Are there valid proxy measures of clinical behaviour? a systematic review

Background

Accurate measures of health professionals' clinical practice are critically important to guide health policy decisions, as well as for professional self-evaluation and for research-based investigation of clinical practice and process of care. It is often not feasible or ethical to measure behaviour through direct observation, and rigorous behavioural measures are difficult and costly to use. The aim of this review was to identify the current evidence relating to the relationships between proxy measures and direct measures of clinical behaviour. In particular, the accuracy of medical record review, clinician self-reported and patient-reported behaviour was assessed relative to directly observed behaviour.

Methods

We searched: PsycINFO; MEDLINE; EMBASE; CINAHL; Cochrane Central Register of Controlled Trials; science/social science citation index; Current contents (social & behavioural med/clinical med); ISI conference proceedings; and Index to Theses. Inclusion criteria: empirical, quantitative studies; and examining clinical behaviours. An independent, direct measure of behaviour (by standardised patient, other trained observer or by video/audio recording) was considered the 'gold standard' for comparison. Proxy measures of behaviour included: retrospective self-report; patient-report; or chart-review. All titles, abstracts, and full text articles retrieved by electronic searching were screened for inclusion and abstracted independently by two reviewers. Disagreements were resolved by discussion with a third reviewer where necessary.

Results

Fifteen reports originating from 11 studies met the inclusion criteria. The method of direct measurement was by standardised patient in six reports, trained observer in three reports, and audio/video recording in six reports. Multiple proxy measures of behaviour were compared in five of 15 reports. Only four of 15 reports used appropriate statistical methods to compare measures. Some direct measures failed to meet our validity criteria. The accuracy of patient report and chart review as proxy measures varied considerably across a wide range of clinical actions. The evidence for clinician self-report was inconclusive.

Conclusion

Valid measures of clinical behaviour are of fundamental importance to accurately identify gaps in care delivery, improve quality of care, and ultimately to improve patient care. However, the evidence base for three commonly used proxy measures of clinicians' behaviour is very limited. Further research is needed to better establish the methods of development, application, and analysis for a range of both direct and proxy measures of behaviour.     

Social behavioural epistemology and the scientific community

The progress of science is influenced substantially by social behaviour of and social interactions within the scientific community. Similar to innovations in primate groups, the social acceptance of an innovation depends not only upon the relevance of the innovation but also on the social dominance and connectedness of the innovator. There are a number of parallels between many well-known phenomena in behavioural evolution and various behavioural traits observed in the scientific community. It would be useful, therefore, to use principles of behavioural evolution as hypotheses to study the social behaviour of the scientific community. I argue in this paper that a systematic study of social behavioural epistemology is likely to boost the progress of science by addressing several prevalent biases and other problems in scientific communication and by facilitating appropriate acceptance/rejection of novel concepts.     

Effects of personality on territory defence in communication networks: a playback experiment with radio-tagged great tits

Individuals often differ consistently in behaviour across time and contexts, and such consistent behavioural differences are commonly described as personality. Personality can play a central role in social behaviour both in dyadic interactions and in social networks. We investigated whether explorative behaviour, as proxy of personality of territorial male great tits (Parus major), predicts their own and their neighbours'' territorial responses towards simulated intruders. Several weeks prior to playback, subjects were taken from the wild to test their exploratory behaviour in a standard context in the laboratory. Exploratory behaviour provides a proxy of personality along a slow–fast explorer continuum. Upon release, males were radio-tracked and subsequently exposed to interactive playback simulating a more or a less aggressive territorial intruder (by either overlapping or alternating broadcast songs with the subjects'' songs). At the same time, we radio-tracked a neighbour of the playback subject. Male vocal responses during playback and spatial movements after playback varied according to male explorative behaviour and playback treatment. Males with lower exploration scores approached the loudspeaker less, and sang more songs, shorter songs and songs with slower element rates than did males with higher exploration scores. Moreover, neighbour responses were related to the explorative behaviour of the subject receiving the playback but not to their own explorative behaviour. Our overall findings reveal for the first time how personality traits affect resource defence within a communication network providing new insights on the cause of variation in resource defence behaviour.     

