a published study. Lastly, several of the outcomes demonstrated statistically significant heterogeneity. It reflects differences across clinically diverse studies; therefore, the pooled effect size and CI should be interpreted as a range across conditions, which may not be applicable to a specific condition. There are several implications for future research. Studies are needed to evaluate the effects of PtDAs on congruence between values and chosen options. Moreover, the methods for quantifying value congruence should be explored. The IPDAS decision processes criteria leading to decision quality should also be measured. It would be helpful to develop a standardized approach to measurement. With the addition of more trials to the database, it may be possible to tease out the reason for heterogeneity of results, including variability in 1) study quality, 2) comparison intervention, 3) elements within PtDAs, 4) decision type, and 5) format of decision aid (e. g. , video, Internet, booklet). The degree of detail in PtDAs that is required for positive effects on IPDAS criteria should also be explored. Downloaded from mdm. sagepub. com by guest on July 22, 2012 Table 3 Exploration of Potential Factors Affecting Heterogeneity Outcome Overall Effect Treatment Decision Screening Decision Video/Computer Decision Aid Audio/Pamphlet Decision Aid Baseline Risk in Usual-Care Groupa Removal of Outliers Knowledge 1. 6 (1. 4, 1. 9) –3. 5 (–12. 9, 5. 8) 1. 6 (1. 1, 2. 3) No data 15. 2 (11. 7, 18. 7) 16. 6 (12. 0, 21. 2) 13. 1 ( 7. 7, 18. 5) 21. 4 (16. 5, 26. 2) 11. 9 (8. 3, 15. 6) 1. 6 (1. 4, 1. 9) 15. 6 (11. 3, 19. 9) 1. 3 (1. 2,1. 5)* 1. 6 (1. 4, 1. 9) 17. 316,28,36 (13. 7, 20. 9) 1. 528 (1. 3, 1. 7) –8. 4 (–11. 9, –4. 8) –9. 4 (–13. 3 –5. 5) 12. 6 (–19. 5, –5. 8) –4. 9 (–7. 6, –2. 3)*** –5. 4 (–7. 7, –3. 2)** –6. 248 (–8. 4, –4. 1)*** –8. 0 (–15. 1, –1. 0) –4. 5 (–8. 4, –0. 6) –3. 6 (–6. 8, –0. 5) –4. 0 r48 (–6. 7, –1. 3) Downloaded from mdm. s agepub. com by guest on July 22, 2012 Accurate risk perceptions Uninformed Subscale of the Decisional Conflict Scale Unclear values subscale of the Decisional Conflict Scale –6. 0 (–9. 8, –2. 3) Insufficient data –6. 3 (–10. 0, –2. 7) Note: Values are presented as the weighted mean treatment effect (95% confidence interval). Chi-square heterogeneity test P value

