Social skills in neurodevelopmental disorders: a study using role-plays to assess adolescents and young adults with 22q11.2 deletion syndrome and autism spectrum disorders

BACKGROUNDS

Social skills are frequently impaired in neurodevelopmental disorders and genetic conditions, including 22q11.2 deletion syndrome (22q11DS) and autism spectrum disorders (ASD). Although often assessed with questionnaires, direct assessment provides a more valid estimate of the constructs. Role-plays (i.e., simulates situational settings) therefore appear to be an appropriate indicator of social skills in daily life.

METHODS

This co-registered study involved 53 individuals with 22q11DS, 34 individuals with ASD, and 64 typically developing (TD) peers aged 12-30 years. All participants were assessed with role-plays as well as parent-reported questionnaires and clinical interviews focusing on social skills, functioning and anxiety.

RESULTS

Both clinical groups showed impaired social skills compared to TD, but distinct social profiles emerged between the groups. Individuals with 22q11DS displayed higher social appropriateness and clarity of speech but weaker general argumentation and negotiation skills, with the opposite pattern observed in participants with ASD. No association was found between social skills measured by direct observation and caregiver reports. Social anxiety, although higher in clinical groups than in TD, was not associated with role-plays.

CONCLUSIONS

This study highlights the need to train social skills through tailored interventions to target the specific difficulties of each clinical population. It also highlights the importance of combining measures as they do not necessarily provide the same outcome.

A natural experiment to assess recess frequency on children's physical activity in Arizona (U.S.) elementary schools

BACKGROUND

In the United States, the number of state policies mandating recess in schools has rapidly increased over the past decade; however, few policies specify recess frequency. Informed by an ecological model of physical activity (PA) policy, this study examined and compared total amounts and intensity of PA expended during recess among children attending schools in compliance with Arizona recess policy ARS§ 15-118 mandating 2 + daily recess periods versus not.

METHODS

PA during recess was measured among grade three children (ages 8-10) in four randomly selected elementary schools (two complying averaging 30 daily recess minutes; two non-complying averaging 15 daily recess minutes) in Maricopa County, Arizona. Group-level PA was assessed by direct observation using the System for Observing Play and Leisure (137 observations). A subset of students (N = 134) from all schools wore ActiGraph GT3X + devices during recess to measure individual PA. General linear mixed effects models were used to analyze the impact of recess frequency on group and individual PA during recess.

RESULTS

Students attending complying schools spent significantly greater proportions of time in moderate-to-vigorous PA (MVPA) based on direct observation (5%) and accelerometry (15%) and less time being sedentary based on accelerometry (14%) during recess. Across the school day, this would equate to 5.1 more MVPA minutes based on systematic direct observation and 9.5 more MVPA minutes based on accelerometry, and 4.1 less minutes being sedentary based on accelerometry if students received two daily 15-minute recess periods compared to one.

CONCLUSIONS

Students attending elementary schools implementing 2 + recesses, in accordance with state policy, demonstrated greater MVPA and less sedentary time, providing preliminary evidence that recess frequency is associated with greater PA intensity among children during recess. Schools that adhere to state-level PA policies may provide a more supportive environment for PA, resulting in increased movement among students. Specifying recess frequency should be considered in statewide recess policy.

A Direct Observation Form for Evaluation of the Psychiatric Interview: Pilot Testing During the Psychiatry Clerkship

OBJECTIVES

The authors evaluated the validity of a structured direct observation form (DOF) to assess medical student performance on psychiatric interviews for use in the psychiatry clerkship.

METHODS

One hundred and forty-eight third-year medical students were evaluated by two DOFs completed by a supervising resident, fellow, attending, or another team member. One DOF was completed early (time 1) and the other late (time 2) during a 4-week psychiatry clerkship.

RESULTS

The DOF showed good internal consistency (Cronbach's alpha = 0.88-0.89). DOFs submitted at time 2 were positively associated with end-of-course clinical grades (p < 0.001); this association remained significant while controlling for time of academic year the course was completed, rater rank, complexity of the case, and difficulty of the interview (time 2 p < 0.001). Mean scores from the DOF were associated with the time of year students took the course with students assessed early in the academic year having lower average scores (p-values = 0.01 at time 1, 0.002 at time 2). Scores on time 1 DOFs were positively associated with rater rank (p = 0.005; residents gave higher scores than faculty). DOFs also correlated with an Entrustable Professional Activity (EPA) assessment of the interview (time 1 r = 0.76, p < 0.001; time 2 r = 0.79, p < 0.001), but not with shelf exam scores (time 1 r = 0.10, p = 0.24; time 2 r = 0.11, p = 0.21).

CONCLUSIONS

A brief structured form evaluating medical student performance on psychiatric interviews provided valid information about performance by third-year medical students during the psychiatry clerkship.

Taste agents as modulators of the feeding behaviour of grazing yaks in alpine meadows

Feeding behaviour plays a significant role in promoting good animal health and welfare. It is also reflective of the quality and quantity of available feed. In fact, grazing livestock do not select their feed randomly, rather their behaviour is influenced by the texture, taste, and smell of each pasture species. Although taste agents are often used to modify feed intake for captive livestock, the effect on the feeding behaviour of grazing livestock has not yet been extensively evaluated in native grasslands. To address this gap in knowledge, herein, we sprayed three types of taste agents-salty (SA), sweet (SW), and bitter (BT)-on alpine meadows to investigate their effect on the grazing behaviour of yaks (Bos Grunniens) on the Qinghai-Tibetan Plateau (QTP). Behavioural observations showed that grazing was concentrated primarily in the morning and afternoon, while ruminating/resting peaked at noon; however, the diurnal behavioural patterns of grazing yaks were not affected by the taste agents. Application of the SA agent significantly increased the yaks' grazing time, bites per minute, bites per step, time per feeding station, and steps per feeding station, while significantly reducing walking time, steps per minute, and number of feeding stations per minute. Meanwhile, application of the SW agent significantly increased the yaks' time per feeding station, however, significantly reduced the steps per minute and number of feeding stations per minute. In contrast, the BT agent significantly increased the yaks' walking time, steps per minute, and number of feeding stations per minute, while significantly reducing grazing time, bites per minute, bites per step, and time per feeding station. Application of the SA agent also significantly increased the intake of favoured, edible, and inedible forage, while the SW agent improved inedible forage intake, however, had a more subtle effect on favoured and edible forage intake. Meanwhile, the BT agent had an inhibitory effect on grazing intake. Hence, the structural equation model suggested that taste agents may directly or indirectly influence grazing behaviour by regulating feeding behaviour. Our findings provide a theoretical basis for using taste agents in grasslands to control the grazing behaviour of livestock and provide a method to promote the stability of grassland communities, while mitigating the degradation of grasslands in the QTP.

Gap between self-evaluation and actual hand hygiene compliance among health-care workers

Hand hygiene (HH) compliance among health-care workers has not satisfactorily improved despite multiple educative approaches. Between October 2019 and February 2020, we performed a self-evaluation test and a direct observation for the compliance of the 5 Moments for Hand Hygiene program advocated by the World Health Organization at two Japanese hospitals. Average percentages of self-evaluated HH compliance were as follows: (i) 76.9% for "Before touching a patient," (ii) 85.8% for "Before clean/aseptic procedures," (iii) 95.9% for "After body fluid exposure/risk," (iv) 84.0% for "After touching a patient," and (v) 69.2% for "After touching patient surroundings." On the other hand, actual HH compliance was 11.7% for "Before touching a patient" and 18.0% for "After touching a patient or patient surroundings." The present study demonstrated a big gap between self-evaluation and actual HH compliance among nurses working at hospitals, indicating the need of further providing the education in infection prevention.

Observational study on medication administration errors at a University Hospital in Brazil: incidence, nature and associated factors

Background

Medication administration errors are frequent and cause significant harm globally. However, only a few data are available on their prevalence, nature, and severity in developing countries, particularly in Brazil. This study attempts to determine the incidence, nature, and factors associated with medication administration errors observed in a university hospital.

Methods

This was a prospective observational study, conducted in a clinical and surgical unit of a University Hospital in Brazil. Two previously trained professionals directly observed medication preparation and administration for 15 days, 24 h a day, in February 2020. The type of error, the category of the medication involved, according to the anatomical therapeutic chemical classification system, and associated risk factors were analyzed. Multivariate logistic regression was adopted to identify factors associated with errors.

Results

The administration of 561 drug doses was observed. The mean total medication administration error rate was 36.2% (95% confidence interval 32.3–40.2). The main factors associated with time errors were interruptions. Regarding technique errors, the primary factors observed were the route of administration, interruptions, and workload.

Conclusions

Here, we identified a high total medication administration error rate, the most frequent being technique, wrong time, dose, and omission errors. The factors associated with errors were interruptions, route of administration and workload, which agrees well with the results of other national and international studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40545-022-00443-x.