How Random Is Social Behaviour? Disentangling Social Complexity through the Study of a Wild House Mouse Population

Out of all the complex phenomena displayed in the behaviour of animal groups, many are thought to be emergent properties of rather simple decisions at the individual level. Some of these phenomena may also be explained by random processes only. Here we investigate to what extent the interaction dynamics of a population of wild house mice (Mus domesticus) in their natural environment can be explained by a simple stochastic model. We first introduce the notion of perceptual landscape, a novel tool used here to describe the utilisation of space by the mouse colony based on the sampling of individuals in discrete locations. We then implement the behavioural assumptions of the perceptual landscape in a multi-agent simulation to verify their accuracy in the reproduction of observed social patterns. We find that many high-level features – with the exception of territoriality – of our behavioural dataset can be accounted for at the population level through the use of this simplified representation. Our findings underline the potential importance of random factors in the apparent complexity of the mice''s social structure. These results resonate in the general context of adaptive behaviour versus elementary environmental interactions.     

Neighbouring chimpanzee communities show different preferences in social grooming behaviour

Grooming handclasp (GHC) behaviour was originally advocated as the first evidence of social culture in chimpanzees owing to the finding that some populations engaged in the behaviour and others do not. To date, however, the validity of this claim and the extent to which this social behaviour varies between groups is unclear. Here, we measured (i) variation, (ii) durability and (iii) expansion of the GHC behaviour in four chimpanzee communities that do not systematically differ in their genetic backgrounds and live in similar ecological environments. Ninety chimpanzees were studied for a total of 1029 h; 1394 GHC bouts were observed between 2010 and 2012. Critically, GHC style (defined by points of bodily contact) could be systematically linked to the chimpanzee''s group identity, showed temporal consistency both within and between groups, and could not be accounted for by the arm-length differential between partners. GHC has been part of the behavioural repertoire of the chimpanzees under study for more than 9 years (surpassing durability criterion) and spread across generations (surpassing expansion criterion). These results strongly indicate that chimpanzees'' social behaviour is not only motivated by innate predispositions and individual inclinations, but may also be partly cultural in nature.     

Phenotypic variability in unicellular organisms: from calcium signalling to social behaviour

Historically, research has focused on the mean and often neglected the variance. However, variability in nature is observable at all scales: among cells within an individual, among individuals within a population and among populations within a species. A fundamental quest in biology now is to find the mechanisms that underlie variability. Here, we investigated behavioural variability in a unique unicellular organism, Physarum polycephalum. We combined experiments and models to show that variability in cell signalling contributes to major differences in behaviour underpinning some aspects of social interactions. First, following thousands of cells under various contexts, we identified distinct behavioural phenotypes: ‘slow–regular–social’, ‘fast–regular–social’ and ‘fast–irregular–asocial’. Second, coupling chemical analysis and behavioural assays we found that calcium signalling is responsible for these behavioural phenotypes. Finally, we show that differences in signalling and behaviour led to alternative social strategies. Our results have considerable implications for our understanding of the emergence of variability in living organisms.     

Not in their genes: Phenotypic flexibility, behavioural traditions and cultural evolution in wild bonnet macaques

Phenotypic flexibility, or the within-genotype, context-dependent, variation in behaviour expressed by single reproductively mature individuals during their lifetimes, often impart a selective advantage to organisms and profoundly influence their survival and reproduction. Another phenomenon apparently not under direct genetic control is behavioural inheritance whereby higher animals are able to acquire information from the behaviour of others by social learning, and, through their own modified behaviour, transmit such information between individuals and across generations. Behavioural information transfer of this nature thus represents another form of inheritance that operates in many animals in tandem with the more basic genetic system. This paper examines the impact that phenotypic flexibility, behavioural inheritance and socially transmitted cultural traditions may have in shaping the structure and dynamics of a primate society — that of the bonnet macaque (Macaca radiata), a primate species endemic to peninsular India. Three principal issues are considered: the role of phenotypic flexibility in shaping social behaviour, the occurrence of individual behavioural traits leading to the establishment of social traditions, and the appearance of cultural evolution amidst such social traditions. Although more prolonged observations are required, these initial findings suggest that phenotypic plasticity, behavioural inheritance and cultural traditions may be much more widespread among primates than have previously been assumed but may have escaped attention due to a preoccupation with genetic inheritance in zoological thinking. This paper is dedicated with admiration and gratitude to the late Dr Raja Ramanna, a man who held all primates in great esteem.     

