New tools for systematic evaluation of teaching qualities of medical faculty: results of an ongoing multi-center survey

Background

Tools for the evaluation, improvement and promotion of the teaching excellence of faculty remain elusive in residency settings. This study investigates (i) the reliability and validity of the data yielded by using two new instruments for evaluating the teaching qualities of medical faculty, (ii) the instruments'' potential for differentiating between faculty, and (iii) the number of residents'' evaluations needed per faculty to reliably use the instruments.

Methods and Materials

Multicenter cross-sectional survey among 546 residents and 629 medical faculty representing 29 medical (non-surgical) specialty training programs in the Netherlands. Two instruments—one completed by residents and one by faculty—for measuring teaching qualities of faculty were developed. Statistical analyses included factor analysis, reliability and validity exploration using standard psychometric methods, calculation of the numbers of residents'' evaluations needed per faculty to achieve reliable assessments and variance components and threshold analyses.

Results

A total of 403 (73.8%) residents completed 3575 evaluations of 570 medical faculty while 494 (78.5%) faculty self-evaluated. In both instruments five composite-scales of faculty teaching qualities were detected with high internal consistency and reliability: learning climate (Cronbach''s alpha of 0.85 for residents'' instrument, 0.71 for self-evaluation instrument, professional attitude and behavior (0.84/0.75), communication of goals (0.90/0.84), evaluation of residents (0.91/0.81), and feedback (0.91/0.85). Faculty tended to evaluate themselves higher than did the residents. Up to a third of the total variance in various teaching qualities can be attributed to between-faculty differences. Some seven residents'' evaluations per faculty are needed for assessments to attain a reliability level of 0.90.

Conclusions

The instruments for evaluating teaching qualities of medical faculty appear to yield reliable and valid data. They are feasible for use in medical residencies, can detect between-faculty differences and supply potentially useful information for improving graduate medical education.     

Good clinical teachers likely to be specialist role models: results from a multicenter cross-sectional survey

Context

Medical educational reform includes enhancing role modelling of clinical teachers. This requires faculty being aware of their role model status and performance. We developed the System for Evaluation of Teaching Qualities (SETQ) to generate individualized feedback on previously defined teaching qualities and role model status for faculty in (non) academic hospitals.

Objectives

(i) To examine whether teaching qualities of faculty were associated with their being seen as a specialist role model by residents, and (ii) to investigate whether those associations differed across residency years and specialties.

Methods & Materials

Cross-sectional questionnaire survey amongst 549 Residents of 36 teaching programs in 15 hospitals in the Netherlands. The main outcome measure was faculty being seen as specialist role models by residents. Statistical analyses included (i) Pearson''s correlation coefficients and (ii) multivariable logistic generalized estimating equations to assess the (adjusted) associations between each of five teaching qualities and ‘being seen as a role model’.

Results

407 residents completed a total of 4123 evaluations of 662 faculty. All teaching qualities were positively correlated with ‘being seen as a role model’ with correlation coefficients ranging from 0.49 for ‘evaluation of residents’ to 0.64 for ‘learning climate’ (P<0.001). Faculty most likely to be seen as good role models were those rated highly on ‘feedback’ (odds ratio 2.91, 95% CI: 2.41–3.51), ‘a professional attitude towards residents’ (OR 2.70, 95% CI: 2.34–3.10) and ‘creating a positive learning climate’ (OR 2.45, 95% CI: 1.97–3.04). Results did not seem to vary much across residency years. The relative strength of associations between teaching qualities and being seen as a role model were more distinct when comparing specialties.

Conclusions

Good clinical educators are more likely to be seen as specialist role models for most residents.     

The teacher, the physician and the person: how faculty's teaching performance influences their role modelling

Objective

Previous studies identified different typologies of role models (as teacher/supervisor, physician and person) and explored which of faculty''s characteristics could distinguish good role models. The aim of this study was to explore how and to which extent clinical faculty''s teaching performance influences residents'' evaluations of faculty''s different role modelling statuses, especially across different specialties.

Methods

In a prospective multicenter multispecialty study of faculty''s teaching performance, we used web-based questionnaires to gather empirical data from residents. The main outcome measures were the different typologies of role modelling. The predictors were faculty''s overall teaching performance and faculty''s teaching performance on specific domains of teaching. The data were analyzed using multilevel regression equations.