Linguage

Wall Street crush-, it created a split inside the labor leadership so the task would be very difficult. The leader Ramsey MacDonald accepted to form coalition with the conservatives but many others did not accept & he seen as traitor & he was expelled from the party – the Great Betrayal-. The conservatives in 1931 took part in government. -Why would the British go to war after what they had lost in the WWW? – Britain was not in favor of going to another war; it found herself involved in the WI unwillingly.The Germans had invaded Poland, so England was in war against Germany â€Å"the People's War†. In 1940, Churchill became a national coalition government -all parties will Join & make a government-. They were fighting a war, all the effort of the country will be directed to winning it. – Why did labor socialists representatives of the working class Join the government? Preparing themselves for after the war. During war time, the NAG put into place a shared â€Å"head† by a liberal member of parliament.The sociologist â€Å"William Henry Beverage† gave the government the â€Å"Beverage Report† of 1942, in order to offer solutions & look after what was wrong in the war with Britain. The report started to revive the ideas of the â€Å"Welfare State†, which came as an opposition to what Hitler was promising â€Å"Total Destruction†. Welfare through government intervention was what kept the high spirit of people. The pamphlet became a best seller-hope for a better future-. The report had identified 5 giant evils in the British society which had to be destroyed with the government help: 1- bad living conditions. – Diseases 3- ignorance, illiteracy. 4- Poverty 5- idleness, joblessness. These are the evils that a given society face, combated by the government intervention which explains why the liberate did not like the government o interfere in peoples' lives. Labor socialists adopted this idea of w elfare & in 1945 made it part their election program & because of this labor was elected & won the 1945 general election. Armistice was the the signed in the 5 of May 1945; the coalition government kept & waited until July 5 , waiting the soldiers to vote for them.The labor had a very large majority of votes â€Å"landslide victory'. The hero that led Britain to victory & wins the Dark Hours was Churchill. 2- Re-entering peace time: In order to assess labor achievement we should see the context of time, how was Britain after the war? What was the social, lattice, economic reality of that time? There were deaths â€Å"sass's†, widows & orphans as a negatives social consequence for the country. Britain had to payback huge depths due to the finance in the war, as the country borrowed money from the US, Canada & Australia.Britain's infrastructure was terribly damaged, factories, bridges, in this period she was facing reality. Politically: India, new powers were emerging like the US. 3- Laborer's achievements: 1- Economic side: 1945, labor government began to nationalize, take into control. E. G. The Bank of England â€Å"the Central Bank†, also it nationalized the coal lines. In 1946, it nationalized the transport industry, civil aviations, ports, airways, energy sifter and gas.Also, in 1948 the iron & steel industry with big difficulties. There was resistance from the owners because it was a highly profit making industry. But the coal owners were happy to sell their lines since they already were striving. Labor government nationalized about 20% of the economic sectors; the rest remained in private hands, why? – Labor implemented a social democracy, this 20 % created a debate within the party. The Clause 4: State Ownership of All means, production, exchange, distribution.Keynesian T. M. Keynes: the Theory of the Demand Management. 2- Political side: there were two sides – domestic & foreign- : Domestic side: there were no major changes , as the monarchy was not abolished, & the House of Lord which was not elected but mainly hereditary. But labor reduced its power in 1949; it could no longer stop a law in the House of Commit, it also lost its power to Veto. Foreign side: Labor Joined NATO: the North Atlantic Treaty Organization, which had a big financial cost.At this time, the labor Government embarked on a nuclear program â€Å"Atomic Bomb† as many other countries, despite the opposition of the US to to do so; this cost a lot for the country which is not a productive program in the short term & this was while Britain was in need for money, but it has a long term benefits as developing technology; from the military side, it's a kind of a buy product, the government accepted to withdraw India – the beginning of the end of the British Empires- Social side: the British labor party was a pioneer in introducing the Welfare State.Squirrel had to be fought by offering housing & town planning; it was done thr ough encouraging private & local authorities building new towns, but there as a shortage of raw materials & skill owners. As the need was important, tour blocks or high rise flats. British housing changed because of the urgent need built by the local authorities & rented for the people. Result: Labor made the class the division more visible separating the classes which was what they were aviate.Moon 14 December 2009 Social: through legislation, labor defeated the housing problems as well as the other evils, that was in giving employment offers, child allowance for families; education or illiteracy was defeated through the Buckler Act 1944 which is an education act that add secondary education free & compulsory from child age 6 to 1 5 for each English child. There also existed private schools -Public- & Seven state schools. The evil of unemployment tried to be defeated through nationalization.For diseases or illnesses there was the implementation of a INS National Health Services 194 8 made to provide medical care for all; it was free at the beginning but after one or two years people started to pay. Generated by Fixity PDF Creator O Fixity Software Result: There was a sort of broken promises which created a lot of discontent within he labor leadership party & the public felt that it was a betrayal. The labor http:// www. Fox-trotted. Com For evaluation only. Deed money that they have taken it from other sources, since the country invested in the nuclear program & built many houses, labor was very proud that it has implemented â€Å"the Welfare State† â€Å"State help from Cradle to Grave†, also it meant to be a safety net. These were more significant achievements of the welfare program. Why did it lose in 1951? Labor was obliged to run new elections, there was some infighting inside. There was an internal division between the left, centre & right.The labor party was never homogeneous, also the problem of inflation because the Pound Sterling in 194 7 was devaluation which created inflation, the cost of ling was very expensive so the public was unhappy. Another reason which created devaluation especially within the middle class was that labor created Rosining!!!! In order to create a sense of equality but it created dissatisfaction among the middle class which usually follows a black market. Wartime: what was promised during the war, in-between the interwar years?Before coming to power – 45- , what was the situation of the country? What the labor did or failed to do? What was the promise? What was the social, political & economic reality? Labor party achievement could be asserted through time, what did it achieve? The nuclear program which is debatable made Britain a powerful country, many people were afraid of this program & there