The Predictive Value of Early Behavioural Assessments in Pet Dogs – A Longitudinal Study from Neonates to Adults

Studies on behavioural development in domestic dogs are of relevance for matching puppies with the right families, identifying predispositions for behavioural problems at an early stage, and predicting suitability for service dog work, police or military service. The literature is, however, inconsistent regarding the predictive value of tests performed during the socialisation period. Additionally, some practitioners use tests with neonates to complement later assessments for selecting puppies as working dogs, but these have not been validated. We here present longitudinal data on a cohort of Border collies, followed up from neonate age until adulthood. A neonate test was conducted with 99 Border collie puppies aged 2–10 days to assess activity, vocalisations when isolated and sucking force. At the age of 40–50 days, 134 puppies (including 93 tested as neonates) were tested in a puppy test at their breeders'' homes. All dogs were adopted as pet dogs and 50 of them participated in a behavioural test at the age of 1.5 to 2 years with their owners. Linear mixed models found little correspondence between individuals'' behaviour in the neonate, puppy and adult test. Exploratory activity was the only behaviour that was significantly correlated between the puppy and the adult test. We conclude that the predictive validity of early tests for predicting specific behavioural traits in adult pet dogs is limited.     

The behavioural diversity of Atlantic cod: insights into variability within and between individuals

Cod (Gadus morhua) are an iconic fish species of cultural, historical and economical significance across the Atlantic and adjacent seas. Among many scholarly investigations, this interest has prompted behavioural research, rendering cod one of the few commercially harvested marine fishes for which behaviour has been studied in a comprehensive manner. In our review of this behavioural work, we examine the variability in cod behaviour across five functional domains: foraging, predation, social interactions, migration and reproduction. Research to date suggests a high level of behavioural sophistication in cod that is underpinned by complex learning strategies and long-term memory. Cod also demonstrate substantial variability in how they respond to different ecological circumstances. Considerable variation is evident both within and between individuals, and in some instances, between populations. There are a number of pathways from which this variation appears to arise, such as asocial and social learning, environmental control of phenotypic plasticity and genetic control, but there are no known examples of behaviours that are purely the result of one of these mechanisms. Behavioural variation is therefore likely to result from a combination of these factors, underscoring the need for a quantitative, multivariate approach to understand behavioural variation in cod.     

The medical student as behavioural psychotherapist.

A group of medical students were randomly selected from a larger group to carry out behaviour therapy under supervision. Ten patients with phobic disorders and two with obsessive-compulsive neurosis were treated, and the results, assessed by ratings of proved reliability, compared favourably with other studies in which psychiatrists or nurses acted as therapists. A questionnaire survey showed that students involved in therapy had a more favourable opinion about this kind of treatment than those receiving only theoretical instruction. The results suggested not only that medical students make good behavioural psychotherapists but also that the subject is a worthwhile training experience which warrants inclusion in the curriculum.     

Annual Review

In recent years, the science teaching community and curriculum developers have emphasised the importance of teaching inquiry and teaching science as inquiry. One way of developing learners' skills for planning and carrying out scientific research is by allowing them to perform independent research, guided by a teacher. It was recently discovered that there are considerable differences between experiments conducted by scientists and those conducted by students, with regard to the cognitive processes that the experimenters go through. Developing inquiry study activities that emphasise authentic inquiry was suggested in order to introduce students to cognitive activity that more closely resembles that of scientific professionals. This article describes the Biomind programme, intended for students of Grades 11 and 12 (ages 16 to 18 years) majoring in biology. The curriculum, developed by biology teachers, enables students to conduct independent research under teacher guidance. The curriculum emphasises the learning process, not just the outcome, and so students must reflect upon the work in progress. Moreover, the Biomind curriculum follows the principles of authentic inquiry. Biomind may improve students' scientific thinking abilities, expand the guidance aspect of teachers' work, and inspire curriculum developers to further emphasise inquiry.     