Measuring Quality of Maternal, Neonatal, Child, Reproductive Health and Nutrition Care with tools developed by the RADAR project and tested in Sub Saharan Africa

Increasing coverage of evidence-based maternal, neonatal, child, reproductive health and nutrition (MNCRHN) programs in low- and middle-income countries has coincided with dramatic improvements in health despite variable quality of implementation. Comprehensive evaluation to inform program improvement requires standardized but adaptable tools, which the Real Accountability, Data Analysis for Results (RADAR) project has developed. To inform selection of tools and methods packages (‘packages’) to measure program quality of care (QoC), we documented experiences testing the packages, which were developed and adapted based on global and local expertise, and pre- and pilot-testing. We conducted cross-sectional studies in 2018–2019 on the quality of 1) integrated community case management, 2) counseling on maternal, infant, and young child feeding, 3) intrapartum care, and 4) family planning counseling in Mali, Mozambique, Tanzania, and Malawi. Herein we describe package performance and highlight experiences that inform their selection and use. Direct observation packages provided high-quality, immediately applicable results but they required specialized expertise, in-person collection, adequate patient volume, reasonable wait times, and unambiguously ‘correct’ provision of care. General satisfaction questions from exit interview packages produced unvaryingly positive responses despite variable observed quality of care. Variation increased when questions were more targeted, but findings on caregiver and client’s recall of recommendations were more actionable. When interactive, clinical vignettes can capture knowledge of clinical care. But for conditions that can be simulated, like provision of family planning counseling, we could capture provider practice from simulated clients. Clinicians could more easily demonstrate tactile aspects of intrapartum care using observed structured clinical examinations, but this method required storage and transport of the required mannequins. Based on our findings we recommend ten questions upon which evaluators can base package selection. Findings from these packages inform programs and, in the context of comprehensive program evaluation enable us to link programs with impact.

[Adequacy of pre-surgical hand hygiene in an university teaching hospital in Madrid (Spain).]

OBJECTIVE

We know the importance of hand hygiene in the prevention of healthcare-associated infections. However, its compliance is still a challenge. Moreover, when it is complied with, as in the case of preoperative hygiene, there are few studies on the proper performance of the technique. The aim of this paper is to assess adequacy of pre-surgical hand hygiene in operating room staff of different surgical specialities at a university teaching hospital in Madrid.

METHODS

A cross-sectional study was made. Adequacy of pre-surgical hand hygiene was assessed in operating room staff of the different specialities and professional categories by direct covert observation. It was evaluated in 852 opportunities during the months of October, November and December 2020. A specific form was designed for data collection, following the recommendations of the World Health Organisation (WHO). Adequacy was described with frequency distributions of the different groups observed. Whether Chi-square or Fisher's exact tests were used to compare the different categories.

RESULTS

Pre-surgical hand hygiene opportunities were evaluated, 75.5% in surgeons and 24.5% in nurses. Overall compliance with pre-surgical hand hygiene technique was 80.5 % (686). The most frequent surgical service evaluated was General Surgery with 240 observations. The professional category with the best adequacy was nursing (86.1%) and the surgical service one was Traumatology (90.2%). An stopwatch was used by some 25.8% of the evaluated professionals, with an adequate hygiene time of 96,8% (p<0,05) for that group.

CONCLUSIONS

The overall adequacy of pre-surgical hand hygiene in the operating room professionals is high. Significant statistically differences in adequacy are found between professional categories and surgical specialities, with better compliance in nursing staff and in Traumatology. Better results are achieved by the use of an stopwatch.

Relationship of Physical Examination Technique to Associated Clinical Skills: Results from a Direct Observation Assessment

BACKGROUND

The purpose of this research was to use direct observation of the physical examination to elucidate the role physical examination technique plays in diagnostic accuracy. Physical examination is important for quality clinical care and requires multiple interrelated skills. The relationship of physical examination technique to related skills is poorly understood. Current methods of teaching and assessing physical examination skills provide few opportunities to evaluate physical examination technique and accuracy.

METHODS

The authors developed a clinical examination assessment using volunteer patients and direct observation. Trained faculty preceptors rated resident performance in 7 domains: 1) physical examination technique, 2) identification of physical signs, 3) clinical communication, 4) differential diagnosis, 5) clinical judgment, 6) managing patient concerns, and 7) maintaining patient welfare. The Pearson correlation coefficient was used to determine relationships between performance in each of these domains. Data on residents' self-assessed competency in the physical examination and perceptions of feedback received during the assessment were collected.

RESULTS

From December 2018 to February 2020, 113 interns from 2 internal medicine residency programs participated in the assessment. Physical examination technique was significantly correlated with accurate identification of physical signs, differential diagnosis and clinical judgment. Time spent in graduate medical education was negatively correlated with performance. Interns more highly rated the feedback received from this assessment than traditional clinical skills feedback.

CONCLUSIONS

Our findings emphasize the necessity of multi-dimensional physical examination assessment. Observed deterioration of physical examination skill during internship may reflect contemporary practice patterns, which deprioritize the physical examination. Future research on physical examination education should focus on the interface between physical examination technique and related clinical skills.

Factors and Interactions Influencing Direct Observation: A Literature Review Guided by Activity Theory

PhenomenonEnsuring that future physicians are competent to practice medicine is necessary for high quality patient care and safety. The shift toward competency-based education has placed renewed emphasis on direct observation via workplace-based assessments in authentic patient care contexts. Despite this interest and multiple studies focused on improving direct observation, challenges regarding the objectivity of this assessment approach remain underexplored and unresolved. Approach: We conducted a literature review of direct observation in authentic patient contexts by systematically searching databases PubMed, Embase, Web of Science, and ERIC. Included studies comprised original research conducted in the patient care context with authentic patients, either as a live encounter or a video recording of an actual encounter, which focused on factors affecting the direct observation of undergraduate medical education (UME) or graduate medical education (GME) trainees. Because the patient care context adds factors that contribute to the cognitive load of the learner and of the clinician-observer we focused our question on such contexts, which are most useful in judgments about advancement to the next level of training or practice. We excluded articles or published abstracts not conducted in the patient care context (e.g., OSCEs) or those involving simulation, allied health professionals, or non-UME/GME trainees. We also excluded studies focused on end-of-rotation evaluations and in-training evaluation reports. We extracted key data from the studies and used Activity Theory as a lens to identify factors affecting these observations and the interactions between them. Activity Theory provides a framework to understand and analyze complex human activities, the systems in which people work, and the interactions or tensions between multiple associated factors. Findings: Nineteen articles were included in the analysis; 13 involved GME learners and 6 UME learners. Of the 19, six studies were set in the operating room and four in the Emergency department. Using Activity Theory, we discovered that while numerous studies focus on rater and tool influences, very few study the impact of social elements. These are the rules that govern how the activity happens, the environment and members of the community involved in the activity and how completion of the activity is divided up among the members of the community. Insights: Viewing direct observation via workplace-based assessment through the lens of Activity Theory may enable educators to implement curricular changes to improve direct observation of assessment. Activity Theory may allow researchers to design studies to focus on the identified underexplored interactions and influences in relation to direct observation.

Creating a win-win for the health system and health Profession's education: a direct observation clinical experience with feedback iN real-time (DOCENT) for low acuity patients in the emergency department

BACKGROUND

Clinical education across the professions is challenged by a lack of recognition for faculty and pressure for patient throughput and revenue generation. These pressures may reduce direct observation of patient care provided by students, a requirement for both billing student-involved services and assessing competence. These same pressures may also limit opportunities for interprofessional education and collaboration.

METHODS

An interprofessional group of faculty collaborated in a sequential quality improvement project to identify the best patients and physical location for a student teaching clinic. Patient chief complaint, use of resources, length of stay, estimated severity of illness and student participation and evaluation of the clinic was tracked.

RESULTS

Clinic Optimization and Patient Care: Five hundred and thirty-two emergency department (ED) patients were seen in the first 19 months of the clinic. A clinic located near the ED allowed for patients with higher emergency severity index and greater utilization of imaging. Patients had similar or lower lengths of stay and higher satisfaction than patients who remained in the ED (p < 0.0001). In the second clinic location, from October 2016-June 2019, 644 patients were seen with a total of 667 concerns; the most common concern was musculoskeletal (50.1%). Student Interprofessional Experience: A total of 991 students participated in the clinic: 68.3% (n = 677) medical students, 10.1% (n = 100) physician assistant students, 9.7% (n = 96) undergraduate nursing students, 9.1% (n = 90) physical therapy students, and 2.8% (n = 28) nurse practitioner students. The majority (74.5%, n = 738) of student participants worked with students from other professions. More than 90% of students reported that faculty set a positive learning environment respectful of students. However, 20% of students reported that faculty could improve provision of constructive feedback. Direct Observation: Direct observation of core entrustable professional activities for medical students was possible. Senior medical students were more likely to be observed generating a differential diagnosis or management plan than first year medical students.

CONCLUSIONS

Creation of a DOCENT clinic in the emergency department provided opportunities for interprofessional education and observation of student clinical skills, enriching student experience without compromising patient care.

A phenomenological investigation of patients' experiences during direct observation in residency: busting the myth of the fly on the wall

Direct observation (DO) of residents by supervisors is a highly recommended educational tool in postgraduate medical education, yet its uptake is poor. Residents and supervisors report various reasons for not engaging in DO. Some of these relate to their interaction with patients during DO. We do not know the patient perspectives on these interactions, nor, more broadly, what it is like to be a patient in a DO situation. Understanding the patient perspective may lead to a more complete understanding of the dynamics in DO situations, which may benefit patient wellbeing and improve the use of DO as an educational tool. We conducted a phenomenological interview study to investigate the experience of being a patient in a DO situation. Our analysis included multiple rounds of coding and identifying themes, and a final phase of phenomenological reduction to arrive at the essential elements of the experience. Constant reflexivity was at the heart of this process. Our results provide a new perspective on the role of the supervisor in DO situations. Patients were willing to address the resident, but sought moments of contact with, and some participation by, the supervisor. Consequently, conceptions of DO in which the supervisor thinks she is a fly on the wall rather than a part of the interaction, should be critically reviewed. To that end, we propose the concept of participative direct observation in workplace learning, which also acknowledges the observer's role as participant. Embracing this concept may benefit both patients' wellbeing and residents' learning.