Results

In total 219 (69% response rate) residents filled out 2111 questionnaires about 423 (96% response rate) faculty. Faculty''s overall teaching performance influenced all role model typologies (OR: from 8.0 to 166.2). For the specific domains of teaching, overall, all three role model typologies were strongly associated with “professional attitude towards residents” (OR: 3.28 for teacher/supervisor, 2.72 for physician and 7.20 for the person role). Further, the teacher/supervisor role was strongly associated with “feedback” and “learning climate” (OR: 3.23 and 2.70). However, the associations of the specific domains of teaching with faculty''s role modelling varied widely across specialties.

Conclusion

This study suggests that faculty can substantially enhance their role modelling by improving their teaching performance. The amount of influence that the specific domains of teaching have on role modelling differs across specialties.     

Effect of the Learning Climate of Residency Programs on Faculty’s Teaching Performance as Evaluated by Residents

Background

To understand teaching performance of individual faculty, the climate in which residents’ learning takes place, the learning climate, may be important. There is emerging evidence that specific climates do predict specific outcomes. Until now, the effect of learning climate on the performance of the individual faculty who actually do the teaching was unknown.

Objectives

This study: (i) tested the hypothesis that a positive learning climate was associated with better teaching performance of individual faculty as evaluated by residents, and (ii) explored which dimensions of learning climate were associated with faculty’s teaching performance.

Methods and Materials

We conducted two cross-sectional questionnaire surveys amongst residents from 45 residency training programs and multiple specialties in 17 hospitals in the Netherlands. Residents evaluated the teaching performance of individual faculty using the robust System for Evaluating Teaching Qualities (SETQ) and evaluated the learning climate of residency programs using the Dutch Residency Educational Climate Test (D-RECT). The validated D-RECT questionnaire consisted of 11 subscales of learning climate. Main outcome measure was faculty’s overall teaching (SETQ) score. We used multivariable adjusted linear mixed models to estimate the separate associations of overall learning climate and each of its subscales with faculty’s teaching performance.

Results

In total 451 residents completed 3569 SETQ evaluations of 502 faculty. Residents also evaluated the learning climate of 45 residency programs in 17 hospitals in the Netherlands. Overall learning climate was positively associated with faculty’s teaching performance (regression coefficient 0.54, 95% confidence interval: 0.37 to 0.71; P<0.001). Three out of 11 learning climate subscales were substantially associated with better teaching performance: ‘coaching and assessment’, ‘work is adapted to residents’ competence’, and ‘formal education’.

Conclusions

Individual faculty’s teaching performance evaluations are positively affected by better learning climate of residency programs.     

Development and Validation of an Instrument for Measuring the Quality of Teamwork in Teaching Teams in Postgraduate Medical Training (TeamQ)

Background

Teamwork between clinical teachers is a challenge in postgraduate medical training. Although there are several instruments available for measuring teamwork in health care, none of them are appropriate for teaching teams. The aim of this study is to develop an instrument (TeamQ) for measuring teamwork, to investigate its psychometric properties and to explore how clinical teachers assess their teamwork.

Method

To select the items to be included in the TeamQ questionnaire, we conducted a content validation in 2011, using a Delphi procedure in which 40 experts were invited. Next, for pilot testing the preliminary tool, 1446 clinical teachers from 116 teaching teams were requested to complete the TeamQ questionnaire. For data analyses we used statistical strategies: principal component analysis, internal consistency reliability coefficient, and the number of evaluations needed to obtain reliable estimates. Lastly, the median TeamQ scores were calculated for teams to explore the levels of teamwork.

Results

In total, 31 experts participated in the Delphi study. In total, 114 teams participated in the TeamQ pilot. The median team response was 7 evaluations per team. The principal component analysis revealed 11 factors; 8 were included. The reliability coefficients of the TeamQ scales ranged from 0.75 to 0.93. The generalizability analysis revealed that 5 to 7 evaluations were needed to obtain internal reliability coefficients of 0.70. In terms of teamwork, the clinical teachers scored residents'' empowerment as the highest TeamQ scale and feedback culture as the area that would most benefit from improvement.

Conclusions

This study provides initial evidence of the validity of an instrument for measuring teamwork in teaching teams. The high response rates and the low number of evaluations needed for reliably measuring teamwork indicate that TeamQ is feasible for use by teaching teams. Future research could explore the effectiveness of feedback on teamwork in follow up measurements.     