A multilevel analytical framework for studying cultural evolution in prehistoric hunter–gatherer societies

Over the past decade, a major debate has taken place on the underpinnings of cultural changes in human societies. A growing array of evidence in behavioural and evolutionary biology has revealed that social connectivity among populations and within them affects, and is affected by, culture. Yet the interplay between prehistoric hunter–gatherer social structure and cultural transmission has typically been overlooked. Interestingly, the archaeological record contains large data sets, allowing us to track cultural changes over thousands of years: they thus offer a unique opportunity to shed light on long‐term cultural transmission processes. In this review, we demonstrate how well‐developed methods for social structure analysis can increase our understanding of the selective pressures underlying cumulative culture. We propose a multilevel analytical framework that considers finer aspects of the complex social structure in which regional groups of prehistoric hunter–gatherers were embedded. We put forward predictions of cultural transmission based on local‐ and global‐level network metrics of small‐scale societies and their potential effects on cumulative culture. By bridging the gaps between network science, palaeodemography and cultural evolution, we draw attention to the use of the archaeological record to depict patterns of social interactions and transmission variability. We argue that this new framework will contribute to improving our understanding of social interaction patterns, as well as the contexts in which cultural changes occur. Ultimately, this may provide insights into the evolution of human behaviour.     

Navigating challenges and opportunities of land degradation and sustainable livelihood development in dryland social–ecological systems: a case study from Mexico

Drylands are one of the most diverse yet highly vulnerable social–ecological systems on Earth. Water scarcity has contributed to high levels of heterogeneity, variability and unpredictability, which together have shaped the long coadaptative process of coupling humans and nature. Land degradation and desertification in drylands are some of the largest and most far-reaching global environmental and social change problems, and thus are a daunting challenge for science and society. In this study, we merged the Drylands Development Paradigm, Holling''s adaptive cycle metaphor and resilience theory to assess the challenges and opportunities for livelihood development in the Amapola dryland social–ecological system (DSES), a small isolated village in the semi-arid region of Mexico. After 450 years of local social–ecological evolution, external drivers (neoliberal policies, change in land reform legislation) have become the most dominant force in livelihood development, at the cost of loss of natural and cultural capital and an increasingly dysfunctional landscape. Local DSESs have become increasingly coupled to dynamic larger-scale drivers. Hence, cross-scale connectedness feeds back on and transforms local self-sustaining subsistence farming conditions, causing loss of livelihood resilience and diversification in a globally changing world. Effective efforts to combat desertification and improve livelihood security in DSESs need to consider their cyclical rhythms. Hence, we advocate novel dryland stewardship strategies, which foster adaptive capacity, and continuous evaluation and social learning at all levels. Finally, we call for an effective, flexible and viable policy framework that enhances local biotic and cultural diversity of drylands to transform global drylands into a resilient biome in the context of global environmental and social change.     

The Welfare Consequences and Efficacy of Training Pet Dogs with Remote Electronic Training Collars in Comparison to Reward Based Training

This study investigated the welfare consequences of training dogs in the field with manually operated electronic devices (e-collars). Following a preliminary study on 9 dogs, 63 pet dogs referred for recall related problems were assigned to one of three Groups: Treatment Group A were trained by industry approved trainers using e-collars; Control Group B trained by the same trainers but without use of e-collars; and Group C trained by members of the Association of Pet Dog Trainers, UK again without e-collar stimulation (n = 21 for each Group). Dogs received two 15 minute training sessions per day for 4–5 days. Training sessions were recorded on video for behavioural analysis. Saliva and urine were collected to assay for cortisol over the training period. During preliminary studies there were negative changes in dogs'' behaviour on application of electric stimuli, and elevated cortisol post-stimulation. These dogs had generally experienced high intensity stimuli without pre-warning cues during training. In contrast, in the subsequent larger, controlled study, trainers used lower settings with a pre-warning function and behavioural responses were less marked. Nevertheless, Group A dogs spent significantly more time tense, yawned more often and engaged in less environmental interaction than Group C dogs. There was no difference in urinary corticosteroids between Groups. Salivary cortisol in Group A dogs was not significantly different from that in Group B or Group C, though Group C dogs showed higher measures than Group B throughout sampling. Following training 92% of owners reported improvements in their dog''s referred behaviour, and there was no significant difference in reported efficacy across Groups. Owners of dogs trained using e-collars were less confident of applying the training approach demonstrated. These findings suggest that there is no consistent benefit to be gained from e-collar training but greater welfare concerns compared with positive reward based training.     

