Randomized controlled trial of decision aids for women considering prenatal testing: The effect of the Ottawa Personal Decision Guide on decisional conflict

Authors


Naoko Arimori, St Luke’s College of Nursing, 10-1 Akashi-cho, Chuo-ku, Tokyo 104-0044, Japan. Email: naoko-arimori@slcn.ac.jp

Abstract

Aim:  The aim of this research study was to clarify the effect that counseling using the Ottawa Personal Decision Guide had on pregnant women in helping them to decide whether or not to undergo prenatal testing. It compared the “decisional conflict” of a group of women interviewed by a nurse using the guide with that of a second group who were only given standard genetic counseling.

Methods:  A group of pregnant women attending the hospital for genetic counseling was randomly divided into an intervention group and a control group. The women in the intervention group were given standard genetic counseling, followed by an interview based on the decision aid guide. The women in the control group were given only standard genetic counseling. Both groups were followed up. The primary outcome of the study was to determine the level of decisional conflict, as measured by the Japanese version of the Decisional Conflict Scale. The secondary outcome was self-esteem, based on the Rosenburg Self-Esteem Scale. The outcome indicators were obtained from responses given in patient questionnaires conducted after standard genetic counseling (pre-intervention) and after the conclusion of the decision-making process (postintervention).

Results:  The pre-intervention and postintervention changes in decisional conflict scores (primary outcome) indicated no significant difference between the two groups. However, with regard to postintervention decisional conflict, the rate of the response “mild to high decisional conflict” was lower for the intervention group than the control group. No significant difference between the two groups was detected for the secondary outcome of self-esteem.

Conclusions:  The reasons for the lack of a clear effect on the level of decisional conflict are that the pre-intervention responses for both groups were obtained after completion of the standard genetic counseling program and because follow-up conducted by the nurses took the form of care given in response to patients’ needs. The use of decision aids to assist in the decision-making process had no effect on the level of self-esteem in the two groups. As a result, there was a similar level of intervention for both groups. However, as there was no clear indication that the use of the Ottawa Personal Decision Guide was harmful, it will be a useful tool in the medical care setting.

INTRODUCTION

Background

In 2002, the number of amniocentesis procedures was 10-fold higher than 20 years earlier, with the majority conducted because of the advanced age of the mother (Mothers’ and Children’s Health and Welfare Association, 2004; Sago et al., 2000). Various studies (Ando, 1996; Aoki & Arimori, 2004; Rothenberg & Thomson, 1994) have indicated that women who undergo prenatal testing do not necessarily feel relieved after the test has been conducted. They experience conflict prior to testing, anxiety about the results, and feelings of guilt about having the test at all. There is also the added stress because they have to make the decision as to whether or not to undergo prenatal testing before the 22nd week of pregnancy, the cut-off date for pregnancy termination (Bryar, 1997; Kolker & Burke, 1993; Nakagomi, 2000).

In Japan, physicians largely provide genetic counseling independently. In this approach, the psychological stress of the client has not been resolved adequately. The genetic counseling system, including prenatal testing, was implemented in 2002 (Furuyama, 2001), with expectations that nurses would provide psychological support for the client’s decision as part of the team providing genetic counseling.

But there have been no reports of nurses using specific decision aid procedures (Arimori et al., 2004; Mihara, 2003; Nakagomi, Yokoo, Momota, Samura & Miharu, 2002; Suzuki et al., 2003; Yamashita, 2003; Yokoo, 2003). The Cochrane Library holds a systematic review of decision aids for people facing health treatment or decisions based on the results of screening tests (O’Connor et al., 2003). The Ottawa Personal Decision Guide, a unique decision aid developed for individuals, and its application in the health fields has been researched and discussed in particular. Therefore, the development of a decision aid program for women in Japan considering prenatal testing and a clear evaluation of its effectiveness would assist the decision-making process.

Aim

The aim of this study was to explore the effect of the Ottawa Personal Decision Guide on “decisional conflict” in women considering prenatal testing in Japan.