was going to be a Cold War. Economic side: nationalization, taking into state country.The point is that the British didn't have the experience of state sectors, now the government was going to manage these sectors, which objectives would be to create Jobs with no competition since state impasses are monopolies, It was no change for workers these state companies are going to be over manning, having more workers than needed, these state companies are going to be lose making, black holes, the alternative would be to give it subsidies SF State Financial Help to rescue them. The state would get the money from taxes causing the big managers to emigrate.So, nationalization was an issue for the future years. The welfare state was created through social policies which interact with the economy which is a political decision. Labor accepted to intervene in people's life wrought political decision. How is it going to be financed? How do we pay for these services? From tax payers, we have two kinds: direct & indirect 1- The working people -income taxes that goes to the & Indirect VAT Value Direct Tax TVA, as alcohol & tobacco. Sometimes on imports. There are two main ways, of course another source which is the N. I. C National Insurance Contribution.All this will be part of what would be called the Budget that will be given to different ministries each responsible of a sector. Giving this situation, the Welfare State, when you look & assess it through mime, you see that what characterizes it is that the middle class would make the most profit of it. Therefore, people from the left & right would criticize it. The social policy should be looked from 3 parts: short, long & medium term: since it might solve problems TODAY but what about LATER? E. G. Housing has more or less solved problems but later people will have more children who will be unemployed.As far as the health services, we get into problems of term, e. G. Population after the war was in bad shape, but after it started to increase meaning more demand for health care nice medicine is developing as a result, the cost is increasing. Population becomes older so they needed social services e. G. Home for Old s. Therefore, we get into spiral; someone needs to pay for this. Also, concerning education & extending school life which is another cost for the country. All of these social costs became known as The Bottomless Sectors. There was always room for improvement. Becoming more & more expensive, how was it going to be financed?Should health be only for the people who can pay for it or everybody? Healthy country is more productive as well as education hat creates a wealthy society, but the key is who's going to finance? A Welfare State will be costly but is it necessary? The private sectors might be performing better because they are paying, but the state sectors are underfeed. It is up to the society to decide what kind of Welfare they want for the country. The Nanny or Milky Cow will be taken advantage from by some people. Dependency culture, scroungers = the 4 January 2010: people living in the back of others.The Welfare States' help sustain capitalist society. Marxist, believed in Cla ss Struggle. Social policy, it interacts with economy as it has a elation with politics but at the call of it, it's a social policy because some governors liked it others not because of how it was financed â€Å"taxation†. How much people are going to accept to pay? A social policy can be on a long, short or big or term, the rewards might come later (housing 45/ 54) inhabited by the working class, they had solved a short term problem but later on it created problems, people will pay more & more taxes.Marxist believed in the class struggle that without the welfare state the working class would revolve, life as a class struggle that without the Welfare state the t working would revolt; he also criticized the welfare state because the middle class would be the 1 t profit from it. The capitalists, people who believed in the laissez- fairer, self-help, it was for them a question of paying â€Å"the richer you are the more you pay' because they have their own private sets, they ha ve means to have access to better benefits since they pay.The state sector is under stuffed not highly efficient; it's never enough this is the dilemma of the welfare states. People of the right criticized the welfare states because it created a dependency culture, it is called the ilk cow and there were many scroungers. The Welfare State is rewarding for society because it can offer a better educated society, after 1945 education was for all, health after that bettered – they lived longer- but with it there is a cost â€Å"Taxes†. Rewarding is costing & necessary because without a minimum welfare state, a revolt might happen.As we shall see, the classes were divided but with time there will be an underclass of those who were excluded & merged from society; the British have accepted the idea of providing some help. The Welfare State -Milky Cow- can provide milk as long as there is green grass in the entry, I. E. A healthy economy, when you have it, you don't have a lot of unemployment, the problem is when there are a lot of people out of work, the government will pay for them which will be costly.The problem of taxes is a political decision, are you willing to redistribute the wealth â€Å"make the rich richer or less rich† as we shall see, it's the wealth of people who has a say. The party's program says â€Å"promises to spend more†; it's up to people to decide. The welfare state is a problematic issue. SST Economically: Nationalization, another issue which was 1 implanted by the labor overspent of 45-51 , state took control of some strategic sectors 25% was going to be managed by the state, coal, iron, transport†¦ Through Act Legislation.These sectors were employing large numbers of people e. G. 5 million people in the Coal industry; these large numbers would be represented by the trade union who had a good power. The bosses' objective was not only to make profit, priority was to provide Jobs because after 1945 it was the ti me of reconstruction and it needed a full employment. Also, not to forget, the British industries in the mid of 21st Century was coming old as the coal & iron equipments needed to be renewed â€Å"invest more money on these equipments†.Moreover, with the pressures of the Trade Union, wages increased & the British companies started to become over-manning â€Å"more workers than necessary', as a result, the return of the Law of Diminution & later on -ass's- inflation -Prices increase-will begin. Http:// www. Fox-trotted. Com For evaluation only. They would get By this loss making, they could reduce workers â€Å"private†, or subsidies, more taxation â€Å"State Financial Help† they would create discontent, closing a state company would be seen as a political suicide.There were monopolies because there was no competition, the quality was not great & the prices were low. As a result, The British people would buy foreign products since they are cheaper, there would be more imports & a little export, no balance â€Å"the country is going to be in red, it could reduce the value of the currency in order to export† another alternative was to increase taxation or to print money -monkey money instead of Sound money = solid- .This is how the nationalize Sector was going to find itself because it was monopolistic & uncompetitive; Britain industry became now as the Lame Duck Industries. Post War Consensus: it is a general agreement, compromise between different members of society, it is not written and is not a law, gathered by different components of society as a result of history (Britain was lucky because it has one dominant language, one religion and has only white people I. E. No ethic groups), Britain's' history had played a big role in shaping herself; it became a nation state earning†¦Monarchy has been there, so there is an agreement on an institutional Monarchy & religion is set. Post war was about how to rebuild the country; a hou se is lilt with Pillars -it was an agreement on pillars-: we are interested in the 4 pillars that England united in wartime on which post-war Britain was going to be reconstructed: 1- The Welfare State, it is the 1942 Beverage Report, well-being of citizens -social side. 2- Government intervention in economy, mixed economy, it is Keynesian through the acceptance of John Keynes theory. – Belonging to NATO North Atlantic Treaty Organization, Western Allies. 