What can experience add to early medical education? Consensus survey

Objective To provide a rationale for integrating experience into early medical education (“early experience”).Design Small group discussions to obtain stakeholders'' views. Grounded theory analysis with respondent, internal, and external validation.Setting Problem based, undergraduate medical curriculum that is not vertically integrated.Participants A purposive sample of 64 students, staff, and curriculum leaders from three university medical schools in the United Kingdom.Results Without early experience, the curriculum was socially isolating and divorced from clinical practice. The abruptness of students'' transition to the clinical environment in year 3 generated positive and negative emotions. The rationale for early experience would be to ease the transition; orientate the curriculum towards the social context of practice; make students more confident to approach patients; motivate them; increase their awareness of themselves and others; strengthen, deepen, and contextualise their theoretical knowledge; teach intellectual skills; strengthen learning of behavioural and social sciences; and teach them about the role of health professionals.Conclusion A rationale for early experience would be to strengthen and deepen cognitively, broaden affectively, contextualise, and integrate medical education. This is partly a process of professional socialisation that should start earlier to avoid an abrupt transition. “Experience” can be defined as “authentic human contact in a social or clinical context that enhances learning of health, illness or disease, and the role of the health professional.”     

Infectious disease and sickness behaviour: tumour progression affects interaction patterns and social network structure in wild Tasmanian devils

Infectious diseases, including transmissible cancers, can have a broad range of impacts on host behaviour, particularly in the latter stages of disease progression. However, the difficulty of early diagnoses makes the study of behavioural influences of disease in wild animals a challenging task. Tasmanian devils (Sarcophilus harrisii) are affected by a transmissible cancer, devil facial tumour disease (DFTD), in which tumours are externally visible as they progress. Using telemetry and mark–recapture datasets, we quantify the impacts of cancer progression on the behaviour of wild devils by assessing how interaction patterns within the social network of a population change with increasing tumour load. The progression of DFTD negatively influences devils'' likelihood of interaction within their network. Infected devils were more active within their network late in the mating season, a pattern with repercussions for DFTD transmission. Our study provides a rare opportunity to quantify and understand the behavioural feedbacks of disease in wildlife and how they may affect transmission and population dynamics in general.     

The Impact of Adult Vitamin D Deficiency on Behaviour and Brain Function in Male Sprague-Dawley Rats

Background

Vitamin D deficiency is common in the adult population, and this has been linked to depression and cognitive outcomes in clinical populations. The aim of this study was to investigate the effects of adult vitamin D (AVD) deficiency on behavioural tasks of relevance to neuropsychiatric disorders in male Sprague-Dawley rats.

Methods

Ten-week old male Sprague-Dawley rats were fed a control or vitamin D deficient diet for 6 weeks prior to, and during behavioural testing. We first examined a range of behavioural domains including locomotion, exploration, anxiety, social behaviour, learned helplessness, sensorimotor gating, and nociception. We then assessed locomotor response to the psychomimetic drugs, amphetamine and MK-801. Attention and vigilance were assessed using the 5 choice serial reaction time task (5C-SRT) and the 5 choice continuous performance task (5C-CPT) and, in a separate cohort, working memory was assessed using the delay match to sample (DMTS) task. We also examined excitatory and inhibitory neurotransmitters in prefrontal cortex and striatum.