Comparison of video-based observation and direct observation for assessing the operative performance of residents undergoing phacoemulsification training

Purpose:

To compare the video observation of procedural skills (VOPS) method with the direct observation of procedural skills (DOPS) method in the assessment of senior residents' performance utilizing the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubric for phacoemulsification (ICO-OSCAR; phaco).

Methods:

This is a prospective comparative study conducted at a university-affiliated hospital. Six ophthalmology residents of postgraduate year 4 participated. Their performance in phacoemulsification was rated via DOPS and later in a masked manner through VOPS by a single faculty assessor.

Results:

Seventy-one surgeries were evaluated. There were no statistically significant differences between the scores of VOPS and DOPS regarding all ICO-OSCAR indices except “instrument insertion into the eye” in which DOPS had higher scores (P = 0.035). A significant correlation was observed in total scores of “task-specific” (r = 0.64, P < 0.001) and “global” (r = 0.38, P = 0.003) indices between VOPS and DOPS while some subscales did not show a correlation between the two methods of assessment. The Bland-Altman analysis demonstrated that nearly all data points of total “task-specific” and “global” scores fell within the 95% limits of agreement ([-5.84, 6.87] and [-4.78, 4.86], respectively).

Conclusion:

This study demonstrated that VOPS holds promise for a general rating of residents' performance.

Observing cultural competence of healthcare professionals: A systematic review of observational assessment instruments

OBJECTIVE

Observational instruments are preferred for assessment of cultural competence. The aim of the current study is to identify observational instruments to assess cultural competence in healthcare providers and dieticians specifically and assess their psychometric properties.

METHODS

A systematic review was conducted in Cinahl, Cochrane, EMBASE, PsycInfo, Pubmed, and Web of Science using search terms related to cultural competency and measurement properties. Methodological quality of the selected studies of observational cultural competence instruments in dieticians, other healthcare professionals and psychological counsellors and the measurement properties of instruments were assessed using the COSMIN checklist.

RESULTS

From 11,913 articles, six articles on five instruments were selected. Instruments were targeted at health professionals and counsellors only, and designed for face-to-face communication (n = 4) or verbal responses to videotaped simulated interactions (n = 1). The instruments' content varied largely, with main focus on attitude, and little on knowledge and skills. The measurement properties were suboptimal.

CONCLUSION

No observational instrument are available to evaluate cultural competence of dieticians. Studies on psychometric properties of instruments targeted at other health professionals lack methodological rigour.

PRACTICE IMPLICATIONS

Future work should focus on developing an instrument that encompasses both 'general' cultural competences necessary for all healthcare professionals and dietetic specific competences.

Medical record bias in documentation of obstetric and neonatal clinical quality of care indicators in Uganda

OBJECTIVE

To achieve a high quality of care (QoC), accurate measurements are needed. This study evaluated the validity of QoC data from the medical records for childbirth deliveries and assessed whether medical records can be used to evaluate the efficacy of interventions to improve QoC.

STUDY DESIGN AND SETTING

This study was part of a larger study of QoC training program in Uganda. Study data were collected in two phases: (1) validation data from 321 direct observations of deliveries paired with the corresponding medical records; (2) surveillance data from 1,146 medical records of deliveries. Sensitivity, specificity, and predictive values were used to measure the validity of the medical record from the validation data. Quantitative bias analysis was conducted to evaluate QoC program efficacy in the surveillance data using prevalence ratio and odds ratio.

RESULTS

On average, sensitivity (84%) of the medical record was higher than the specificity (34%) across 11 QoC indicators, showing a higher validity in identifying the performed procedure. For 5 out of 11 indicators, bias-corrected odds ratios and prevalence ratios deviated significantly from uncorrected estimates.

CONCLUSION

The medical records demonstrated poor validity in measuring QoC compared with direct observation. Using the medical record to assess QoC program efficacy should be interpreted carefully.

Reliability of streetscape audits comparing on-street and online observations: MAPS-Global in 5 countries

BACKGROUND

Microscale environmental features are usually evaluated using direct on-street observations. This study assessed inter-rater reliability of the Microscale Audit of Pedestrian Streetscapes, Global version (MAPS-Global), in an international context, comparing on-street with more efficient online observation methods in five countries with varying levels of walkability.

METHODS

Data were collected along likely walking routes of study participants, from residential starting points toward commercial clusters in Melbourne (Australia), Ghent (Belgium), Curitiba (Brazil), Hong Kong (China), and Valencia (Spain). In-person on the street and online using Google Street View audits were carried out by two independent trained raters in each city. The final sample included 349 routes, 1228 street segments, 799 crossings, and 16 cul-de-sacs. Inter-rater reliability analyses were performed using Kappa statistics or Intraclass Correlation Coefficients (ICC).

RESULTS

Overall mean assessment times were the same for on-street and online evaluations (22 ± 12 min). Only a few subscales had Kappa or ICC values < 0.70, with aesthetic and social environment variables having the lowest overall reliability values, though still in the "good to excellent" category. Overall scores for each section (route, segment, crossing) showed good to excellent reliability (ICCs: 0.813, 0.929 and 0.885, respectively), and the MAPS-Global grand score had excellent reliability (ICC: 0.861) between the two methods.

CONCLUSIONS

MAPS-Global is a feasible and reliable instrument that can be used both on-street and online to analyze microscale environmental characteristics in diverse international urban settings.

An audit tool for longitudinal assessment of the health-related characteristics of urban neighborhoods: implementation methods and reliability results

BACKGROUND

Improving the neighborhood environment may help address chronic disease and mortality. To identify neighborhood features that are predictors of health, objective assessments of the environment are used. Multiple studies have reported on cross-sectional assessments of health-related neighborhood features using direct observation. As study designs expand to better understand causation and predictors of change, there is a need to test whether direct observation methods are adequate for longitudinal assessment. To our knowledge, this is the first study to report on the reliability of repeated measurements of the neighborhood environment, and their stability, over time.

METHODS

The Pittsburgh Hill/Homewood Research on Neighborhood Change and Health (PHRESH) study conducted longitudinal assessments in two low-income, African American neighborhoods at three waves (years 2012, 2015, 2017). The PHRESH audit tool is a modification of earlier validated tools, with an emphasis on environment features relevant for physical activity, sleep, and obesogenic behaviors. Trained data-collector pairs conducted direct observations of a 25% sample of street segments in each neighborhood. At each wave, we audited a sub-sample of street segments twice and assessed reliability using percentage inter-observer agreement and krippendorf's alpha statistics. Stability of these items was assessed as exhibiting moderate or high agreement at every time point.

RESULTS

Across waves, a majority (81%) of the items consistently demonstrated moderate to high agreement except for items such as public/communal space, amount of shade, sidewalk features, number of traffic lanes, garden/flower bed/planter, art/statue/monument, amount of trash, and physical disorder. The list of items with poor agreement includes features that are easy to miss (e.g. flower bed/planter), hard to assess from outside (e.g. public/communal space), or may change quickly (e.g. amount of trash).

CONCLUSION

In this paper, we have described implementation methods, reliability results and lessons learned to inform future studies of change. We found the use of consistent methods allowed us to conduct reliable, replicable longitudinal assessments of the environment. Items that did not exhibit stability are less useful for detecting real change over time. Overall, the PHRESH direct observation tool is an effective and practical instrument to detect change in the neighborhood environment.

Sun-protective clothing and shade use in public outdoor leisure settings from 1992 to 2019: Results from cross-sectional observational surveys in Melbourne, Australia

Skin cancer presents a significant public health burden in Australia. The present study aimed to supplement population-based estimates of sun protection behaviour by examining setting-specific trends in directly observed sun protection in public outdoor leisure settings. Repeated cross-sectional observational surveys of adolescents and adults were conducted on summer weekends between 11 am and 3 pm from 1992 to 2002, 2006 to 2012, and 2018 to 2019 (N = 44,979) at pools/beaches and parks/gardens within 25 km of the centre of Melbourne, Victoria. The primary outcome was a binary index representing individuals having above or below the median level of body surface covered by hat, shirt, and leg garments in each setting type. The prevalence of above-median body coverage increased between 1992 and 2002 in both settings. At pools/beaches, a slight decline in above-median body coverage between 2006 and 2019 in males and females (adjusted odds ratio, AOR = 0.96 [0.94, 0.97]; 0.94 [0.93, 0.95]) appeared to be driven by a decline in leg coverage, while arm coverage, hat, sunglasses, and shade use remained stable. At parks/gardens, a decline in above-median body coverage between 2006 and 2019 (AOR = 0.90 [0.89, 0.91]; 0.94 [0.93, 0.95]) was accompanied by small declines across other protective behaviours that varied between males and females. Patterns in protective behaviours observed in outdoor leisure settings may reflect the changing composition of individuals choosing to remain outdoors during peak UV times and highlight the importance of continued promotion and monitoring of the use of multiple measures to protect against UV damage in Australia.