Conceptual framework

The intervention in this study was based on the Ottawa Decision Support Framework (O’Connor et al., 1998), which uses a three-step process (Fig. 1):

Figure 1.

Conceptual framework based on the Ottawa Personal Decision Guide. The dotted boxes (. . . .) indicate that intervention was conducted for both groups.

  • 1Assess needs (determinants of decisions).
  • 2Provide decision support intervention that addresses the determinants to improve the quality of the decision-making process and the decision aid.
  • 3Evaluate the success of the decision support in affecting the quality of the decision process, the decision, and the decision outcome.

The interventions, as outlined in the Ottawa Personal Decision Guide (O’Connor et al., 2003), are:

  • 1Clarify the decision.
  • 2Identify your role in decision-making.
  • 3Assess your decision-making needs.
  • 4Weigh the options.
  • 5Plan the next steps.

The outcomes were identified as determining the level of decisional conflict (primary outcome) and to assess self-esteem (SE; secondary outcome).The antecedents were identified as the clients’ and practitioners’ sociodemographic and clinical characteristics.

METHODS

Design

The research study was a randomized controlled trial to determine the effect of the Ottawa Personal Decision Guide, translated into Japanese, on decisional conflict in women considering prenatal testing.

Subject recruitment

The participants were recruited from the population of pregnant women who had made an appointment for prenatal genetic counseling at a metropolitan general hospital between May 2004 and February 2005. Women who did not speak Japanese or who had a serious psychiatric condition were excluded.

A plain-language information sheet about the study was provided to potential participants by the investigator and written informed consent was obtained from all women who voluntarily chose to participate. This research obtained approval from the ethical committee of St Luke’s College of Nursing and the metropolitan general hospital.

Sample size

It was estimated that, taking into account an attrition rate of 10%, the required sample size was 96 women, 48 in each group. Based on evidence provided by another study (O’Connor et al., 1998), the effect size for the Decisional Conflict Scale (DCS) was set at 0.6, with α = 0.05 and β = 0.2.

Randomization

Research assistants who did not take part in the interview process randomized participants into either the intervention group or the control group using the permutated block randomization method, with a block size of 4, to ensure that an equal number of women were allocated to each group. The result of each participant’s group allocation was concealed in a numbered, untransparent envelope, which was opened by the research assistants after participants had given informed consent.

Intervention

Intervention group

Three nurses (research assistants) conducted the interventions after they had completed training in genetic nursing and genetic counseling. They attended the prenatal genetic counseling session conducted between the obstetrician and the subject, and then conducted the decision aid intervention through interviews with the subjects, explaining and guiding the women through the five-step process. These nurses also provided postcounseling follow-up according to each subject’s needs, including answering questions about prenatal testing and attending the amniocentesis procedure.

Control group

Five nurses (research assistants) looked after the women in the control group. Three of them also were in charge of the intervention group. After the nurses attended the prenatal genetic counseling session conducted by the obstetrician, they provided the same individual postcounseling follow-up as for the intervention group.

Data collection

The data were collected on two occasions: the first time was immediately after the genetic counseling conducted by the obstetrician and the second time was by mail after the subject had made her decision about prenatal testing. The data collected on the first occasion addressed the level of decisional conflict, SE, and demographic information. On the second occasion, the data regarding the level of decisional conflict, SE, and the final decision about prenatal testing were collected. All data were collected by self-reporting questionnaire.

Measurement

Primary outcome: The level of decisional conflict

The primary outcome was determined as the level of decisional conflict (O’Connor, 2003) and measured using the DCS. The English version of the scale is made up of five subscales and 16 items and uses the five-point Likert scale, from “1” (strongly agree) to “5” (strongly disagree) to rate responses, so the higher the score, the higher the level of decisional conflict. Scores of ≤ 2 are considered to be “low decisional conflict” and normally indicate little difficulty in decision-making or implementation of the decision. Scores of ≥ 2.5 are associated with a delay in the decision-making process. In this study, scores >2 were taken to indicate “mild to high decisional conflict”.

The Japanese DCS was developed by translating the original English version into Japanese and then retranslating it back into English. Factor analysis was subjected to the maximum-likelihood method with promax rotation.