4- Trade Unions' reconciliation with the government; now they are partners & they have some power, a 3 parasite: Government, Trade Union and Representatives + Bosses. The post war consensus had gone through different stages; it was introduced and established during war time by the four elements mentioned above. 1945- 1951 the labor maintained the consensus The Thirteen Wasted Years, 1951-1964: Three concussive conservative prime ministers in government; Winston Churchill.Anthony Eden Harold Macmillan; they did not undo anyth ing & they kept the Welfare State because it is a symbol of socialism & kept negotiating with the Trade Union. These years were good for Britain; it was the age of affluence- plenty of things- the age of prosperity & full employment, he age consumerism, cars, fashion & music. The age of cinema, movies, sports & leisure; it is the beginning of a permissive society. It is wasted years because labor who planted & concoctive who fruit from it. People wanted what was available or provided.The British politicians were divided on the issue of the Suez Canal, in the 1959 general elections the labor party did not use the 1956 humiliation -the war between Britain, France and Israel- because it was for all Britain not only one party but a defeat for Britain. In this stage, the conservatives did not change a lot, their only changed was the prevarication of iron and steel industry because, as we said, during the ass's and early ass's there was prosperity and full employment as the youth started to enjoy their life.It was easy to keep consensus, but 1964-1970 is the return of labor, people for some reason were fed up of the conservatives. We can say that consensus is sustain, keep it with some difficulty, the beginning of troubles, Britain started declining & the British from different parts started to accept this idea of decline. 1964 labor came to modernize Britain, now there is inflation. Some people ill begin losing Jobs workers want more wages†¦ 1964- 1970: labor party under Harold Wilson, consensus was sustained, difficulties and the British started to speak of crisis and decline.The British economy was prosperous but not as her competitors, Britain began to lose some trade as a result unemployment problems appeared. Britain lived on exports and her competitors were making better and cheaper products. Thus, it lost exporting which led to unemployment later to inflation. Therefore, trade union asked for higher wages leading to strikes in the middle of the ass's, c onsequently, trade unions' reconciliation was no more valid. It had acquired power in favor; this power has become a problem for government, so the Labor Party started to think of reducing T Vs. power, I. . , putting commission led by Baroness to stop the T. V power, the L P at that time wanted more planning of the economy to modernize Britain, it had a control on the economy of Britain. People of money were afraid of the L P government; they became more socialist and started to invest outside what led to a shortage of money. In 1967 labor devalued, I. E. , lost its value in the next election because they lost the support of trade union and some people. Remark: because of the economic problems, the labor government forced to go to the I. M.F -international Monastery Fund- for a loan to ease then through their financial troubles, what meant the adoption of more liberal economic program by the Labor Party. British Decline: Britain after the WI was in reconstruction; it reconstructed i tself by providing employment, in the late ass's and ass's entered in a period of affluence; people had money in their pocket, Jobs were available, it is an age of affluent society, the age of love and peace, television and music as well as automobiles which became accessible to use. However, in the Middle of the ass's, people started to speak about the sick man of Europe.They discovered that their economy did not grow as its competitors, Japan, Germany, USA and France who were doing better. Also this sick man was characterized by the rise of SST inflation, of course, we are dealing with the 1 industrial nation and we compare it when Britain was a vast Empire, where Britain was the workshop of the world described by the bygone age. The acknowledgment of this loss was in the middle of the ass's because many British refused to accept this new position and they believed hat there was still an empire after the WI, but the loss of the Jewel of the Crown – India- was the best illus tration of this loss.The British decline has to be understood as a loss of power, spread of crisis, troubles and disorder. The most unarguable fact is that the seeds of Britain's decline are seen mostly in all fields and in particular political and economic ones that eventually led to the deterioration of its position. Causes and consequences of the British Decline: As far as the causes are concerned, we have two perceptions, we have the LEFT POINT OF VIEW that supported the State interference and socialist communism planning, and we have the RIGHT POINT that had its own argument.Concerning the left point, they thought that the decline had roots in the Victorian Britain where we find society of contrast paradoxes; there were also political, economic and social causes. Beginning with the political causes, in fact one of the most disappointing causes that Britain endured is the effects of two world wars which diminished its role as a world power. Though Britain's decline during the tr oubled years was arrested; it constructed her economy rapidly often theWI and it remained in late sass's an extremely rich country but the heavy costs of the war and the millions causalities weakened her capacity to maintain the vast empire. Another feature to this decline in world power was the loss of some territories e. G. India (with the rise of colonial nationalism) which was one of the most important components of the British empire since it was its largest source of revenue. Thus the loss of India meant the beginning of the end of the British Empire. N.B.: the end of the British rule in Ireland had also been a negative effect on Britain rower.Moreover, the Empire did not really benefit Britain; in fact, it was made by industrialists and traders who exclusively benefited from it. Also, in case of a problem the beneficiaries were the few and the expanses of the problem come from tax payers, the best example is the Ireland problem, also because they had two party systems: the li berals and the conservatives. Nevertheless, the most striking point was when the left stressed its criticism on the Laissez-fairer ideology which had a sense of paradoxes; it was advocated in Britain and in its colonies people were not free.