Quality of written feedback given to medical students after introduction of real-time audio monitoring of clinical encounters

BACKGROUND

Direct observation is necessary for specific and actionable feedback, however clinicians often struggle to integrate observation into their practice. Remotely audio-monitoring trainees for periods of time may improve the quality of written feedback given to them and may be a minimally disruptive task for a consultant to perform in a busy clinic.

METHODS

Volunteer faculty used a wireless audio receiver during the second half of students' oncology rotations to listen to encounters during clinic in real time. They then gave written feedback as per usual practice, as did faculty who did not use the listening-in intervention. Feedback was de-identified and rated, using a rubric, as strong/medium/weak according to consensus of 2/3 rating investigators.

RESULTS

Monitoring faculty indicated that audio monitoring made the feedback process easier and increased confidence in 95% of encounters. Most students (19/21 respondents) felt monitoring contributed positively to their learning and included more useful comments. 101 written evaluations were completed by 7 monitoring and 19 non-monitoring faculty. 22/23 (96%) of feedback after monitoring was rated as high quality, compared to 16/37 (43%) (p < 0.001) for monitoring faculty before using the equipment (and 20/78 (26%) without monitoring for all consultants (p < 0.001)). Qualitative analysis of student and faculty comments yielded prevalent themes of highly specific and actionable feedback given with greater frequency and more confidence on the part of the faculty if audio monitoring was used.

CONCLUSIONS

Using live audio monitoring improved the quality of written feedback given to trainees, as judged by the trainees themselves and also using an exploratory grading rubric. The method was well received by both faculty and trainees. Although there are limitations compared to in-the-room observation (body language), the benefits of easy integration into clinical practice and a more natural patient encounter without the observer physically present lead the authors to now use this method routinely while teaching oncology students.

Longitudinal resident coaching in the outpatient setting: A novel intervention to improve ambulatory consultation skills

BACKGROUND

Direct observation with feedback to learners should be a mainstay in resident education, yet it is infrequently done and its impact on consultation skills has rarely been assessed.

APPROACH

This project presents the framework and implementation of a longitudinal low-frequency, high-intensity direct observation and coaching intervention, and elaborates on insights learned. Internal medicine interns at one residency training program were randomized to an ambulatory coaching intervention or usual precepting. Over one year, coached interns had three complete primary care visits directly observed by a faculty clinician-coach who provided feedback informed by a behavior checklist. Immediately after each of the coached patient encounters, interns completed a structured self-assessment and coaches led a 30-minute feedback session informed by intern self-reflection and checklist items. Interns with usual precepting had two mini-CEX observations over the course of the year without other formal direct observation in the ambulatory setting.

EVALUATION

As part of the post-intervention assessment, senior faculty members blinded to intervention and control group assignments evaluated videotaped encounters. Coached interns completed an average of 21/23 behaviors from the checklist, while interns from the control group completed 18 (p < 0.05). The median overall grade for coached interns was B+, compared to B-/C+ for controls (p < 0.05).

REFLECTION

Coaching interns longitudinally using a behavior checklist is feasible and associated with improved consultation performance. Direct observation of complete clinical encounters followed by systematic coaching is educationally valuable, but time and resource intensive.

Evaluating autumn phenology derived from field observations, satellite data, and carbon flux measurements in a northern mixed forest, USA

Common approaches currently used to monitor forest phenology include direct field observation and indirect approaches such as satellite remote sensing and carbon flux measurements. However, differences in both temporal and spatial scales of these methods make direct comparison challenging. In order to evaluate the reliability of indirect measures of autumn phenology in estimating direct observations, we compared the timing of three transition dates and the rate of autumn progression derived from (i) satellite data (MOD13Q1 006 enhanced vegetation index (EVI) and normalized difference vegetation index (NDVI) products, 2000-2017), (ii) carbon flux measurements (net ecosystem exchange (NEE) and gross primary production (GPP), 1997-2016), and (iii) field observation (2010, 2012 for the north site and 2010, 2012, and 2013 for the south site) from a mixed forest in northern Wisconsin, USA. Overall, the transition dates and progression rates derived from NDVI were closest to that of field observations. Furthermore, the start of autumn derived from satellite data was earlier than directly observed leaf coloration (LC), which resulted from species-specific canopy senescence patterns and the sensitivity of the vegetation indices. Even after full leaf fall was reached, EVI continued to detect coloring which was likely due to the presence of understory plant species. Finally, NEE and GPP changes tended to start before LC as a result of tree physiological and environmental changes and continued after full leaf fall possibly due to understory and coniferous activity. These results highlight the need for long-term field observations of both trees and understory species, information on species-specific canopy senescence patterns, and species composition in understanding the efficiency of indirect approaches in estimating autumn forest phenology.

Perceptions of scheduled vs. unscheduled directly observed visits in an internal medicine residency outpatient clinic

INTRODUCTION

Learners may subconsciously change their behavior once they know they are being observed, and this Hawthorne effect should be considered when designing assessments of learner behavior. While there is a growing body of literature to suggest direct observation is the ideal standard for formative assessment, the best method to directly observe learners is unknown. We explored scheduled and unscheduled methods of direct observation among internal medicine residents in the outpatient continuity clinic to advance the understanding of both observation methods.

METHODS

We conducted a thematic analysis of faculty and internal medicine residents in an outpatient clinic setting. A semi-structured interview guide for focus group sessions was created. Focus groups were used to explore the internal medicine resident and core teaching faculty perceptions of the scheduled and unscheduled direct observation methods in the outpatient clinc. An experienced qualitative research interviewer external to the internal medicine residency was moderating the sessions. Eight peer focus groups were held. Abstraction of themes from focus group transcripts identified resident and faculty perceptions of the different observation methods.

RESULTS

Focus groups had 14 resident participants and 14 faculty participants. Unscheduled observations were felt to be more authentic than scheduled observations since residents perceived their behavior to be unmodified. Unscheduled observations allowed for increased numbers of observations per resident, which permitted more frequent formative assessments. Residents and faculty preferred remote video observation compared to in-room observation. Participants found direct observation a useful learning tool for high-yield, specific feedback.

CONCLUSIONS

Unscheduled remote direct observation captures authentic clinical encounters while minimizing learner behavior modification. An unscheduled observation approach results in more frequent formative assessment and therefore in more instances of valuable feedback compared to scheduled observations. These findings can help guide the best practice approaches to direct clinical observation in order to enhance residents learning and experience.

Assessing the Hawthorne effect on hand hygiene compliance in an intensive care unit

Background

The influence of the Hawthorne effect on hand hygiene compliance in an intensive care unit was assessed using covert and overt direct observation.

Methods

The observational study was conducted from February to November 2018 in a 24-bed adult intensive care unit in a 243-bed tertiary care hospital, in four periods (P): P-1, February 5-March 3, 29 h (covert) and P-2, March 15-April 16, 33 h (overt), prior to an educational campaign on hand hygiene; and P-3, August 27-September 28, 33 h (covert) and P-4, October 3-November 6, 35 h (overt), after the campaign. Three 20-min observation sessions were performed daily, randomly distributed in the morning, afternoon and evening shifts, including holidays and weekends. Hand hygiene compliance rates observed in Periods 2 and 4 were displayed on an electronic panel installed in the unit. Hand hygiene compliance was assessed according to the World Health Organization “My Five Moments for Hand Hygiene” guidelines.

Results

Before the campaign, the overall hand hygiene compliance rate was 31.95% (340/1064, covert) versus 68.10% (790/1160, overt), and afterwards was 56.11% (615/1096, covert) versus 80.98% (1086/1341, overt). The infection rate was reduced by 22.62% (18.87% versus 14.60%).

Conclusions

The Hawthorne effect and educational campaign markedly influenced compliance with hand hygiene recommendations. The results suggest that combining overt and covert observation methods, including regular feedback on hand hygiene compliance displayed on an electronic panel, may be a valid alternative to increase real hand hygiene compliance rates in hospital practice.

Hand hygiene compliance monitoring: Do video-based technologies offer opportunities for the future?

Hand hygiene is universally recognised as the primary measure to reduce healthcare-associated infections. Studies have convincingly demonstrated a link between increased hand hygiene compliance and reductions in rates of healthcare-associated infections. Direct observation is considered the gold standard method for monitoring hand hygiene compliance. Despite the acknowledged benefits of this approach, recent literature has highlighted a range of issues impacting on the reliability and validity of this data collection technique. The rise of technology in healthcare provides opportunity for alternative methods that promise advantages over direct human observation. There have been no published examples of systems that are able to capture data consistent with all the WHO '5 Moments for Hand Hygiene'. In this paper we explore current human-based auditing practises for monitoring hand hygiene compliance and raise for discussion and debate video-based technologies to monitor hand hygiene compliance. We raise questions regarding hybrid approaches that incorporate both direct human observation and indirect video-based surveillance, and the possible advantages and disadvantages therein for monitoring hand hygiene compliance. We suggest that such methods have the potential to ameliorate, or minimise, the inherent biases associated with direct observation, notably the Hawthorne Effect. Future research into the utility of a hybrid approach to auditing, including the technical specifications, efficacy, cost effectiveness and acceptability of such a model is warranted.

An analysis of directly observed weight communication processes between primary care practitioners and overweight patients

OBJECTIVE

To analyse weight-related communication prevalence and processes (content/context) between primary care practitioners (PCPs) and overweight patients within routine primary healthcare consultations.