Validation of an Instrument to Measure Older Adults' Expectations Regarding Movement (ERM)

Background

Many individuals with Parkinson''s disease are not diagnosed and treated. Attitudes about aging and related help-seeking may affect the timely diagnosis of Parkinson''s disease. Our objectives were to develop measures of older adults'' expectations regarding movement with aging, specifically related to parkinsonism, and their beliefs about seeking healthcare for the diagnosis and treatment of parkinsonism.

Methods

We established content and face validity from interviews with experts, review of the literature, and pre-testing with key informants. Two 9-item instruments resulted: Expectations Regarding Movement (ERM) and Healthcare Seeking Beliefs for parkinsonism (HSB). These instruments were administered to 210 older adults at senior centers to investigate internal consistency and construct validity.

Results

192 (91%) of the older adults completed more than 90% of the survey. The mean age was 76; 17 (9%) reported parkinsonism. Both scales demonstrated good internal consistency (α = 0.90). Factor analysis supported construct validity of the ERM and HSB scores. Older age, lower education, worse self-reported health and African American race each were associated with lower ERM scores, but not HSB scores.

Conclusion

The ERM, a brief measure of expectations regarding movement with aging, shows reliability and validity. This scale may be useful in identifying older adults at increased risk for under-identification of Parkinson''s disease. Further work is needed to measure healthcare seeking for parkinsonism.     

Reliability and validity of the Ethiopian version of the hospital anxiety and depression scale (HADS) in HIV infected patients

Background

The hospital anxiety and depression scale (HADS) is a widely used instrument for evaluating psychological distress from anxiety and depression. HADS has not yet been validated in Ethiopia. The aim of this study was to evaluate the reliability and validity of the Amharic (Ethiopian language) version of HADs among HIV infected patients.

Methods

The translated scale was administered to 302 HIV/AIDS patients on follow up for and taking anti-retroviral treatment. Consistency assessment was conducted using Cronbach''s alpha, test-retest reliability using intra-class correlation coefficients (ICC). Construct validity was examined using principal components analysis (PCA). Parallel analysis, Kaiser''s criterion and the scree test were used for factor extraction.

Results

The internal consistency was 0.78 for the anxiety, 0.76 for depression subscales and 0.87 for the full scale of HADS. The intra-class correlation coefficient (ICC) was 80%, 86%, and 84% for the anxiety and depression subscales, and total score respectively. PCA revealed a one dimensional scale.

Conclusion

This preliminary validation study of the Ethiopian version of the HADs indicates that it has promising acceptability, reliability and validity. The adopted scale has a single underlying dimension as indicated by Razavi''s model. The HADS can be used to examine psychological distress in HIV infected patients. Findings are discussed and recommendations made.     

Psychometric properties of the Chinese version of the Perceived Stress Scale in policewomen

Background

The 10-item Perceived Stress Scale (PSS-10) is one of most widely used instruments to measure a global level of perceived stress in a range of clinical and research settings. This study was conducted to examine the psychometric properties of the Simplified Chinese version of the PSS-10 in policewomen.

Methodology

A total of 240 policewomen were recruited in this study. The Simplified Chinese versions of the PSS-10, the Beck Depression Inventory Revised (BDI-II), and the Beck Anxiety Inventory (BAI) were administered to all participants, and 36 of the participants were re-tested two weeks after the initial testing.

Principal Findings

The overall Cronbach''s alpha was 0.86, and the test–retest reliability coefficient was 0.68. Exploratory Factor Analysis (EFA) yielded 2 factors with eigenvalues of 4.76 and 1.48, accounting for 62.41% of variance. Factor 1 consisted of 6 items representing “negative feelings”; whereas Factor 2 consisted of 4 items representing “positive feelings”. The item loadings ranged from 0.72 to 0.83. The Confirmatory factor analysis (CFA) indicated a very good fit of this two-factor model to this sample. The PSS-10 significantly correlated with both BDI-II and BAI, indicating an acceptable concurrent validity.

Conclusions

The Simplified Chinese version of the PSS-10 demonstrated adequate psychometric properties for evaluating stress levels. The results support its use among the Chinese population.     