Factor analysis confirmed that the Japanese DCS was similar to the English DCS. The Japanese version of the DCS comprised five factors and a total of 15 items. The five factors were similar to the subscales of the English version:

  • 1Feeling uninformed about options and unclear about the value of each one.
  • 2Perception of the quality of the decision made.
  • 3Lack of advice about the decision.
  • 4Uncertainty.
  • 5Feeling unsupported by others in the decision-making process.

Cronbach’s α was set at 0.866 across the five factors and internal consistency was maintained (Table 1).

Table 1.  Factor analysis of Japanese Decisional Conflict Scale (maximum likelihood method with promax rotation)
Factor/question item (overall scale α = 0.866)Factor loading
Factor IFactor IIFactor IIIFactor IVFactor V
Factor I: Feeling uninformed about options and unclear about the value of each one (α = 0.802)
 I know the advantages of prenatal testing 0.878−0.262 0.201 0.001−0.153
 In making this decision, I am clear about how important the disadvantages of prenatal testing are to me 0.773 0.087 0.036−0.134−0.024
 In making this decision, I am clear about how important the advantages of prenatal testing are to me  −0.138−0.137 0.092
 In making this decision, I am aware of the options available to me 0.565−0.115−0.012 0.230 0.055
 For the main options I am considering, I am clear about which are more important to me (the advantages or the disadvantages) 0.484 0.191−0.258 0.350 0.062
Factor II: Perception of the quality of the decision made (α = 0.818)
 I expect to stick with my decision−0.134 0.7970.080 0.004−0.023
 My decision shows what is important to me 0.123 0.7730.147−0.036−0.083
 I am satisfied with my decision 0.001 0.6130.056 0.171−0.031
Factor III: Lack of advice about the decision (α = 0.898)
 I feel I have made an informed choice−0.045 0.1450.918 0.007−0.088
 I have received enough advice about the options available to me 0.128 0.0670.761−0.006 0.029
Factor IV: Uncertainty (α = 0.731)
 I am clear about what is the best choice for me 0.020−0.0520.118 0.952−0.099
 This decision is easy for me to make−0.063 0.090−0.129 0.437 0.111
 I am clear about how to make my decision−0.099 0.1310.158 0.432 0.324
Factor V: Feeling unsupported by others in the decision-making process (α = 0.631)
 I have received enough support from others in making this choice 0.088−0.0940.190−0.083 0.947
 I am making this choice without any pressure from others−0.103−0.028−0.185 0.090 0.573
Correlation of factors
 (Factor I) 1.000
 (Factor II) 0.501 1.000
 (Factor III) 0.468 0.5031.000
 (Factor IV) 0.380 0.5670.354 1.000
 (Factor V) 0.344 0.4390.436 0.477 1.000

Secondary outcome: Measuring the level of self-esteem

The secondary outcome was identified as SE, measured using the well-established Japanese version of the Rosenberg Self-Esteem Scale (Cronbach’s α = 0.8), translated by Yamamoto (1982). The scale consists of 10 items and participants respond using a five-point Likert scale from “1” (applies) to “5” (does not apply).

Statistical analysis

Statistical analysis was performed using SPSS (version 13.OJ; SPSS, Chicago, IL, USA). The pre-intervention and postintervention changes in the DCS and SE scores were analyzed for each group by means of an independent t-test to calculate the 95% confidence interval (CI) for RR (relative risk) and ARR (absolute risk reduction) of mild to high decisional conflict (DCS score > 2). A significance level of 5% was applied to both groups.

RESULTS

Recruitment and participation

As shown in Figure 2, during the course of the study 159 women made appointments for prenatal genetic counseling and, of these, 118 (74.2%) met all eligibility criteria. However, 22 women declined to participate, so a total of 96 pregnant women were randomly assigned to the two groups. The response rate to the postintervention questionnaire was high: 40/48 subjects from the intervention group (83.3%) and 43/48 subjects (89.6%) from the control group.

Figure 2.