Results

AVD-deficient rats were deficient in vitamin D₃ (<10 nM) and had normal calcium and phosphate levels after 8–10 weeks on the diet. Overall, AVD deficiency was not associated with an altered phenotype across the range of behavioural domains tested. On the 5C-SRT AVD-deficient rats made more premature responses and more head entries during longer inter-trial intervals (ITI) than control rats. On the 5C-CPT AVD-deficient rats took longer to make false alarm (FA) responses than control rats. AVD-deficient rats had increases in baseline GABA levels and the ratio of DOPAC/HVA within the striatum.

Conclusions

AVD-deficient rats exhibited no major impairments in any of the behavioural domains tested. Impairments in premature responses in AVD-deficient rats may indicate that these animals have specific alterations in striatal systems governing compulsive or reward-seeking behaviour.     

Quality of Life of Medical Students in China: A Study Using the WHOQOL-BREF

Objective

The aim of this study was to assess the quality of life (QOL) of medical students during their medical education and explore the influencing factors of the QOL of students.

Methods

A cross-sectional study was conducted in June 2011. The study population was composed of 1686 medical students in years 1 to 5 at China Medical University. The Chinese version of WHOQOL-BREF instrument was used to assess the QOL of medical students. The reliability and validity of the questionnaire were assessed by Cronbach’s α coefficient and factor analysis respectively. The relationships between QOL and the factors including gender, academic year level, and specialty were examined using t-test or one-way ANOVA followed by Student-Newman–Keuls test. Statistic analysis was performed by SPSS 13.0.

Results

The overall Cronbach’s α coefficient of the WHOQOL-BREF questionnaire was 0.731. The confirmatory factor analysis provided an acceptable fit to a four-factor model in the medical student sample. The scores of different academic years were significantly different in the psychological health and social relations domains (p<0.05). Third year students had the lowest scores in psychological health and social relations domains. The scores of different specialties had significant differences in psychological health and social relations domains (p<0.05). Students from clinical medicine had the highest scores. Gender, interest in the area of study, confidence in career development, hometown location, and physical exercise were significantly associated with the quality of life of students in some domains (p<0.05).

Conclusions

The WHOQOL-BREF was reliable and valid in the assessment of the QOL of Chinese medical students. In order to cope with the influencing factors of the QOL, medical schools should carry out curriculum innovation and give the necessary support for medical students, especially for 3^rd year students.     

Social structure and indirect genetic effects: genetics of social behaviour

The social environment modulates gene expression, physiology, behaviour and patterns of inheritance. For more than 50 years, this concept has been investigated using approaches that include partitioning the social component out of behavioural heritability estimates, studying maternal effects on offspring, and analysing dominance hierarchies. Recent advances have formalized this ‘social environment effect’ by providing a more nuanced approach to the study of social influences on behaviour while recognizing evolutionary implications. Yet, in most of these formulations, the dynamics of social interactions are not accounted for. Also, the reciprocity between individual behaviour and group‐level interactions has been largely ignored. Consistent with evolutionary theory, the principles of social interaction are conserved across a broad range of taxa. While noting parallels in diverse organisms, this review uses Drosophila melanogaster as a case study to revisit what is known about social interaction paradigms. We highlight the benefits of integrating the history and pattern of interactions among individuals for dissecting molecular mechanisms that underlie social modulation of behaviour.     

Behavioural variation in 172 small-scale societies indicates that social learning is the main mode of human adaptation

The behavioural variation among human societies is vast and unmatched in the animal world. It is unclear whether this variation is due to variation in the ecological environment or to differences in cultural traditions. Underlying this debate is a more fundamental question: is the richness of humans’ behavioural repertoire due to non-cultural mechanisms, such as causal reasoning, inventiveness, reaction norms, trial-and-error learning and evoked culture, or is it due to the population-level dynamics of cultural transmission? Here, we measure the relative contribution of environment and cultural history in explaining the behavioural variation of 172 Native American tribes at the time of European contact. We find that the effect of cultural history is typically larger than that of environment. Behaviours also persist over millennia within cultural lineages. This indicates that human behaviour is not predominantly determined by single-generation adaptive responses, contra theories that emphasize non-cultural mechanisms as determinants of human behaviour. Rather, the main mode of human adaptation is social learning mechanisms that operate over multiple generations.