Evaluation of the London Measure of Unplanned Pregnancy in a United States population of women

Objective

To evaluate the reliability and validity of the London Measure of Unplanned Pregnancy (a U.K.-developed measure of pregnancy intention), in English and Spanish translation, in a U.S. population of women.

Methods

A psychometric evaluation study of the London Measure of Unplanned Pregnancy (LMUP), a six-item, self-completion paper measure was conducted with 346 women aged 15–45 who presented to San Francisco General Hospital for termination of pregnancy or antenatal care. Analyses of the two language versions were carried out separately. Reliability (internal consistency) was assessed using Cronbach''s alpha and item-total correlations. Test-retest reliability (stability) was assessed using weighted Kappa. Construct validity was assessed using principal components analysis and hypothesis testing.

Results

Psychometric testing demonstrated that the LMUP was reliable and valid in both U.S. English (alpha = 0.78, all item-total correlations >0.20, weighted Kappa = 0.72, unidimensionality confirmed, hypotheses met) and Spanish translation (alpha = 0.84, all item-total correlations >0.20, weighted Kappa = 0.77, unidimensionality confirmed, hypotheses met).

Conclusion

The LMUP was reliable and valid in U.S. English and Spanish translation and therefore may now be used with U.S. women.     

Vitamin E supplementation increases the attractiveness of males' scent for female European green lizards

Background

In spite that chemoreception is important in sexual selection for many animals, such as reptiles, the mechanisms that confer reliability to chemical signals are relatively unknown. European green lizards (Lacerta viridis) have substantial amounts of α-tocopherol ( = vitamin E) in their femoral secretions. Because vitamin E is metabolically important and can only be attained from the diet, its secretion is assumed to be costly. However, its role in intraspecific communication is unknown.

Methodology/Principal Findings

Here, we experimentally show that male European green lizards that received a dietary supplement of vitamin E increased proportions of vitamin E in their femoral secretions. Furthermore, our experiments revealed that females preferred to use areas scent marked by males with experimentally increased vitamin E levels in their secretions. Finally, female preferences were stronger when vitamin E differences between a pair of males'' secretions were larger.

Conclusions/Significance

Our results demonstrate that female green lizards are able to discriminate between males based on the vitamin E content of the males'' femoral secretions. We suggest that the possible cost of allocating vitamin E to secretions, which might be dependent on male quality, may be a mechanism that confers reliability to scent marks of green lizards and allows their evolution as sexual signals.     

Reliability and validity of simplified Chinese version of Roland-Morris questionnaire in evaluating rural and urban patients with low back pain

Objective

The causes of low back pain in China and Western countries are extremely different. We attempted to analyze the risk factors of low back pain in urban and rural patients under the dual economy with the simplified Chinese version of Roland-Morris disability questionnaire (SC-RMDQ) to demonstrate that SC-RMDQ could evaluate patients with low back pain arising from different causes.

Methods

Roland-Morris disability questionnaire was translated into SCRMDQ according to international guidelines for questionnaire adaptation. In this study, causes of low back pain of 187 outpatients and inpatients (99 urban patients and 88 rural patients) were analyzed. All patients underwent simplified Chinese version of Roland-Morris disability questionnaire (SC-RMDQ), simplified Chinese Oswestry disability index (SCODI) and visual analogue scale (VAS). Reliability was tested using reproducibility (intraclass coefficient of correlation – ICC) and internal consistency (Cronbach''s alpha). Validity was tested using Pearson correlation analysis.

Results

The leading causes for low back pain were sedentariness (38.4%) and vibration (18.1%) in urban patients and waist bending (48.9%) and spraining (25%) in rural patients. Although causes of low back pain in the two groups of population were completely different, SCRMDQ had high internal consistency (Cronbach''s α value of 0.874 in urban patients and 0.883 in rural patients) and good reproducibility (ICC value of .952 in urban patients and 0.949 in rural patients, P<0.01). SCRMDQ also showed significant correlation with Simplified Chinese version of Oswestry disability index (SCODI) and visual analogue scale (VAS) in rural areas (SCRMDQ-SCODI r = 0.841; SCRMDQ -VAS: r = 0.685, P<0.01) and in urban areas (SCRMDQ-SCODI: r = 0.818, P<0.01; SCRMDQ –VAS: r = 0.666, P<0.01).

