Negative feedback for ALPHA form.

VOL 50: MAY • MAI 2004d Canadian Family Physician • Le Médecin de famille canadien 697

Letters

Corresp ondance

Which test is best?

I

n his letter¹ commenting on the article “Assessing antenatal psychosocial health,”² Dr Taiwo is cor- rect that, for ordinal data, proportions, percentages, and medians are the most appropriate form of data analysis. Th e other consideration is that ordinal data require the use of nonparametric statistics. Th at is what was done in this study.

Mann-Whitney test statistics were used to test for diff erences between medians. Th is is noted in the data analysis section.² For ease of interpreta- tion, the results were reported as means because medians do not mean as much to readers. This should have been noted in the article,² and we thank Dr Taiwo for raising this point.

Another side of this issue is that using Likert scales as ordinal- versus interval-level data is some- what contentious. When several items are included in a scale, as is the case here, most people agree that the data can be considered interval level.

—Janet Bryanton, RN, PHD(CL)

Charlottetown, PEI References

1. Taiwo T. Summarizing ordinal data. What is appropriate? [letter]. Can Fam Physician 2004;50:537.

2. Midmer D, Bryanton J, Brown R. Assessing antenatal psychosocial health. Randomized controlled trial of two versions of the ALPHA form. Can Fam Physician 2004;50:80-7.

Negative feedback for ALPHA form

W

e were interested to read about the eff ective- ness and acceptability of the ALPHA form used in Prince Edward Island in the article¹ by Midmer et al. We were particularly interested that this population tended to prefer the ALPHA self- report. When the Maternity Centre of Hamilton, Ont, opened in September 2001, we began using the ALPHA self-report form for all our patients.

Because of the negative feedback we received from our patients, we had to discontinue its use. Many of

them found this form to be intimidating, intrusive, and threatening. In fact, we had patients refuse to attend our clinic because of this form.

We suspect that this might relate to the diff er- ence in patient populations. Th e PEI population was largely white, married, well educated, and for the most part regular patients of the providers.

In contrast, the Maternity Centre is located in the urban downtown Hamilton core and draws heavily on patients with high psychosocial needs.

A substantial proportion of our patients do not speak English as their fi rst language. In fact, in our patient population we found that almost 40%

of our patients has one or more psychosocial risk factors (single, teenager, substance abuser, recent immigrant, etc). Generally, these patients see our providers for maternity care only and return to their family physicians postpartum.

The ALPHA tool clearly seems useful in the PEI culturally and ethnically homogenous popu- lation. It might have serious limitations in diff er- ent populations (immigrants, refugees, multiracial groups). It would be interesting to see whether our patient population would respond more favourably to the physician-completed form. Research needs to defi ne the best way to incorporate antenatal psy- chosocial history taking in ethnically and socio- economically diverse populations and in diff erent models of care.

—David Price, MD, CCFP

—Elizabeth Shaw, MD, CCFP, FCFP Hamilton, Ont by e-mail Reference

1. Midmer D, Bryanton J, Brown R. Assessing antenatal psychosocial health. Randomized controlled trial of two versions of the ALPHA form. Can Fam Physician 2004;50:80-7.

Response

D

rs Price and Shaw write that the self-report ALPHA form, which was found acceptable to women in PEI, was not favourably received at their

698 Canadian Family Physician • Le Médecin de famille canadien dVOL 50: MAY • MAI 2004

Letters Correspondance

Maternity Centre and that they have discontinued its use. This seems like a very sensible idea, given that they report the women found the form to be

“intimidating, intrusive, and threatening.” I find these descriptors disturbing and wonder whether they came from many different women or from women with similar risk factors, eg, teenagers and substance users.

Drs Price and Shaw also comment, quite cor- rectly, that the population in PEI is very homo- genous. This made it ideal as a research site, yet, as mentioned in the paper, limited the generalizability of study findings.

Historically, the self-report form owes its gen- esis to feedback received during the pilot test of a very early iteration of the provider ALPHA form in Ontario in the early 1990s. Some immi- grant women, less proficient in oral than in writ- ten English, indicated they wanted a self-report version they could complete and return to their health care providers. Some of the prenatal nurses in the pilot study concurred. And some providers wanted self-report forms because of time consid- erations. Consequently, the self-report form was developed to correspond directly to the provider ALPHA, with scaling questions and space for writ- ten comments rather than open-ended interview questions.

It was never suggested or intended that one ver- sion of the ALPHA form be used to the exclusion of the other. Having different versions meant that providers could assess the women in their practice and determine which form was most suitable. It is my experience that many pregnant women crave time with their obstetrical provid-

ers. Using the provider ALPHA, which takes about 20 minutes to complete, is very satisfying for many women and gives them

“quality time” with their caregiv- ers. Providers can assess women and choose one version or offer women both versions and allow them to choose.

I agree that there are rich research possibilities with respect

to the two forms. I am currently involved in a study of the self-report form with substance-using preg- nant women. I am not aware of any adverse reac- tions in this group to the wording of questions on the form. A replication of the PEI study in the Maternity Centre of Hamilton would be inexpen- sive, fairly simple, and ultimately fascinating. I would be happy to work with Drs Price and Shaw to see whether the same results are forthcoming.

—Deana Midmer, MED, EDD Toronto, Ont

Choosing our values

T

he CFPC Committee on Ethics thanks Dr Alan Katz for his thoughtful and compre- hensive letter¹ about our paper Family Practice Concepts and Values: Benchmarks for Health Reform. We would have enjoyed having him working with us on its composition. He pro- foundly appreciates the urgent need to define these issues and work toward their incorpora- tion in the health care plans that will dictate our professional life.

His point that the “Ethical Apgar Score” is an oversimplification in that it gives equal point scores to several major concepts and values with- out grading their weight is well taken. But the scoring system is only a tool for initiating analy- sis and discussion. In the Newborn Apgar Score, is muscle tone really as important as heartbeat or respiration? Yet they are all equally weighted as two points out of 10. The Ethical Apgar Score is a slightly ironic introduction to the more formal discussion offered in our website paper.

It is heartening for all of us to know that there are people out there reading as carefully and thoughtfully as Dr Katz.

—Michael Malus, MDCM, CCFP, FCFP, for the CFPC Committee on Ethics Reference

1. Katz A. Debating the values of family medicine [letter]. Can Fam Physician 2004;50:538-41.