Flow of participants through the study and the data collection plan. DCS, Decisional Conflict Scale; SE, self-esteem.

Demographic characteristics

As shown in Table 2, the analysis of demographic parameters (age, stage of pregnancy, risk, education level, employment, attendance status, decision stage, preferred role in decision-making process) revealed no significant difference between the two groups.

Table 2.  Demographic characteristics
ParameterTotal (n = 93)
N (%)
Intervention group (OPDG) (n = 45)
N (%)
Control group (Standard counseling) (n = 48)
N (%)
  1. OPDG, Ottawa Personal Decision Guide.

Age36.84 ± 3.9536.96 ± 3.8436.73 ± 4.09
Stage of pregnancy (weeks)13.41 ± 2.2913.20 ± 2.1113.60 ± 2.45
Parity
 Primiparous65 (69.9)30 (66.7)35 (72.9)
 Multiparous28 (30.1)15 (33.3)13 (27.1)
Risk
 High risk56 (60.2)29 (64.4)27 (56.3)
 >35 years31 (33.3)14 (31.1)17 (35.4)
 None 6 (6.5) 2 (4.4) 4 (8.3)
Education
 High school graduate 7 (7.5) 4 (8.9) 3 (6.3)
 Junior college graduate34 (36.6)14 (31.1)20 (41.7)
 University graduate/postgraduate52 (55.9)27 (60.0)25 (52.1)
Employment
 Full-time34 (36.6)15 (33.3)19 (39.6)
 Part-time 8 (8.6) 3 (6.7) 5 (10.4)
 Not employed51 (54.8)27 (60.0)24 (50.0)
Attendance status
 No one in attendance (pregnant woman only)51 (54.8)22 (48.9)29 (60.4)
 Partner in attendance36 (38.7)19 (42.2)17 (35.4)
 Other person in attendance 6 (6.5) 4 (8.9) 2 (4.2)
Stage of the decision process
 Already decided51 (54.8)25 (55.6)26 (54.2)
 Not yet decided42 (45.2)20 (44.4)22 (45.8)
Preferred role in decision-making process
 I want to make the decision by myself21 (22.6)11 (24.4)10 (20.8)
 I want to make the decision by myself after discussion with the doctor51 (54.8)25 (55.6)26 (54.2)
 I want to make the decision together with the medical team18 (19.4) 9 (20.0) 9 (18.8)
 I want the medical team to make the decision after discussion with me 1 (1.1) 0 (0.0) 1 (2.1)
 I want the medical team to make the decision 2 (2.2) 0 (0.0) 2 (4.2)
Outcome of the decision
 I will undergo testing61 (65.6)30 (66.7)31 (64.6)
 I will not undergo testing22 (23.7)10 (22.2)12 (25.0)
 Missing value10 (10.8) 5 (11.1) 5 (10.4)
Type of prenatal testing (includes multiple tests)
 Amniocentesis40 (43.0)18 (40.0)22 (45.8)
 Serum screening test only 6 (6.5) 5 (11.1) 1 (2.1)
 Amniocentesis following serum screening test14 (15.1) 7 (15.6) 7 (14.6)
 Other 2 (2.2) 1 (2.2) 1 (2.1)
 Missing value33 (35.5)15 (33.3)18 (37.5)

The number of women who ultimately decided to undergo prenatal testing was 30/45 from the intervention group (66.7%) and 31/48 from the control group (64.6%). There was no significant difference between the groups in the number of women who chose prenatal testing in the form of amniocentesis: 18 women from the intervention group and 22 women from the control group, giving a total of 40 women (43%).

Although there was no significant difference between the groups in the pre-intervention DCS score, the postintervention DCS score for the intervention group was lower than that of the control group (P = 0.04). There were no significant differences detected between the groups for the pre-intervention and postintervention SE scores.

Primary outcome

Pre-intervention and postintervention changes

As shown in Tables 3 and 4, the pre-intervention change on the Japanese version of the DCS was 2.19 (standard deviation, SD = 0.44) for the intervention group and 2.38 (SD = 0.49) for the control group, indicating no significant difference between the two groups. However, there was a significant difference in the postintervention DCS score, with the intervention group measuring 2.00 (SD = 0.52) and the control group measuring 2.23 (SD = 0.44), indicating a lower level of decisional conflict for the intervention group (P = 0.04).