Brass heat treatment

Copper in pure form has found its significant use only in electrical applications. But with the continued study of copper, the addition of other metals called alloys was developed which enhanced its various properties. Now, different Copper-based alloys were widely used in different aspects of engineering and manufacturing. One of the best known and is widely used is the Copper-Zinc Alloy or Brass. (De Garmo, Black, Kohser, 1997) Brasses according to Yu Lakhtin (1979) are â€Å"binary and multiple-component alloys based on copper with which the main component is zinc.† Below is the phase diagram of Copper-Zinc Alloy at different Cu-Zi percentage and temperature. The commercial value of Brass is in its ? and ? +? ’ phases. At these two different phases, different characteristics were distinct. Their distinction according to Lukhtin (1979) depended on Zinc content from 48% to 50%. The single-phase or ? -brasses were characterized by Lukhtin (1979) as â€Å"can be readily worked in both the hot and cold conditions† while the two-phase ? +? ’ brasses are â€Å"hot-worked at temperatures corresponding to the regions of the ? ’ or ?+? ’ phases. † He also described ? +? ’ brasses as â€Å"having higher strength and wear resistance but less ductility. According to him, â€Å"? +? ’ brasses were often alloyed with Al, Fe, Ni, Sn, Mn, Pb and other elements. † And â€Å"the addition of these alloying elements, except Ni, reduces Zi solubility in Cu and promotes the formation of ? -phase. † Further he wrote, â€Å"the addition of alloying elements, except Lead, raised the strength and hardness of brass but reduced its ductility. Lead improved the machinability and antrification properties of brasses.† According to De Garmo, et. al, â€Å"Copper-based alloys are commonly identified through a system of numbers standardized by the Copper Development Association (CDA) which was adopted later by the American Society for Testing and Materials (ASTM), Society of Automotive Engineers (SAE), and the US government. † Brasses were classified into wrought and casting brasses. According to Lakhtin (1979), â€Å"wrought brasses are used to make sheets, band stock, tubing, wire and other semi-fabricated products; and casting brasses for making foundry castings.† Owen Ellis (1948) further classified Brasses casting alloys into Red Brass, Leaded Red Brass, Semi-Red Brass, Leaded Semi-Red Brass, Yellow Brass, Leaded Yellow Brass, High-Strength Yellow Brass (Manganese Bronze), Leaded High-Strength Yellow Brass (Leaded Manganese Bronze), Silicon Brass, Tin Brass, Tin-Nickel Brass, Nickel Brass (Nickel Silver) and Leaded Nickel Brass (Leaded Nickel Silver). In his classification, Red Brasses consisted 2%-8% zinc, less 0.5% lead, and with tin less than the zinc; the same amount consisted the Leaded Red Brass except that lead is over 0. 5%; Semi-Red Brass consisted 8%-17% zin c, less than 6% tin, and less than 0. 5% lead; the same amount consisted the Leaded Semi-Red Brass except that lead is over 0. 5%; Yellow Brass consisted over 17% zinc, less than 6% tin, under 2% total of aluminum, manganese, nickel, iron, or silicon, and with less than 0. 5% lead; the same constitutes for Leaded Yellow Brass except for lead which is over 0.5%; High-Strength Yellow Brass consisted of over 17% zinc, over 2% total of aluminum, manganese, tin, nickel and iron, under 0. 5% silicon, under 0. 5% lead and less than 6% tin; Leaded High-Strength Yellow Brass has the same constituents except that lead is over 0. 5%; Silicon Brass has over 0. 5% silicon and over 5% zinc; Tin-Nickel Brass has over 6% tin, over 4% nickel and with zinc more than tin; Nickel Brass has over 10% zinc, with nickel in amount sufficient enough to give white color, and with lead under 0.5%; and Leaded Nickel Brass has the same but with lead over 0. 5%. From these differed composition of Copper-Zinc Allo ys different properties were possessed which gave them different uses. Ellis (1948) also wrote that tThe different required properties of Brass such as conductivity and hardness can be secured through heat treatment,† Below is a table of the different compositions, properties and uses of common Copper-Zinc Alloys. Works Cited De Garmo, P. , Black, J., Kohser, R. (1997). Materials and processes in manufacturing. (8th Ed. ). Upper Saddle River, NJ: Prentice-Hall International, Inc. Ellis, O. (1948). Copper and copper alloys. Cleveland, Ohio: American Society for Metals. Lakhtin, Y. (1979). Engineering physical metallurgy and heat treatment. (Weinstein, N. , Trans. ). Moscow: MIR Publishers. Mayers, J. Visual library. Retrieved Jan. 29, 2007 from http://www. sv. vt. edu/classes/MSE2094_NoteBook/96ClassProj/pics/Cu_Zn1. gif.

International Relations for Mao Zedong and Deng Xiaoping Essay

International Relations for Mao Zedong and Deng Xiaoping - Essay Example Actually, Mao Zedong through his Communist Party of China collaborated even with the capitalist states like the United States of America, Japan and many European countries. Mao Zedong had a great quest for dominance over the perceived neighbors and trade partners like Russia and Germany. As demonstrated by Wang (27), this made him appear resistant to the external forces advising him how to manage the government to find a throughway towards better economic development. In fact, Mao Zedong did ignore otherwise good advice from Stalin who wanted China to become a fully communist state. Mao also appeared to cheer over the death of Stalin hoping that he would become the next powerful leader to control the allied group. This however did not materialize when Khrushchev ascended to power to continue the initial state of power held by Stalin. Mao’s continued opposition against the ideologies of his fellow leaders in the Communist world including Khrushchev soured to the extent of causing withdrawal of China dismissal from the Communist Movement. Mao continually resisted moves and policies adopted by Khrushchev towards defending their members. One such op position occurred when Khrushchev backed down to Cuban missile milieu. Deng appears as one of the Chinese leaders who took the revolution vehicle to the right direction. After the death of Mao Zedong in 1976, and his rise to power, Deng repaired their tutored relationship with the international community by denouncing communism and adopting socialism form of rule. Deng went ahead to reconcile with Soviet Union and all countries that surrounded China having he pains of the peasant citizens at hand (Deng 23). In fact, Deng is one lead who contributed to the economic classification of countries as first class, second and third. In the classification, Deng admitted that Soviet Union and United States were in the first class. Deng also