Conclusions

Although causes of low back pain are completely different in rural and urban patients, SCRMDQ has a good reliability and validity, which is a reliable clinical method to evaluate disability of rural and urban patients.     

Comparison between EQ-5D and SF-6D Utility in Rural Residents of Jiangsu Province, China

Background

The SF-6D and EQ-5D are widely used generic index measures as health-related quality of life. We assessed within-subject agreement between SF-6D and EQ-5D utilities with different preference weights, and their validities in measuring Chinese rural residents, before and after standardization scores.

Methodology/Principal Findings

Rural residents over 18 years old were interviewed using EQ-5D and SF-6D in Jiangsu Province, China. EQ-5D utility-scoring algorithms were used from three conversion tables from the United Kingdom, Japan, and the United States. Validities, Sensitivity and agreement between instruments were computed and compared. Factors affecting utility difference were explored with multiple liner regression models. Scores with standardization intervals of 0–1 in the two instruments were analyzed by the use of the above methods again. In 929 respondents, relative efficiency statistic and receiver operating characteristic curves analysis showed SF-6D to be the more efficient, followed by the EQ-5D model in Japan weights. Bland–Altman plot analysis showed paired SF-6D/EQ-5D in UK weights had better agreement. Though some risk factors were found, multiple liner regression demonstrated most coefficients were weaker than 0.2, and all R² values were less than 0.06. Standardization did not significantly influence these results except scores'' value.

Conclusions/Significance

SF-6D and next EQ-5D in Japan weights could be used for Chinese rural residents. Further research with larger sample size of population is needed to establish and determine the feasibility of standardization score.     

McMaster-Toronto Arthritis Patient Preference Disability Questionnaire sensitivity to change in low back pain: influence of shifts in priorities

Objective

To assess the sensitivity to change of the McMaster Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR) in chronic low back pain (CLBP) and shifts in patients'' priorities of disabling activities over time.

Methods

A prospective longitudinal survey of 100 patients (38 males) with CLBP in a tertiary care teaching hospital. Evaluation at baseline and 6 months by the MACTAR, Quebec Back Pain Disability Questionnaire (QUEBEC), Hospital Anxiety and Depression scale (HAD), Fear-Avoidance Beliefs Questionnaire (FABQ), Coping Strategies Questionnaire (CSQ), and pain and handicap visual analogue scales (VASs). Patients'' perceived improvement or worsening of condition was assessed at 6 months. Effect size (ES) and Standardized response mean (SRM) and effect size (ES) were used to evaluate sensitivity to change of the MACTAR.

Results

The MACTAR SRM and ES values (SRM = 0.25; ES = 0.37) were among the highest for the instruments evaluated. For patients considering their condition as improved, the SRM was 0.66 and the ES 1. The 3 disability domains, classified by the International Classification of Functioning, Disability and Health (ICF), most often cited as priorities at baseline remained the most cited at follow-up: mobility (40.9% of patients); community, social and civic life (22.7%); and domestic life (22.4%). At 6 months, 48 patients shifted their priorities, for a decrease in MACTAR SRM and ES values for patients considering their condition improved and an increase in these values for those considering their condition deteriorated.

Conclusions

Although the MACTAR has similar sensitivity to change as other outcome measures widely used in CLBP, shifts in patient priorities over time are common and influence scores and sensitivity to change.     

Local spatial and temporal processes of influenza in Pennsylvania, USA: 2003-2009

Background

Influenza is a contagious respiratory disease responsible for annual seasonal epidemics in temperate climates. An understanding of how influenza spreads geographically and temporally within regions could result in improved public health prevention programs. The purpose of this study was to summarize the spatial and temporal spread of influenza using data obtained from the Pennsylvania Department of Health''s influenza surveillance system.

Methodology and Findings

We evaluated the spatial and temporal patterns of laboratory-confirmed influenza cases in Pennsylvania, United States from six influenza seasons (2003–2009). Using a test of spatial autocorrelation, local clusters of elevated risk were identified in the South Central region of the state. Multivariable logistic regression indicated that lower monthly precipitation levels during the influenza season (OR = 0.52, 95% CI: 0.28, 0.94), fewer residents over age 64 (OR = 0.27, 95% CI: 0.10, 0.73) and fewer residents with more than a high school education (OR = 0.76, 95% CI: 0.61, 0.95) were significantly associated with membership in this cluster. In addition, time series analysis revealed a temporal lag in the peak timing of the influenza B epidemic compared to the influenza A epidemic.