Table 3.  Mean decisional conflict score (DCS) and self-esteem score measured before and after intervention
CriteriaFactorNo. of itemsPeriodIntervention groupControl groupt-test
NMeanSDNMeanSDt-valued.f.SP (Both sides)Difference in mean valuesStandard margin of errorRange of 95% CI for difference
  • *

    P < 0.05; for self-esteem, the total scores were used. SP, significant probability.

DCSOverall DCS score15Before35 2.190.4433 2.380.49−1.65660.10−0.190.11−0.41–0.04
After38 2.000.5243 2.230.44−2.12790.04*−0.230.11−0.44– −0.01
I: Feeling uninformed about options and unclear about the value of each one 5Before40 1.940.4243 2.190.50−2.52810.01*−0.260.10−0.46– −0.05
After39 1.740.5243 2.000.43−2.46800.02*−0.260.10−0.46– −0.05
II: Perception of the quality of the decision made 3Before35 2.160.6134 2.200.62−0.23670.82−0.030.15−0.33–0.26
After40 1.840.6343 1.990.57−1.18810.24−0.150.13−0.42–0.11
III: Lack of advice about the decision 2Before35 1.940.7037 2.110.69−1.01700.32−0.170.16−0.49–0.16
After39 1.920.7343 2.160.81−1.41800.16−0.240.17−0.58–0.10
IV: Uncertainty 3Before40 3.050.8243 3.140.86−0.48810.63−0.090.19−0.46–0.28
After40 2.680.9143 2.800.81−0.66810.51−0.120.19−0.50–0.25
V: Feeling unsupported by others in the decision-making process 2Before40 2.250.8243 2.470.87−1.16810.25−0.220.19−0.58–0.15
After40 2.160.9243 2.350.90−0.93810.35−0.190.20−0.58–0.21
Self-esteem10Before4037.056.054235.484.61 1.33800.19 1.571.18−0.78–3.93
After4036.985.294335.515.28 1.26810.21 1.461.16−0.85–3.77
Table 4.  Difference in decisional conflict score (DCS) and self-esteem score before and after intervention
VariableIntervention group (OPDG)Control group (Standard counseling)t-test Effect size
NMeanSDNMeanSDt-valued.f.SP (Both sides)Difference in mean valuesStandard margin of errorRange of 95% CI for difference
  1. OPDG, Ottawa Personal Decision Guide; SP, significant probability.

Overall DCS score33−0.200.4533−0.160.36−0.36640.72−0.040.10−0.24–0.16 0.09
Factor I: Feeling uninformed about options and unclear about the value of each one39−0.170.4543−0.190.45 0.22800.83 0.020.10−0.18–0.22−0.05
Factor II: Perception of the quality of the decision made35−0.360.7434−0.190.55−1.12670.27−0.180.16−0.49–0.14 0.27
Factor III: Lack of advice about the decision34−0.030.7137 0.010.58−0.28690.78−0.040.15−0.35–0.26 0.07
Factor IV: Uncertainty40−0.380.9243−0.340.63−0.20810.85−0.030.17−0.38–0.31 0.04
Factor V: Feeling unsupported by others in the decision-making process40−0.090.8843−0.120.86 0.15810.88 0.030.19−0.35–0.41−0.03
Self-esteem40−0.082.5842 0.072.89−0.24800.81−0.140.61−1.35–1.06

There was no significant difference between the two groups for pre-intervention and postintervention changes in the DCS score (intervention group: −0.24 [SD = 0.51]; control group: −0.19 [SD = 0.35]).