THE LEVEL OF EMPLOYEE SATISFACTION AND COMMITMENT AT LLOYDS TSB BANK Dissertation

THE LEVEL OF EMPLOYEE SATISFACTION AND COMMITMENT AT LLOYDS TSB BANK (FRONT DESK STAFF) - Dissertation Example Employee satisfaction is absolutely necessary among front desk staff especially those working in investment banks or other sales related companies as they represent an organization and bring in a greater portion of the revenue. The purpose of this study is to measure the employee satisfaction levels among Lloyds TSB front desk staff, one of the leading banks of UK. A questionnaire based survey was conducted and it was found that although the pay package and benefits provided by the bank were quite attractive, employee satisfaction was average among the Lloyds TSB front desk staff. An analysis of the questionnaire using popular satisfaction/motivation theories revealed that along with money other factors such as communication with the employees, respect and recognition and appreciation are also important. It was found that hard HRM is mostly practiced in Lloyds Bank TSB branches and hence it is recommended that a blend of both hard and soft HRM should be applied in order to improve th e employee satisfaction levels. ... ies 15 2.3 Maslow’s Theory 16 2.4 Herzberg’s Two Factor Theory 18 2.5 Alderfer’s ERG Theory 19 2.5.1 Using Alderfer’s ERG Theory at Workplace 20 2.6 Vroom’s Theory of Expectancy 20 2.6.1 Applying Vroom’s Expectancy Theory in an Organization 21 2.7 Locke’s Path Goal Theory 21 2.8 Studies on Employee Satisfaction 22 2.9 Theoretical Framework 24 3.RESEARCH METHODOLOGY 26 3.1 Research Philosophies 26 3.2 Research Design 27 3.3 Data Sources 28 3.4 Data Collection Tools 28 3.5 Sampling Strategy and Sample Size 29 3.6 Data Analysis 31 3.7 Validity and Reliability Concerns 32 3.8 Ethical Considerations 33 4.FINDINGS 34 4.1 Section A: Demographics 34 4.2 Section B: Human Resource Policies 37 4.3 Section C: Job satisfaction at Lloyd’s bank 43 4.4 Section D: Employee Training and Development Practices 48 4.5 Section E: Performance and Evaluation 48 4.6 Section F: Compensation 49 4.7 Section G: Employee Retention 51 4.8 Section H: Employee Commitment 52 5.DISCUSSION AND ANALYSIS 54 5.1 Analysis 56 6.CONCLUSION 59 6.1 Recommendations 61 6.2 Revisiting Aims and Objectives 62 6.3 Research Limitations and Future Research Scope 63 References 64 Appendix- I 73 THE LEVEL OF EMPLOYEE SATISFACTION AND COMMITMENT AT LLOYDS TSB BANK (FRONT DESK STAFF) 1. INTRODUCTION Employee satisfaction is commonly defined as the measure of how happy and content an employee is with his/her job and working environment (Kennet & Salini 2011). It has been observed that at times even though the package offered to the employee is good, the employees become discouraged and resign from their jobs. Certain factors like limited growth opportunity, lack of appreciation and recognition, high job stress and even lack of communication within the organization discourage and frustrate an employee. The

Self regulation and adolescent choices in friends Essay

Self regulation and adolescent choices in friends - Essay Example Hence, Self efficacy and Choice is the topic that deserves to be analyzed and substantiated for. Recent studies on self regulation have provided an insight into how students effectively respond to influences from the outside and then integrate them with their personal experiences. In the opinion of Michael Blocher, who has analyzed individual behavior, â€Å"Self- regulation has been recently studied to provide understanding for attributes of how traditional classroom students use their cognition, meta cognition and motivation to provide a successful learning experience. Locus of self- control, learning style, self regulation skills form a part of the wholesome development of the individual as a student, a researcher and as a learned scholar† (Blocher). This fact is crucial enough to provide proof to the fact that self regulation skills are essential to the formation of attitudes, behavior styles as well as response to external environment. Further, linkages between self regulatory processes and achievement are noted to be co existent factors. In a certain assessment for 3 years, among 732 children, who were identified as possessing lower grades, it was deduced that lower achieving students were not given initiation into self regulatory methods. This draws insight into the fact that early efforts to promote self efficacy in children, self regulatory skills would enhance further academic performance, promote self belief and enhance achievement, particularly in literacy. (Liew, p.515-526). Academic performance depends largely on the ability of the student to integrate scholastic knowledge with personal experience. The ability to synthesize knowledge with experience is the chief faculty of adolescents. â€Å"They posses increasingly higher levels of abstract thinking, engage in more sophisticated and elaborate information and their processing

Assignment asks you to check newspapers and other news websites and Essay

Assignment asks you to check newspapers and other news websites and come up with a list of at least 12 examples of news stories revolving around religion - Essay Example The winners, if holding spirits in the same, always link the most to their gods for handing them victory. However, this is not the case because winning games are subject to fate. The Super Bowl is one amongst these games linked to religion. Super Bowl serves as a major religious festival to Americans relevant to conservation of the culture. Joseph Price , in the article, â€Å"The Super Bowl as Religious Festival† retrieved on February 23 2014 from http://www.religion-online.org/showarticle.asp?title=1375 asserts that in such events, various personalities always become party, thus elevating the spirits and enthusiasm amongst those in attendance. As a cultural event, Super Bowl serves to reinforce religious myths connoting national innocence as well as apotheosis. The issue of religion and banking is of crucial importance. Vicente Sansano asserts in his article, â€Å" Islamic banking, halal banking† retrieved on February 23, 2014 from http://www.webislam.com/articles/68057-islamic_banking_halal_banking.html that several issues have arisen following the possibility of Islamic banks offering loans and finances to people of different religions. The issue of accessing such banks has been a subject of discussion following the terms and conditions of borrowing from halal banks. However, it is welcoming that Islamic banks share risks, lend money to borrowers as well as grant credits. This is similar to other banks owned by other religions. However, it is worth noting that Islamic banks lack financial speculation. They focus most on real money. The issue of religion and politics has been a major subject of concern. Nicholas Didonato, in the article, â€Å"Five ways religion can influence politics† retrieved on February 23, 2014 from http://www.patheos.com/blogs/scienceonreligion/2013/06/five-ways-religion-can-influence-political-beliefs/ asserts that religion can influence one to decide which political party to cast a vote. The issue