METHODS

Consultations between 14 PCPs and 218 overweight patients (BMI ≥ 25 kg/m²) were video recorded. Weight communication was coded using the Roter Interaction Analysis System (RIAS) and the novel St Andrews Issue Response Analysis System (SAIRAS). Communication code frequencies were analysed.

RESULTS

Weight discussion occurred in 25% of consultations with overweight patients; 26% of these had weight-related consultation outcomes (e.g. weight-related counselling and referrals, stated weight-related intention from patients). Weight discussions were more likely to occur if PCPs provided space to patient attempts to discuss weight (p = 0.013). Longer weight discussions (p < 0.001) and contextualising weight as problematic when PCP/patient-initiated weight discussion (p < 0.001) were associated with weight-related consultation outcomes.

CONCLUSION

Weight was rarely discussed with overweight patients, however PCP space provision to patient weight-discussion initiation attempts increased weight discussion. When weight was discussed, increased time and/or contextualising weight as a problem increased the likelihood of weight-related consultation outcomes.

PRACTICAL IMPLICATION

PCP use of specific communication approaches when discussing, contextualising and responding to patient weight may facilitate weight-related discussion and consultation outcomes and could lead to more effective patient weight management.

Internal Medicine Attendings' Perception of Barriers to Outpatient Exam Room Presentations in Resident Continuity Clinic

Outpatient exam room presentations (OERPs) in resident continuity clinic (RCC) can operationalize competency-based medical education and enhance patient satisfaction. We aimed to assess current OERP use and OERP barriers by surveying internal medicine attendings prior to and following a 4-week pilot of OERPs in RCC. Twenty-six out of an eligible 35 attendings completed the pre-pilot survey. Twenty attendings participated in the pilot and completed the post-pilot surveys. On the pre-pilot survey, 65% (17/26) of participants reported never using OERPs. Attendings' perception of learner discomfort with OERPs as somewhat of or a significant barrier significantly decreased from pre-pilot to post-pilot (96% (25/26) v. 65% (13/20), p = 0.03). Time, feedback, and sensitive topics were frequently rated as barriers on both the pre-pilot and post-pilot surveys. On the post-pilot survey, most participants reported patient discomfort with OERPs, attending physician discomfort with OERPs, difficulty writing attestations during OERPs, and difficulty teaching during OERPs were not barriers. Additionally, 45% (9/20) reported planning to use OERPs in the future. Despite benefits of OERPs, there are several barriers to OERPs that need to be addressed prior to more routine implementation in resident continuity clinic. Further research should focus on strategies for overcoming barriers and maximizing benefits of OERPs as well as developing a set of OERP best practices to support routine implementation in RCC.

A Focus on Feedback: Improving Learner Engagement and Faculty Delivery of Feedback in Hospital Medicine

Feedback is an integral part of medical education. However, there is great variation of training and effectiveness of feedback delivery, especially in the inpatient setting. The unique learning environment provided in hospital medicine allows teachers the opportunity to provide feedback on learner performance under several longitudinal observations in areas such as direct patient care, procedural tasks, and interdisciplinary team leadership skills. Most important, feedback should occur on more than one occasion to truly empower change in knowledge, attitude, and skills. This article aims to provide the reader with foundational theories on feedback and strategies to use best practices for delivery.

Use of a public park for physical activity in the Caribbean: evidence from a mixed methods study in Jamaica

BACKGROUND

Small island Caribbean countries such as Jamaica are now facing an epidemic of obesity and decreased physical activity (PA) levels. Public parks have been shown to be important resources for PA that also provide psychological and social benefits associated with increased PA. There are no studies that document PA in parks in the Caribbean.

METHODS

This study utilized a mixed method approach by using the System for Observing Play and Recreation in Communities (SOPARC) to obtain baseline data on park usage patterns in Emancipation Park, a large urban public park in Jamaica. In addition, in-depth interviews were conducted to gain additional insights on the park's use for PA.

RESULTS

The park was used mostly by females, in the evenings and by persons 18-64 years old. Females had significantly lower mean energy expenditure (EE) than males (0.078 versus 0.080 kcal/kg/min, p < 0.05). In-depth interviews revealed that safety, a central location within a business district, aesthetic appeal, a walking track and individual health benefits were key reasons for persons engaging in PA at the park.

CONCLUSIONS

This is the first study to describe the usage of a public park for PA in Jamaica. The study elicited aspects of park use for PA in a major urban park in Jamaica from different vantage points by using direct systematic observation augmented with a qualitative approach. It revealed important differential park use for PA by sex, age group and EE levels, and provided insights into factors that motivate and hinder park usage for PA. This can be used by policymakers in Jamaica to inform PA interventions to reduce obesity, provide baseline data for comparisons with other parks in developing countries and to advocate for well-designed public parks.

"All the ward's a stage": a qualitative study of the experience of direct observation of handoffs

Direct observation of clinical skills is central to assessment in a competency-based medical education model, yet little is known about how direct observation is experienced by trainees and observers. The objective of the study is to explore how direct observation was experienced by residents and faculty in the context of the I-PASS Handoff Study. In this multi-center qualitative study, we conducted focus groups and semi-structured interviews of residents and faculty members at eight tertiary pediatric centers in North America that implemented the I-PASS Handoff Bundle. We employed qualitative thematic analysis to interpret the data. Barriers to and strategies for direct observation were described relating to the observer, trainee, and clinical environment. Residents and faculty described a mutual awareness that residents change their performance of handoffs when observed, in contrast to their usual behavior in a clinical setting. Changes in handoff performance may depend on the nature of the observer or 'audience'. Direct observation also highlighted the importance of handoffs to participants, recognized as a clinical activity that warrants feedback and assessment. Dramaturgical theory can be used to understand our finding of 'front-stage' (observed) versus 'backstage' (unobserved) handoffs as distinct performances, tailored to an "audience". Educators must be cognizant of changes in performance of routine clinical activities when using direct observation to assess clinical competence.

A comprehensive study on the generation of reactive oxygen species in Cu-Aβ-catalyzed redox processes

In the amyloid plaques, a signature of AD, abnormally high Cu²⁺ concentrations are found bound to Aβ. Most of previous studies reported that Cu-Aβ could contribute to oxidative stress, as H₂O₂ and •OH are catalytically generated by Cu-Aβ with the assistance of biological reductant, with only one recent report stated that free O₂^•- is also generated in the Cu-Aβ catalyzed processes, where an indirect technique was applied. To comprehensively investigate the free radicals produced during this Cu-Aβ-mediated process with a biological reductant, DNA-cleavage assay, an indirect method, and two direct methods including electron paramagnetic resonance (EPR) spectroscopy and transient absorption spectroscopy (TAS), both having qualitative and quantitative power, were employed in this work. All the experimental results obtained from the three methods demonstrated that Cu-Aβ in the biological reducing environment was not only able to catalyze the production of H₂O₂ and •OH, but also to generate free O₂^•-. The results further indicated that O₂^•- was the precursor of H₂O₂ and •OH. It is also important to note that the results obtained from EPR spectroscopy and TAS provided direct evidence for the presence of O₂^•- and •OH. By virtue of the direct techniques, we also found that the longest peptide fragments of Aβ₁₆, Aβ₄₀, and Aβ₄₂ produced the least radicals with a lowest rate. More interestingly, the fibrillar forms of Aβ generated less O₂^•- and •OH compared with oligomeric and monomeric forms.

The relationship between responsive caregiving and child outcomes: evidence from direct observations of mother-child dyads in Pakistan

Background

Responsive caregiving, or interactions in which caregivers give appropriate responses to a child’s signals, is linked to improved psychosocial, cognitive and physical outcomes in children. However, much remains unknown about how responsive caregiving affects child development across cultural and socioeconomic contexts. The purpose of this study is to examine predictors of maternal responsive caregiving and investigate how these interactions are associated with children’s development.

Methods

Data for the current analyses came from a longitudinal study designed to follow mothers from the third trimester through the first three years of the child’s life. To assess responsive caregiving, the Observation of Mother-Child Interaction (OMCI) measure was used to examine maternal and child behaviors during a 5-min picture book activity at 24 months. Outcomes included child height-for-age z-score and child socioemotional development, using the Ages and Stages Questionnaire-Socioemotional (ASQ-SE) in which lower scores demonstrated better development. Using mean comparisons, the effects of baseline sociodemographic factors and maternal depression on responsive caregiving were tested. Analyses utilized hierarchical linear regressions to examine cross-sectional associations between responsive caregiving and child development outcomes at 24 months. Additional analyses controlled for the Home Observation for Measurement of the Environment (HOME), a common measure in low-income contexts of caregiving, to assess whether OMCI was uniquely predictive of child outcomes.

Results

Higher maternal education attainment, lower number of children, greater socioeconomic assets, and lack of maternal depression were associated with higher levels of observed responsive caregiving behaviors. Higher total OMCI scores were associated with positive child socioemotional outcomes in adjusted models (β: -0.84, 95% CI [− 1.40, − 0.29]). The finding was statistically significant, even after controlling for HOME score (β: -0.83, 95% CI [− 1.38, − 0.27]). There was no association between OMCI scores and child linear growth.

Conclusions

Responsive caregiving is linked to positive child socioemotional development in rural Pakistan. Our findings suggest that incorporating responsive caregiving into child health interventions in LMIC may have valuable impacts on child socioemotional development. The OMCI may be useful in identifying important pathways for change to responsive caregiving behaviors and may be of service for future interventions that optimize child development through responsive caregiving.