When the changes in the DCS score before and after intervention were compared across the two groups according to demographic characteristics, it was evident that intervention made a significant difference to Factor II, the evaluation of the quality of the decision made, for the group of women exhibiting the following characteristics:

  • 1Primiparous (t = −2.4, P = 0.019).
  • 2Multiple risk factors apart from advanced age (t =−2.4, P = 0.023).
  • 3A decision about testing had not yet been made (t =−2.2, P = 0.031).
  • 4An average pre-intervention DCS score = 2.5, indicating a high level of decisional conflict (t = −2.4, P = 0.023).
  • 5The final decision was made in ≤ 13 days (t = 2.01, P = 0.043).

Pre-intervention and postintervention shifts

The number of women for whom there was a drop in the DCS score following intervention was 30 in the intervention group (75%) and 30 in the control group (69.8%), indicating no significant difference between the two groups. Moreover, in the group that recorded a rise in the DCS score, the number of women with high decisional conflict after intervention was five in the intervention group (50%) and five in the control group (38.5%), again indicating no significant difference between the two groups.

Effect size

The effect size was initially estimated at 0.6, but decreased to 0.09. Analysis by factor revealed that Factor II, at 0.27, was the highest of all the factors (range = −0.03–0.09).

Decisional conflict level

For the intervention group, 17 women (44.7%) were identified with mild to high decisional conflict, while 31 (72.1%) women were identified in the control group. The rate of mild to high decisional conflict was significantly lower in the intervention group than in the control group (RR = 0.62, 95%CI = 0.42–0.93; ARR = 0.27, 95%CI = 0.07–0.48; number needed to treat = 3.704) (Table 5).

Table 5.  Comparison of “mild to high decisional conflict” levels between the two groups
StageIntervention group (OPDG)Control group (Standard counseling)%Relative risk95% CIAbsolute risk reduction
N%N95% CI
  1. Decisional Conflict Scale score > 2.0. OPDG, Ottawa Personal Decision Guide.

Before intervention21/3560.023/3369.70.8610.606–1.2230.100−0.129–0.323
After intervention17/3844.731/4372.10.6210.416–0.9250.274 0.066–0.480

Secondary outcome

There was no significant difference between the groups in the pre-intervention and postintervention SE scores (intervention group: −0.01 [SD = 0.26]; control group: −0.01 [SD = 0.29]).

DISCUSSION

Decisional conflict and self-esteem in women who undergo prenatal testing

This study established a postintervention decisional conflict score of 2.0, a similar result to that of O’Connor’s (1999) study of Western women; however, the pre-intervention DCS score of 2.19 was lower than O’Connor’s score of 2.7. In O’Connor’s study, the pre-intervention DCS score was measured prior to any meeting with the obstetrician, whereas in the current study, it was measured after the obstetrician had conducted genetic counseling with the subject. Therefore, it is likely that the decision-making support provided by the obstetrician during counseling helped to lower the subject’s level of pre-intervention decisional conflict.

The changes in decisional conflict before and after the intervention and the changes in the number of women measuring high decisional conflict indicated that there was a drop in the level of decisional conflict at the point of making the final decision about testing, which supports O’Connor and Jacobsen’s (2004) findings.

However, the women who still experienced mild to high decisional conflict, even after having made their final decision (postintervention), comprised nearly half of the intervention group and > 70% of the control group. In particular, a DCS score > 2.5 was recorded both before and after intervention in both groups for Factor IV (uncertainty), which suggests that decisional conflict is ongoing, a finding that supports the results of both O’Connor’s (1999) study and the Japanese study conducted by Aoki and Arimori (2004). Furthermore, in the present study, 23 women overall were found to have an increased level of conflict after intervention (27.7%), a finding that suggests that further research into the demographic characteristics for those particular women is required.

The level of SE of the women in this study was compared with that of the women in a study conducted by Y. Kataoka (unpublished data, 2003), who compared the difference in SE between women who were subjected to domestic violence during pregnancy and those who were not affected by domestic violence during pregnancy. The present study found that the SE of the pregnant women facing decisions about prenatal testing was not as low as that of the women who had suffered domestic violence and were in such a dangerous situation that they were no longer able to make effective decisions. Moreover, there was no significant difference between the present two groups in terms of the level of SE before and after intervention. It remained constant in both groups, from which it can be concluded that the use of decision aids to assist in the decision-making process had no effect on the level of SE in the two groups.