Observation Research Paper Example | Topics and Well Written Essays - 500 words

Observation - Research Paper Example Enough space is left between the groups to allow the teacher move around the classroom. The physical setting is characterized by drawings on charts placed on class walls. These drawings are mostly at the back wall and at times at the side walls. The front wall does not have these drawings. On the drawing are colorful. Letters and numbers are also written on these walls. Nouns are commonly written beneath objects drawn on the walls. Children were casual clothing while in preschool. However, some private schools require parents to dress children in uniforms. Male children mostly wear pairs of shorts. Female children are commonly dressed in trousers or skirts. Dialogue used in the preschool classroom setting is very interactive. It is mostly teacher-student or student-student. Gestures are highly utilized during learning. In most instances, children also respond collectively as per instructions of the instructor. Language used in very simple and direct. Short sentences are frequently used as opposed to long sentences. Preschool settings are quite dynamic. Constant changes of a classroom setting are purposed not only to help children understand what is being taught but also to capture the attention of the pupils since they easily lose concentration. The traditional setting is used when the teacher intends to impact new knowledge to pupils. It is also used when children are perform individual tasks such as writing during dictation sessions. The traditional setting helps children focus on the contents written on blackboard. A cluster setting is used during group works. Its main purpose is help children interact with each other. Children easily loose concentration during the traditional setting. The cluster setting captures student’s attention due to pupil-pupil interaction. The physical setting of a class has charts and colorful pictures on the walls except the front. Children learn

Connection journal about nutrient cycling Assignment

Connection journal about nutrient cycling - Assignment Example Meanwhile, biotic components may refer to various staff or personnel who takes up the nutrients or ideas for publication. Now that we are quite familiar to the connection that we established, let us take nutrient cycling inside the magazine office. Ideas are always present in the atmosphere, just like nitrogen. Ideas can be converted into functional ideas with the help of creative staff. It is comparable to the role of nitrogen-fixing bacteria that converts nitrogen to nitrates. Next, the creative director takes in the ideas of the creative staff and forms the cover and photo concepts. The same goes through with the cycle when plants take in nitrogen and form proteins. The next level of hierarchy goes to the managing director who is constantly in contact with the creative director and consumes the proteins formed within a span of time. In the absence of both the creative and managing director, the tasks may not be completed and eventually phase-out. When both plants (creative director) and animals (managing director) die or become absent in the process, proteins (final ideas) formed decompose into nitr ogen in atmosphere. In this case, the role of the editor-in-chief to oversee the whole process takes effect until the editor-in-chief establish constant contact again with the creative and managing directors or until the cycle starts

Unit 4 Assignment Example | Topics and Well Written Essays - 500 words

Unit 4 - Assignment Example On the contrary, Muslims oppose the notion that Jesus is God’s Son, notwithstanding, they believe that they honor Him more than even those in the Christian faith. Accordingly, Jesus Christ forms the basis of discussion in terms of similarities and dissimilarities between Christianity and the Islam faith. Christians and Muslims do believe that Jesus Christ was a messenger sent from God. The Qur’an acknowledges that Jesus was born of Virgin Mary and was sent to be a Messenger among messengers who had ceased to be in existence (Qur’an 5:75). On the other hand, the Bible speaks of God choosing Mary to bear the pregnancy of Jesus Christ. Accordingly, God sends the Angel Gabriel to go and inform Mary of the expected child born of the Spirit. The conditions under which Mary conceived Jesus are considered to be miraculous in both religions. For instance, the Qur’an says that Angel Gabriel introduced himself as a Messenger of Allah to give her news of the gift of a son. (Qur’an 19:16). On the other hand, the Bible supports these sentiments on a Christian view through the Book of Look chapter one verse twenty-six (Sayre, 2011). Accordingly, Jesus’s main purpose as God’s Messenger was to convey God’s message to the people and perform miracles am ong other duties as stipulated in the Bible and the Qur’an. Despite Jesus Christ being a common denominator among Muslims and Christians, there is a certain predicament that both religions disagree over. On one hand, Christians believe that Christ is the Son of God, and on the contrary, Muslims refute this notion by claiming that: just like other Messengers from Allah, Jesus Christ was a Prophet. Sayre (2011) states that Christians confine their divinity to Jesus Christ through worshipping Him and according him the title as the â€Å"Messiah† to mean, their Savior sent from God. In contrast, the Muslim faith believes in the miraculous existence of

Reconstruction Essay Example | Topics and Well Written Essays - 1500 words

Reconstruction - Essay Example The rise was initiated by various factors that included social, economic, legal, and political. The big business era was a source of wealth and capitalization for many Americans most of who were involved in various national corporations that controlled markets (Wilson 214). Sufficient resources such as oil, coal, and iron were foundations for the building of the states after the war. Adequate iron led to the production of iron and steel that were part of inputs in the big businesses. Steel was used to make railroads and cars that were used in the transportation of various products ranging from coal, ores, and agricultural produce from a state to another (Symonds). Oil was a precious good after its discovery, which was used in homes and to power machinery in some of the industries. Coal powered factories were efficient compared to water-powered; hence, the discovery of coal-fueled the increase of steel mills in the U.S. There was a rise in the number of immigrants to Southern States that provided a foundation for investors, investors, and labor. The immigrants worked in the big businesses and agricultural sector; hence, providing cheap labor. The high population required enhanced transportation methods leading to the increase in railroad networks. The increased demand led to a change in the social life of some of the citizens due to enhanced wealth sources. The banks offered loans that were sources of investment capital. Investors in the big businesses would seek assistance from banks to set up steel mills and railroads as part of the reconstruction. Stock markets were used by trusts such as Rockefeller’s to trade shares and purchase other corporations. The Federal Government did not regulate the operations and establishment of businesses. They were free to pool and set cartels that would increase competition opportunities. However, this factor led to the growth of monopolies in the