Trial registration

NCT02111915 (09/18/2015); NCT02658994 (01/22/2016). Trials were prospectively registered.

Effects of Generalization of Engagement in Parkour from Physical Education to Recess on Physical Activity

PURPOSE

To investigate the effect of generalization of engagement in parkour from physical education (PE) to organized and supervised recess on voluntary participation and moderate-to-vigorous physical activity (MVPA).

METHOD

Children received a 6-day parkour unit in PE and every two lessons they could voluntarily participate in 20-min parkour recess. Fourteen elementary school classes constituting 281 children (8-10 years old) and 16 PE teachers were randomized to either three supervised or three organized parkour recess sessions. During supervised recess, PE teachers supervised to ensure safety, and children could play freely on the parkour landscape. During organized recess, PE teachers provided instructional tasks as well as supervision for safety on the parkour landscape. The parkour landscape in the gymnasium was identical in both recess conditions and similar to previous parkour landscape in PE. Participation and MVPA were measured using systematic observation.

RESULTS

Significantly more children from organized compared to supervised recess participated in all three sessions (60% vs. 43%, p = .008, V = .16). Children showed significantly less sedentary behavior (24% vs. 30%, p = .013, η² = .063) and more MVPA (76% vs. 70%, p = .012, η² = .066) during organized compared to supervised recess. The proportion of total MVPA spent doing parkour was significantly higher in organized compared to supervised recess for low- (36% vs. 24%, p = .005, η² = .082) and high-skilled children (33% vs. 26%, p = .034, η² = .048).

CONCLUSION

Generalization of engagement in parkour was higher in organized compared to supervised recess.

Workplace mentoring of residents in generic competencies by an independent coach

INTRODUCTION

During postgraduate education in pulmonology, supervisors are responsible for training residents in generic competencies such as communication, professionalism and collaboration, but their focus commonly lies more on medical-technical competencies. As an alternative approach to supporting residents to develop generic skills, we developed a personal mentoring program with a non-medical professional as mentor. In this study, the residents' experiences with the mentoring program were evaluated.

METHODS

After an introductory session in which individual learning goals were established, pulmonology residents received at least six, 60-90-minute, individual, mentoring sessions largely consisting of feedback after being observed during daily clinical activities, over a period of 9 months. The residents' experiences with mentoring were explored through in-depth interviews followed by a qualitative content analysis.

RESULTS

From March to November 2016, ten residents in pulmonology completed the program. Despite initial scepticism, mentoring encouraged residents to reflect deeply on their professional interactions. This caused an increased awareness of the effects of their communication and behaviour on patients. Experimenting with communication and different behaviours in subsequent interactions felt rewarding and contributed to further development, resulting in increased self-confidence and job satisfaction.

DISCUSSION

Mentoring residents by non-medical coaching was associated with improved residents' proficiency in generic competencies.

Nesting biology of Black-shouldered Kite (Elanus caeruleus) in oil palm landscape in Carey Island, Peninsular Malaysia

Black-shouldered Kite (Elanus caeruleus) is a well-known raptor that inhabits open areas such as oil palm plantation or paddy field. To determine preferable habitat and nesting site of Black-shouldered Kite in oil palm landscape, we conducted a study on Black-shouldered Kite's nesting biology in Carey Island, Selangor, Malaysia. We divided the island into six types of habitat and conducted road-side count of Black-shouldered Kite from April 2009 to February 2011. Whenever the Black-shouldered Kite was detected, we thoroughly searched the surrounding area for their nest. In total, we have recorded forty nests. The nests were built on 15 species of trees but most of the trees shared common physical characteristics. Some novice breeders also used oil palm tree as their nesting site. Structure and building materials of nests constructed on oil palm trees were different from nests built on other trees. Of all breeding attempts, only four nests which were located in residential area adjacent to young oil palm habitat were successful. Among important characteristics of successful nesting site include taller trees with strong branches and good leaf coverage. These trees not only protect nests from predator detection (except from other predatory birds) and physical environment but also facilitate Black-shouldered Kite's foraging activities by providing good vantage point.

A protocol of human animal interaction to habituate young sheep and goats for behavioural studies

Animal habituation is key to obtain reliable data on behavioural studies but detailed procedures to achieve it are scarce. This study designed a set of actions to habituate sheep and goats to human observers. Pelibuey sheep (n = 15) and Criollo goats (n = 10) were classified as (a) avoider, flight from human interaction, or (b) follower, seek human interaction. Habituation was measured by the reduction of flight distance by avoiders, or number of followers in the presence of observers. The habituation protocol consisted of a gradually increased series of five manoeuvres, either challenge (for avoiders) or evasion (for seekers), performed first inside a pen and subsequently in a grass paddock. Habituation was considered successful when animals could be observed from a 1-m distance without flight or following the observer. In the pen, habituation took 12 and 13 days for sheep and goats, respectively. Meanwhile, in the grass paddock habituation took 10 days, for both species. The number of challenge and evasion series was negatively correlated with the flight distance in sheep and with the number of followers in goats. This protocol is simple and practical to implement and enables animal habituation for behavioural studies.

Assessment of the alcohol consumption among outdoor bar drinkers in Nigeria by qualitative methods

Background

There are indications that drinking in outdoor bars, such as at motor-parks, by the roadsides or street corners have become popular in Nigeria.

Method

Three sets of qualitative assessments were carried out from three outdoor bars, randomly selected from 22 of such in Ibadan, Nigeria. The main sources of data were by direct observation and focus group discussion (FGD), conducted by a non-probabilistic sample of outdoor bar drinkers, alcohol vendors and from community members. The qualitative assessments were recorded, followed by a thematic analysis of the contents of the qualitative assessments.

Results

Widespread use of alcohol was reported. Patrons of outdoor bars reported that their context of drinking was pleasurable to them. Use of local beverages usually called ‘sepe’ is increasing. The majority of them do not have adequate health information about the harmful consequences of alcohol. Alcohol and other substances of abuse were openly displayed, sold and consumed at the study sites. There were poor law provision and enforcement of laws prohibiting open display of alcohol and other substances.

Conclusion

A high proportion of social drinkers in outdoor bars require intervention for their drinking behaviour. This is important because they have little or no information about the health hazards associated with excessive drinking. Presentation of these findings should contribute to increased awareness and improved response from the policy makers.

Physical activity patterns across time-segmented youth sport flag football practice

BACKGROUND

Youth sport (YS) reaches a large number of children world-wide and contributes substantially to children's daily physical activity (PA), yet less than half of YS time has been shown to be spent in moderate-to-vigorous physical activity (MVPA). Physical activity during practice is likely to vary depending on practice structure that changes across YS time, therefore the purpose of this study was 1) to describe the type and frequency of segments of time, defined by contextual characteristics of practice structure, during YS practices and 2) determine the influence of these segments on PA.

METHODS

Research assistants video-recorded the full duration of 28 practices from 14 boys' flag football teams (2 practices/team) while children concurrently (N = 111, aged 5-11 years, mean 7.9 ± 1.2 years) wore ActiGraph GT1M accelerometers to measure PA. Observers divided videos of each practice into continuous context time segments (N = 204; mean-segments-per-practice = 7.3, SD = 2.5) using start/stop points defined by change in context characteristics, and assigned a value for task (e.g., management, gameplay, etc.), member arrangement (e.g., small group, whole group, etc.), and setting demand (i.e., fosters participation, fosters exclusion). Segments were then paired with accelerometer data. Data were analyzed using a multilevel model with segment as unit of analysis.

RESULTS

Whole practices averaged 34 ± 2.4% of time spent in MVPA. Free-play (51.5 ± 5.5%), gameplay (53.6 ± 3.7%), and warm-up (53.9 ± 3.6%) segments had greater percentage of time (%time) in MVPA compared to fitness (36.8 ± 4.4%) segments (p ≤ .01). Greater %time was spent in MVPA during free-play segments compared to scrimmage (30.2 ± 4.6%), strategy (30.6 ± 3.2%), and sport-skill (31.6 ± 3.1%) segments (p ≤ .01), and in segments that fostered participation (36.1 ± 2.7%) than segments that fostered exclusion (29.1 ± 3.0%; p ≤ .01). Significantly greater %time was spent in low-energy stationary behavior in fitness (15.7 ± 3.4%) than gameplay (4.0 ± 2.9%) segments (p ≤ .01), and in sport-skill (17.6 ± 2.2%) than free-play (8.2 ± 4.2%), gameplay, and warm-up (10.6 ± 2.6%) segments (p < .05).

CONCLUSIONS

The %time spent in low-energy stationary behavior and in MVPA differed by characteristics of task and setting demand of the segment. Restructuring the routine of YS practice to include segments conducive to MVPA could increase %time spent in MVPA during practice. As YS reaches a large number of children worldwide, increasing PA during YS has the potential to create a public health impact.

Competency based clinical shoulder examination training improves physical exam, confidence, and knowledge in common shoulder conditions

BACKGROUND

Deficiencies in musculoskeletal knowledge are reported at every stage of learning. Medical programs are looking for effective ways to incorporate competency-based training into musculoskeletal education.

AIM

To evaluate the impact of bedside feedback on learner's shoulder examination skills, confidence, and knowledge of common shoulder conditions.

SETTING

Four-week musculoskeletal clinic rotation.