Effectiveness of decision aids

Changes in Decisional Conflict Scale score in both groups

There was no significant difference between the two groups that indicated any change in decisional conflict before and after intervention, although intervention was found to be effective in reducing the rate of mild to high decisional conflict, a result that supports the findings of O’Connor’s (1999) study.

The reason the present study did not find significant evidence for the effectiveness of intervention is considered to be because the nature of the intervention was, in fact, very similar for both groups. In other words, apart from the fourth step (weigh the options) of the Ottawa Personal Decision Guide, the assistance given in each of the other steps (i.e. clarify the decision, identify your role in decision-making, assess your decision-making needs, and plan the next steps) was duplicated in both groups by the obstetrician during genetic counseling and the nurse during follow-up. Further research is required in a study where the control group is given no intervention at all by nurses and pre-decisional conflict is measured prior to any genetic counseling in order to allow a proper comparison with postintervention levels.

Effectiveness of decision aids according to demographic information

The examination of the effectiveness of the decision aid according to the different demographic characteristics of the subjects indicated that there was a significant difference only for Factor II for women with one of five characteristics:

  • 1Primiparous.
  • 2Multiple risk factors apart from advanced age.
  • 3Not yet made a decision about testing.
  • 4An average pre-intervention DCS score = 2.5, indicating a high level of decisional conflict.
  • 5The final decision was made in ≤ 13 days.

This result suggests that future studies should reconsider the eligibility criteria.

Clinical value of the Ottawa Personal Decision Guide

The Ottawa Personal Decision Guide decision aid, presented in leaflet form, was used for the first time in Japan in this study and it is hoped that the use of decision aids will make a significant contribution to establishing uniformity in the quality of decision-making support provided by health-care professionals. Furthermore, by educating health-care clients with regard to the use of patient decision aids as part of the treatment process, their use can be promoted across a broad spectrum of clinical practise in the future.

The Ottawa Personal Decision Guide was useful to women in considering whether or not to undergo prenatal testing, but it could be useful in other social situations, such as seeking employment. The intervention using the guide demonstrated to both clients and health-care staff the role of the nurse in assisting patients to use decision aids.

Limitations and improvements

It is always difficult to measure the effectiveness of care. Apart from better structuring of the process of measuring the DCS score to determine decisional conflict, which would allow a more thorough examination of the effectiveness of decision aids, there is also a need to search for other outcome indicators to achieve more meaningful results in future studies. At the same time, in setting outcome indicators to measure the changes in pre-intervention and postintervention scores, future studies should ensure that the intervention is significantly different for the intervention and control groups and that pre-intervention data is collected prior to any genetic counseling.

Further consideration also must be given to items in the Japanese version of the DCS that cannot be answered prior to intervention and to the problem of the use of the same Japanese adjective for multiple words in English due to its translation from English into Japanese, possibly influencing the answer trend with this scale.

CONCLUSIONS

This study was able to clarify the effect of decision aids on decisional conflict by comparing an intervention group of women interviewed by nurses using the Ottawa Personal Decision Guide with a control group of women who were not exposed to the same decision aid. The results of the study indicated that the guide had no clear effect on decisional conflict, but there was also no evidence of more decisional conflict with the intervention group than the control group and that the use of the guide is harmful. Accordingly, the author concludes that there is no impediment to its clinical application.

ACKNOWLEDGMENTS

I would like to extend my thanks to the women who participated in this study, their families, and all the staff at the hospital where the study was conducted. In addition, I would like to thank Professor Shigeko Horiuchi and Dr Sarah Porter of St Luke’s College of Nursing, Tokyo, Japan, Dr William Holzemer of the University of California, San Francisco, School of Nursing, and Dr Annette O’Connor of the Ottawa Health Research Institute, Canada, for their assistance. This study is part of a research program conducted with the assistance of a Grant-in-Aid for Scientific Research (Category A [1]) for 2000–2003 and a Grant-in-Aid for Scientific Research for ground-breaking research for 2002–2004.

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