Educating Essay Example for Free

Educating Essay â€Å"Individuals venturing into new experiences may encounter obstacles but may also gain significant rewards†. â€Å"Do you agree with this perspective?† In your response, refer to your prescribed text and atleast one other related text of your own choosing. Individuals venturing into new experiences may encounter obstacles but may also gain significant rewards. This is present in the text ‘Educating Rita’ written by Willy Russell and the film ‘The Help’ written by Kathryn Stockett. In this text we see a fairly un-educated woman blossom and find herself through education; the obstacles she faces on her way to knowledge are the stepping stones in finding herself and entering the new world of education. Rita is a typical uneducated woman; her life is already planned out for her consisting of children, cooking/cleaning, pub trips and the overall expectation to be content with this life and not expect any more. However throughout the text we see Rita break away from this lower class/restricting stereotype to blossoming and finding herself in the world of education. The opening scene portrays to us the two completely different worlds in which Rita and Frank live. Rita has enrolled in an Open University course as she sees education as a way of moving out of her world; she feels out of step with her working class background and wants to discover herself first before having a baby and tying herself down for life. Rita’s constant desire to ‘know everything’ makes Frank feel that he is an appalling teacher because he feels he has nothing to offer her. Frank is Rita’s course tutor; he is a very negative and dismal man who is heavily reliant on alcohol to dull his boredom and frustration. Although being a jaded alcoholic he is also a very precise, formal and educated professor who is just on a downward spiral in his life. Throughout the text we see Rita and Frank’s relationship grow as Rita makes him feel as if he has hope again, therefore his drive comes back. In scene one we observe Rita struggling to open the door into Frank’s office; this symbolises her struggle to enter that world, it’s a barrier, however she’s determined to get what she wants – in this case education – therefore almost breaks the door in order to get in. â€Å"You’re the first breath of air that’s been in this room for years† quoted by Frank symbolises the opening up of a new world for him, he’s now got someone new and different to experience. This is a good change for Frank. Scene two beings with Rita oiling Frank’s office door, then handing the oil to Frank. This is symbolic of giving him the key/tool to open up to another world. Rita still doesn’t portray herself as a ‘proper student’ and her self esteem/confidence is still very low. She doesn’t think she is capable of achieving the great essays that the other students write and doubts herself that she will even finish the course. This scene really reveals the cost that trying to change herself is likely to have on Rita. She is dissatisfied with her life and has a desire to change it, yet it would be easier in her opinion to simply stay as she is and continue her boring life of hairdressing and different flavoured beers. Frank assigns Rita 3 novels to read as her hunger for knowledge is starting to grow extremely. The slow change in Rita is starting to become evident as she can read/take on any book presented to her, â€Å"it feeds me inside†. Her hunger is growing and making her slowly discover who she is, â€Å"it makes me stronger comin’ here†. Although Rita feels as if she’s finally accepted in the university and has a place/fits in with the ‘proper students’, she still has barriers to face in her personal life that are important determining points in her progress and choices as an individual. Rita’s husband Denny isn’t accepting nor happy about her doing this ‘whole learning thing’ and forces her to choose between him and education as he doesn’t understand that this is the first time she’s happy and felt a sense of purpose in her life. Denny has made her constantly feel stupid for even considering getting an education and therefore burns all of her books. The burning of the books is symbolic of Denny trying to prevent Rita from moving away. â€Å"You’d think I was havin’ a bloody affair the way he behaves† â€Å"And aren’t you?† symbolises Rita’s affair with education. Although she may not be cheating on Denny, she still desires to educate herself more than spend time with her husband and is happy with this choice as it is her own choice and no one else’s. In scene six we start to see a notable change in the relationship between Rita and Frank. When Rita bursts into Frank’s office excited to tell him that she saw one of Shakespeare’s plays â€Å"it was bleedin’ great†, Frank thought that something serious had happened – which indicates that he is beginning to care for her. After inviting Rita to a dinner party at his house Frank feels closer to Rita – this invite symbolises the change in the basis of their relationship from teacher and student to a more personal one. Throughout the text we have seen Rita grow and shape herself as an individual, no matter what obstacles and new experiences she has encountered with on her way she has got through them with determination and strength, and as a result has been great personal gain. Towards the end of the text Frank presents Rita with a dress; this is symbolic of a dress for an educated woman, she is now one and can wear the dress with pride. Frank decides to leave the university, as he does not feel it is the right career for him anymore and would prefer to spend his time doing something else. Rita and Frank have both grown and found themselves throughout this text which is also evident in the film ‘The Help’ written by Kathryn Stockett. The Help is set in Mississippi during the 1960s, main character Skeeter (Stone) is a southern society girl who returns from college determined to become a writer, but turns her friends lives and the Mississippi town upside down when she decides to interview the black women who have spent their lives taking care of the richer upper class families. Davis, Skeeters best friends housekeeper, is the first to open up and be interviewed to the shock of her friends in the close black community. Despite Skeeters life long friendships hanging in the balance, she and Davis continue their partnership and soon more women come forward to tell their stories and as it turns out, they have a lot to say. Along the way, unlikely friendships are forged and a new sisterhood emerges, but not before everyone in town has a thing or two to say themselves when they become unsuspectingly/unwillingly caught up in the changing modern times. This is relevant to the text Educating Rita as the women find the co urage and self confidence to venture into new experiences to help better either themselves or their community.