Conclusions

These findings illustrate a distinct spatial cluster of cases in the South Central region of Pennsylvania. Further examination of the regional transmission dynamics within these clusters may be useful in planning public health influenza prevention programs.     

Personality Traits Affect Teaching Performance of Attending Physicians: Results of a Multi-Center Observational Study

Background

Worldwide, attending physicians train residents to become competent providers of patient care. To assess adequate training, attending physicians are increasingly evaluated on their teaching performance. Research suggests that personality traits affect teaching performance, consistent with studied effects of personality traits on job performance and academic performance in medicine. However, up till date, research in clinical teaching practice did not use quantitative methods and did not account for specialty differences. We empirically studied the relationship of attending physicians'' personality traits with their teaching performance across surgical and non-surgical specialties.

Method

We conducted a survey across surgical and non-surgical specialties in eighteen medical centers in the Netherlands. Residents evaluated attending physicians'' overall teaching performance, as well as the specific domains learning climate, professional attitude, communication, evaluation, and feedback, using the validated 21-item System for Evaluation of Teaching Qualities (SETQ). Attending physicians self-evaluated their personality traits on a 5-point scale using the validated 10-item Big Five Inventory (BFI), yielding the Five Factor model: extraversion, conscientiousness, neuroticism, agreeableness and openness.

Results

Overall, 622 (77%) attending physicians and 549 (68%) residents participated. Extraversion positively related to overall teaching performance (regression coefficient, B: 0.05, 95% CI: 0.01 to 0.10, P = 0.02). Openness was negatively associated with scores on feedback for surgical specialties only (B: −0.10, 95% CI: −0.15 to −0.05, P<0.001) and conscientiousness was positively related to evaluation of residents for non-surgical specialties only (B: 0.13, 95% CI: 0.03 to 0.22, p = 0.01).

Conclusions

Extraverted attending physicians were consistently evaluated as better supervisors. Surgical attending physicians who display high levels of openness were evaluated as less adequate feedback-givers. Non-surgical attending physicians who were conscientious seem to be good at evaluating residents. These insights could contribute to future work on development paths of attending physicians in medical education.     

Changes of adult population health status in China from 2003 to 2008

Objectives

The purpose of this study was to examine the change in health status of China''s adult population between the years of 2003 and 2008 due to rapid economic growth and medical system improvement.

Methods

Data from the third and fourth Chinese national health services surveys covering 141,927 residents in 2003 and 136,371 residents in 2008 who were aged >18 years were analyzed.

Results

Chinese respondents in 2008 were more likely to report disease than in 2003. Smoking slightly decreased among men and women, and regular exercise showed much improvement. Stratified analyses revealed significant subpopulation disparities in rate ratios for 2008/2003 in the presence of chronic disease, with greater increases among women, elderly, the Han nationality, unmarried and widow, illiterate, rural, and regions east of China than other groups.

Conclusions

Chinese adults in 2008 had worse health status than in 2003 in terms of presence of chronic disease. China''s reform of health care will face more complex challenges in coming years from the deteriorating health status in Chinese adults.     

Brief measure for screening complicated grief: reliability and discriminant validity

Background

Complicated grief, which is often under-recognized and under-treated, can lead to substantial impairment in functioning. The Brief Grief Questionnaire (BGQ) is a 5-item self-report or interview instrument for screening complicated grief. Although investigations with help-seeking samples suggest that the BGQ is valid and reliable, it has not been validated in a broader population.

Methodology/Principal Findings

A questionnaire was mailed to a randomly selected sample (n = 5000) residing in one of 4 areas of Japan. The BCQ was examined for responders who were bereaved more than 6 months and less than 10 years (n = 915). Non-specific psychological distress was assessed with the K6 screening scale. Multiple group confirmatory factor analysis supported a uni-dimensional factor structure and the invariance of parameters across gender and age. Cronbach''s alpha was sufficiently high (alpha = .75) to confirm internal consistency. Average Variance Extracted (0.39) was higher than the shared covariance (0.14) between BGQ and K6, suggesting discriminant validity.

Conclusions

The results of this study support the reliability and validity of the BGQ in the Japanese population. Future studies should examine predictive validity by using structured interviews or more detailed scales for complicated grief.