PARTICIPANTS

UCSD third year medical students and internal medicine residents.

PROGRAM DESCRIPTION

Learners completed three baseline evaluations: videotaped shoulder examination, attitude survey, and knowledge test. During the 4-week intervention learners received bedside observation and feedback from musculoskeletal experts while evaluating patients with shoulder conditions. Post-intervention learners repeated the three assessments.

PROGRAM EVALUATION

Eighty-nine learners participated. In the primary outcome measure evaluating the pre/post videotaped shoulder examination, significant improvement was seen in 21 of 23 shoulder examination maneuvers. Secondary outcomes include changes in learner confidence and knowledge. Greatest gains in learner confidence were seen in performing the shoulder examination (61.5% improvement) and performing injections (97.1% improvement). Knowledge improved significantly in all categories including anatomy/examination interpretation, diagnosis, and procedures.

DISCUSSION

Direct observation and feedback during clinical evaluation of patients with shoulder pain improves shoulder examination competency, provider confidence, and knowledge of common shoulder conditions.

Playground usage and physical activity levels of children based on playground spatial features

Aim

Being outdoors is one of the strongest correlates of physical activity in children. Playgrounds are spaces especially designed to enable and foster physical activity in children. This study aimed to analyze the relationship between the spatial features of public playgrounds and the usage and physical activity levels of children playing in them.

Subjects and methods

A quantitative, observational study was conducted of ten playgrounds in one district of a middle-sized town in Germany. Playground spatial features were captured using an audit instrument and the playground manual of the town. Playground usage and physical activity levels of children were assessed using a modified version of the System for Observing Play and Leisure Activity in Youth. Negative binomial models were used to analyze the count data.

Results

The number of children using the playgrounds and the number of children actively playing in them were higher in those with more varied facilities and without naturalness. Girls played more actively in playgrounds without multi-purpose areas. Cleanliness, esthetics, play facility quality, division of functional areas and playground size were not related to any outcome variable.

Conclusion

Playground spatial features are related to playground usage and activity levels of the children in the playgrounds. Playgrounds should offer a wide variety of play facilities and provide spaces for diverse play activities to respond to the needs of large numbers of different children and to provide activity-friendly areas enabling their healthy development.

Video-based feedback as a method for training rural healthcare workers to manage medical emergencies: a pilot study

BACKGROUND

Video-based feedback has been shown to aid knowledge retention, skills learning and improve team functionality. We explored the use of video-based feedback and low fidelity simulation for training rural healthcare workers along the Thailand-Myanmar border and Papua New Guinea (PNG) to manage medical emergencies effectively.

METHODS

Twenty-four study participants were recruited from three Shoklo Malaria Research Unit clinics along the Thailand-Myanmar border and eight participants from Kudjip Nazarene Hospital, PNG. The teams were recorded on video managing a simulated medical emergency scenario and the video was used to aid feedback and assess performance using Observed Structured Clinical Examination (OSCE) scoring and Team Emergency Assessment Measure (TEAM) questionnaire. The process was repeated post-feedback at both sites and at 6 weeks at the Thailand-Myanmar border site. Thailand-Myanmar border participants' individual confidence levels and baseline knowledge (using OSCE scoring) were assessed before team assessment and feedback at week 1 and repeated post-feedback and at 6 weeks. Focus group discussions (FGD) were held at each Thailand-Myanmar border clinic at week 1 (8 participants at each clinic).

RESULTS

Individual paired tests of OSCE scores showed significant improvement post-feedback at week 1 (p < 0.001) and week 6 (p < 0.001) compared to baseline OSCE scores. There was a trend for increased team OSCE scores compared to baseline at week 1 (p = 0.068) and week 6 (p = 0.109) although not significant. Thailand-Myanmar border TEAM scores demonstrated improvement post-feedback mainly in leadership, teamwork and task management which was sustained up to week 6. PNG showed an improvement mainly in teamwork and task management. The global rating of the teams' non-technical performance at both sites improved post feedback and at week 6 on the Thailand-Myanmar border site. Self-rated confidence scores by Thailand-Myanmar border participants increased significantly from baseline following training at week 1 (p = 0.020), and while higher at 6 weeks follow up than at baseline, this was not significant (p = 0.471). The FGD revealed majority of participants felt that watching the video recording of their performance and the video-based feedback contributed most to their learning.

CONCLUSION

Video-assisted feedback resulted in an improvement in clinical knowledge, confidence and quality of teamwork for managing medical emergencies in two low resource medical facilities in South East Asia and the South Pacific.

Online versus in-person comparison of Microscale Audit of Pedestrian Streetscapes (MAPS) assessments: reliability of alternate methods

Background

An online version of the Microscale Audit of Pedestrian Streetscapes (Abbreviated) tool was adapted to virtually audit built environment features supportive of physical activity. The current study assessed inter-rater reliability of MAPS Online between in-person raters and online raters unfamiliar with the regions.

Methods

In-person and online audits were conducted for a total of 120 quarter-mile routes (60 per site) in Phoenix, AZ and San Diego, CA. Routes in each city included 40 residential origins stratified by walkability and SES, and 20 commercial centers. In-person audits were conducted by raters residing in their region. Online audits were conducted by raters in the alternate location using Google Maps (Aerial and Street View) images. The MAPS Abbreviated Online tool consisted of four sections: overall route, street segments, crossings and cul-de-sacs. Items within each section were grouped into subscales, and inter-rater reliability (ICCs) was assessed for subscales at multiple levels of aggregation.

Results

Online and in-person audits showed excellent agreement for overall positive microscale (ICC = 0.86, 95% CI [0.80, 0.90]) and grand scores (ICC = 0.93, 95% CI [0.89, 0.95]). Substantial to near-perfect agreement was found for 21 of 30 (70%) subscales, valence, and subsection scores, with ICCs ranging from 0.62, 95% CI [0.50, 0.72] to 0.95, 95% CI [0.93, 0.97]. Lowest agreement was found for the aesthetics and social characteristics scores, with ICCs ranging from 0.07, 95% CI [−0.12, 0.24] to 0.27, 95% CI [0.10, 0.43].

Conclusions

Results support use of the MAPS Abbreviated Online tool to reliably assess microscale neighborhood features that support physical activity and may be used by raters residing in different geographic regions and unfamiliar with the audit areas.

Hand hygiene compliance in a universal gloving setting

BACKGROUND

The use of gloves for every patient contact (ie, universal gloving) has been suggested as an infection prevention adjunct and alternative to contact precautions. However, gloves may carry organisms unless they are changed properly. In addition, hand hygiene is required before donning and after removing gloves, and there are scarce data regarding glove changing and hand hygiene in a universal gloving setting.

METHODS

This nonrandomized observational before-after study evaluated the effect of education and feedback regarding hand hygiene. Compliance with hand hygiene and glove use was directly observed in a universal gloving setting at a 10-bed intensive care unit in a Japanese tertiary care university teaching hospital.

RESULTS

A total of 6,050 hand hygiene opportunities were identified. Overall, hand hygiene compliance steadily increased from study period 1 (16.1%) to period 5 (56.8%), although there were indication-specific differences in the baseline compliance, the degree of improvement, and the reasons for noncompliance. There were decreases in the compliance with universal gloving and the incidence of methicillin-resistant Staphylococcus aureus.

CONCLUSION

It is difficult to properly perform glove use and hand hygiene in a universal gloving setting, given its complexity. Direct observation with specific feedback and education may be effective in improving compliance.

The selection by the Asiatic black bear (Ursus thibetanus) of spring plant food items according to their nutritional values

The present study aimed to investigate the nutritional aspects of the bear diet quantitatively, in order to understand plant food selection in spring. Bears were observed directly from April to July in 2013 and 2014, to visually recognize plant species consumed by bears, and to describe the foraging period in the Ashio-Nikko Mountains, central Japan. Leaves were collected from eight dominant tree species, regardless of whether bears fed on them in spring, and their key nutritional components analyzed: crude protein (CP), neutral detergent fiber (NDF), and total energy. Bears tended to consume fresh leaves of specific species in May, and nutritional analysis revealed that these leaves had higher CP and lower NDF than other non-food leaves. However, CP in consumed leaves gradually decreased, and NDF increased from May to July, when the bears’ food item preference changed from plant materials to ants. Bears may consume tree leaves with high CP and low NDF after hibernation to rebuild muscle mass.

What Do Children Eat in the Summer? A Direct Observation of Summer Day Camps That Serve Meals

BACKGROUND

More than 14 million children in the United States attend summer camp annually, yet little is known about the food environment in day camps.

OBJECTIVE

Our aim was to describe the nutritional quality of meals served to, brought by, and consumed by children attending summer day camps serving meals and snacks, and to describe camp water access.

DESIGN

We conducted a cross-sectional study.

PARTICIPANTS/SETTINGS

Participants were 149 children attending five summer camps in Boston, MA, in 2013.

MAIN OUTCOME MEASURES

Foods and beverages served were observed for 5 consecutive days. For 2 days, children's dietary intake was directly observed using a validated protocol. Outcome measures included total energy (kilocalories) and servings of different types of foods and beverages served and consumed during breakfast, lunch, and snack.

STATISTICAL ANALYSES PERFORMED

Mean total energy, trans fats, sodium, sugar, and fiber served per meal were calculated across the camps, as were mean weekly frequencies of serving fruits, vegetables, meat/meat alternates, grains, milk, 100% juice, sugar-sweetened beverages, whole grains, red/highly processed meats, grain-based desserts, and salty snacks. Mean consumption was calculated per camper per day.

RESULTS

Camps served a mean (standard deviation) of 647.7 (134.3) kcal for lunch, 401.8 (149.6) kcal for breakfast, and 266.4 (150.8) kcal for snack. Most camps served red/highly processed meats, salty snacks, and grain-based desserts frequently, and rarely served vegetables or water. Children consumed little (eg, at lunch, 36.5% of fruit portions, 35.0% of meat/meat alternative portions, and 37.6% of milk portions served) except for salty snacks (66.9% of portions) and grain-based desserts (64.1% of portions). Sugar-sweetened beverages and salty snacks were frequently brought to camp. One-quarter of campers drank nothing throughout the entire camp day.

CONCLUSIONS

The nutritional quality of foods and beverages served at summer day camps could be improved. Future studies should assess barriers to consumption of healthy foods and beverages in these settings.

An intervention to improve the catheter associated urinary tract infection rate in a medical intensive care unit: Direct observation of catheter insertion procedure

BACKGROUND

Healthcare associated infections from indwelling urinary catheters lead to increased patient morbidity and mortality.

AIM

The purpose of this study was to determine if direct observation of the urinary catheter insertion procedure, as compared to the standard process, decreased catheter utilization and urinary tract infection rates.

METHODS

This case control study was conducted in a medical intensive care unit. During phase I, a retrospective data review was conducted on utilsiation and urinary catheter infection rates when practitioners followed the institution's standard insertion algorithm. During phase II, an intervention of direct observation was added to the standard insertion procedure.

RESULTS

The results demonstrated no change in utilization rates, however, CAUTI rates decreased from 2.24 to 0 per 1000 catheter days.

CONCLUSION

The findings from this study may promote changes in clinical practice guidelines leading to a reduction in urinary catheter utilization and infection rates and improved patient outcomes.

A direct observation method for auditing large urban centers using stratified sampling, mobile GIS technology and virtual environments

BACKGROUND

With the expansion and growth of research on neighbourhood characteristics, there is an increased need for direct observational field audits. Herein, we introduce a novel direct observational audit method and systematic social observation instrument (SSOI) for efficiently assessing neighbourhood aesthetics over large urban areas.

METHODS

Our audit method uses spatial random sampling stratified by residential zoning and incorporates both mobile geographic information systems technology and virtual environments. The reliability of our method was tested in two ways: first, in 15 Ottawa neighbourhoods, we compared results at audited locations over two subsequent years, and second; we audited every residential block (167 blocks) in one neighbourhood and compared the distribution of SSOI aesthetics index scores with results from the randomly audited locations. Finally, we present interrater reliability and consistency results on all observed items.

RESULTS

The observed neighbourhood average aesthetics index score estimated from four or five stratified random audit locations is sufficient to characterize the average neighbourhood aesthetics. The SSOI was internally consistent and demonstrated good to excellent interrater reliability. At the neighbourhood level, aesthetics is positively related to SES and physical activity and negatively correlated with BMI.

CONCLUSION

The proposed approach to direct neighbourhood auditing performs sufficiently and has the advantage of financial and temporal efficiency when auditing a large city.

Bedside direct observation of medical student-performed physical examination is highly rated in student satisfaction

This article was migrated. The article was marked as recommended. Objectives: To evaluate satisfaction among third year medical students with a bedside teaching exercise comprised of direct observation of student-performed physical examination skills and related feedback. Methods: An observational, cross-sectional study design was employed to study third year medical students undergoing the Neurology clerkship at the Ohio State University College of Medicine between June and October 2015. Immediately following the bedside physical examination teaching exercise, student satisfaction data was obtained in anonymous survey (n=21). In addition, student satisfaction data from the class cohort (n=51), regarding various learning formats in the curriculum, were collected at the end of a 16-week block of rotations including the Neurology clerkship. Data were summarized using descriptive statistics. Results: Most students felt that their level of confidence increased as a result (85.0%, n=17/21), and they felt they would use what they had learned in the future (95%, n=19/21). Only about half of the students felt strongly that reflection on the learning experience was sought (47.6%, n= 10/21). At the end of the 16 weeks block, the Neurology examination exercise was rated among the most highly in student satisfaction (3.35/4, SD=0.89) as compared to procedural workshops (2.76/4, SD= 0.76), other small group topic format (2.78/4, SD= 0.85), and traditional lecture (2.39/ 4, SD= 0.89). Conclusions: The bedside direct observation of physical examination performed by medical students is highly rated in student satisfaction, and students are most satisfied with this format of teaching among all formats studied. Increased opportunity for reflection in this setting represents an area for further development.

A Validation Study of the Automated Self-Administered 24-Hour Dietary Recall for Children, 2014 Version, at School Lunch

BACKGROUND

Obtaining valid and reliable estimates of usual dietary intake at a reasonable cost is a challenge in school-based nutrition research. The Automated Self-Administered 24-Hour Dietary Recall for Children, 2014 version (ASA24 Kids-2014), a self-administered, computerized 24-hour dietary recall, offers improved feasibility over traditional interviewer-administered 24-hour recalls.

OBJECTIVE

This mixed-methods study examined ASA24 Kids-2014's validity for measuring dietary intake from National School Lunch Program lunches.

PARTICIPANTS/SETTING

After 24% attrition, 96 middle-school students from three urban schools in eastern Pennsylvania participated in the study. A subsample of 27 participants completed qualitative interviews. Data were collected in the spring of 2014.

MAIN OUTCOME MEASURES

Self-reported ASA24 Kids-2014 data were compared to direct observations of school lunch, which served as the criterion measure. Dependent variables included eight meal components selected from the National School Lunch Program guidelines (fruit, vegetables, grains, protein-rich foods, dairy, oils, solid fats, and added sugars). A supplemental interview collected qualitative data regarding students' perceptions of content and substantive validity.

STATISTICAL ANALYSES

The Wilcoxon signed rank test and Spearman's ρ examined criterion-related validity; qualitative content analysis examined content and substantive validity.

RESULTS

Participants inaccurately recalled food items eaten at lunch, as 58% of foods were reported in error. However, among foods recalled correctly, no statistically significant differences emerged for estimates of portions consumed for six meal components (fruit, vegetables, grains, protein-rich foods, oils, and added sugars). In addition, statistically significant positive correlations emerged between ASA24 Kids-2014 and direct observation for all estimates. Qualitative data identified students' interest and motivation, comprehension, memory, and English-language fluency as relevant sources of error.

CONCLUSIONS

Middle school students have difficulty recalling food items eaten at school lunch; however, they are somewhat successful at estimating intake of accurately recalled foods using ASA24 Kids-2014. Like many self-administered computerized recalls, it remains limited by substantial error. Findings have implications for the development of ASA24 Kids-2014 among diverse youth in urban school settings.

Continued direct observation and feedback of hand hygiene adherence can result in long-term improvement

BACKGROUND

Hospital-wide multifaceted approaches can improve hand hygiene compliance in health care workers. However, the true effects of monitoring and feedback interventions are not clear.

METHODS

Hand hygiene compliance was evaluated by applying direct observation techniques over 5 years (2005-2009) in a tertiary care general hospital in Japan. The observed results were periodically reported as feedback to the health care workers.

RESULTS

The overall hand hygiene compliance rate increased from 50.8% in 2005 to 61.0% in 2006 (P = .004) and was sustained at approximately 60% through the completion of the study. The compliance rate for the indication before entering the room increased from 2005 to 2009 (P = .005). The compliance rates for 4 before patient contact indications increased from 2005 to 2009 (P = .002). The combined compliance rate for the 6 indications with the lowest compliance rates in 2005 increased from 2005 to 2009 (P = .001).

CONCLUSIONS

Direct observation and feedback methods are effective strategies that resulted in a long-lasting improvement in hand hygiene compliance that was sustained over 5 years through the completion of the study. Focusing on the procedures with high baseline noncompliance rates can be an effective way to improve the overall compliance.

Associations between TV viewing at family meals and the emotional atmosphere of the meal, meal healthfulness, child dietary intake, and child weight status

BACKGROUND

Research on family meals has demonstrated that family meals are protective for many aspects of child and adolescent health. It is unclear whether distractions at family meals, such as watching TV, are associated with child weight and weight-related behaviors, the emotional atmosphere at the meal, or family meal healthfulness.

METHODS

Direct observational and objective data were collected on primarily low-income and minority families (n = 120) with 6-12 year old children. Data were collected during home visits and included 24-hr dietary recalls, anthropometry, and video-recorded family meals. Video-recorded family meals were coded to assess the presence of TV, whether the family was paying attention to the TV, family group enjoyment and the dietary healthfulness of the foods served at family meals.

RESULTS

The presence of TV was negatively associated with the dietary healthfulness and emotional atmosphere of the meal and the child's overall dietary quality. It was positively associated with serving fast food for family meals. Those families who were paying attention to the TV had significantly worse meal dietary healthfulness and were more likely to have fast food at family meals compared to those who were not paying attention. No significant findings were found between the presence of TV at family meals and child overweight status.

CONCLUSIONS

Study results show that TV is frequently present at family meals. Even if families are not paying attention to the TV, it appears that simply having the TV on as background noise is associated with deleterious outcomes. In addition to increasing family meals, families should be given guidance on turning off the TV and making the family meal a time to connect with one another.