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The Effects Of Feedback On The Communication Of Medical Prescription To Diabetic Patients
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The Effects Of Feedback On The Communication Of Medical Prescription To Diabetic Patients
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This dissertation haB been
microfilmed exactly as received 69“ 19*366
DEACON, Sharon Rae, T942-
THE EFFECTS OF FEEDBACK ON THE
COMMUNICATION OF MEDICAL PRESCRIPTION
TO DIABETIC PATIENTS. [Appendix F, Testing
Booklet not microfilmed at request of School.
Available for consultation at University of
California Library].
University Microfilms, Inc., Ann Arbor, Michigan
This dissertation has been
microfilmed exactly as received 69-19,366
DEACON, Sharon Rae, 1942-
University of Southern California, Ph.D., 1969
Psychology, general
University Microfilms, Inc., Ann Arbor, Michigan
<0 Copyright by
SHARON RAE DEACON
1969
THE EFFECTS , OF FEEDBACK ON THE COMMUNICATION OF
i . * K
MEDICAL PRESCRIPTION TO DIABETIC PATIENTS
by
Sharon Rae Deacon —
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(Psychology)
January 1969
THE GRADUATE SCHOOL
UNIVERSITY PARK
LOS ANGELES, CALIFORNIA 9 0 0 0 7
This dissertation, written by
Sharon Rae Deacon
under the direction of h.JBtX.. Dissertation C om
mittee, and approved by all its members, has
been presented to and accepted by The G radu
ate School, in partial fulfillment of require
ments for the degree of
D O C T O R O F P H I L O S O P H Y
if
Dean
Date J a n . 1 0 , 1 9 6 9
DISSERTATION COMMITTEE
ACKNOWLEDGMENTS
The writer wishes to express her sincere thanks
to Dr. Leona Miller, Associate Professor of Medicine,
University of Southern California Medical School, without
whose assistance and guidance this research would not
have been possible. The experimental phase of the
research was funded by the Professional Staff Association,
Los Angeles County - University of Southern California
Medical Center under project number 2-140. Further
acknowledgment is due to the residents and ward staff
members whose cooperation was so necessary to the study,
and so freely given.
Finally, the writer expresses her special thanks
to Dr. Alfred Jacobs for his encouragement, support,
and good humor from the beginning to the completion of
this dissertation.
ii
TABLE OF CONTENTS
Page
ACKNOWLEDGMENTS.............................. ii
LIST OF TABLES .............................. v
Chapter
I. THE PROBLEM ...................... 1
Introduction
Background of the Problem
Theoretical Framework
Statement of the Problem
II. REVIEW OF THE LITERATURE................ 20
The Concept of Uncertainty
The Concept of Feedback
III. METHODOLOGY........... 39
Subjects
Research Assistant
Materials
Test Booklet
Certainty Scale
Instruction Booklet
Procedure
IV. RESULTS......... 53
Hypothesis I
Hypothesis II
Hypothesis III
Follow-up Data
iii
Chapter Page
V. DISCUSSION............................... 78
Problem and Procedure
Hypothesis I
Hypothesis II
Hypothesis III
Implications for Further Research
Summary
BIBLIOGRAPHY................................... 97
APPENDICES........................................ 110
APPENDIX A. Instructions to the Residents . . . Ill
APPENDIX B. Instructions to the Research
Assistant........................ 113
APPENDIX C. List of Questions on Diabetes . . . 116
APPENDIX D. Dale-Chall Readability Formula . . 134
APPENDIX E. Raw Data . .................... 137
APPENDIX F. Testing Booklet................. 139
iv
LIST OF TABLES
Table Page
1. Changes in Degree of Certainty after First _
and Second Administration............ 48
2. Mean Number of Correct Responses and
Standard Deviation of Scores on Pre- and
Post-Tests............................ 54
3. Analysis of Variance of Pre- and Post-Test
Scores of Subjects in Experimental and
Control Groups........................ 56
4. Analysis of Variance of the Differences
between Pre- and Post-Tests for
Subjects in Experimental and Control
Groups................................ 57
5. Multiple f:-Test Comparing Difference
Score Means for Experimental Group and
Control Groups.......... 58
6. Analysis of Variance of the-Humber of
Correct Post-Test Responses to the 32
Feedback Items for Subjects in Experi
mental and Control Groups............ 60
7. Multiple t-Test Comparing Mean Number of
Correct Post-Test Responses to 32 Feed
back Items for Subjects in Experimental
and Control Groups ............ 61
8. Analysis of Variance of the Number of
Correct Post-Test. Responses to the 16
Previously Correct Feedback Items for
Subjects in Experimental and Control
Groups.................. 63
v
Table Page
9. Multiple t>Test Comparing Mean Humber of
Correct"~Post-Test Responses to 16
Previously Correct Feedback Items for
Subjects in Experimental and Control
Groups . 64
10. Analysis of Variance of the Humber of
Correct Post-Test Responses to the 16
Previously Incorrect Feedback Items for
Subjects in Experimental and Control
Groups................................. 65
11. Multiple t>Test Comparing Mean Humber of
Correct*"Post-Test Responses to 16 Pre
viously Incorrect Feedback Items for
Subjects in Experimental and Control
Groups................................. 67
12. Analysis of Variance of the Humber of
Correct Responses to Post-Test for
Subjects in Experimental and Control
Groups . ............................ 68
13. Multiplex-Test Comparing Humber of Correct
Responses to Post-Test for Subjects in
Experimental and Control Groups .... 69
14. Analysis of Variance of the Humber of
Correct Post-Test Responses for Subjects
in the Post-Test Control Group, and Pre-
Test Responses for All Other Subjects . 71 __
15. Multiple t:-Test Comparing Mean Humber of
Correct~Post-Test Responses for the
Post-Test Control Group with Mean Humber
of Correct Pre-Test Responses for All
Other Subjects...................... . 72
16. Chi-Square Assessing Relationship of
Degree of Uncertainty and Humber of
Items Correct on Post-Test, when
Original Answer Was Correct.......... 74
vi
Table Page
17. Chi-Square Assessing Relationship of
Degree of Uncertainty and Number of
Answers Changed on Post-Test, when
Original Answer Was Incorrect ........ 76
18. Dale-Chall Readability Formula Applied to
60 Questions on a Diabetic's Self-Care
Program........................... . 135
19. Dale-Chall Readability Formula Applied to
60 Questions on a Diabetic's Self-Care
Program while Excluding the Words
“Urine" and "Diabetes"/"Diabetic" . . . 136
20. Raw Data: Number of Correct Responses on
Pre- and Post-Test of Subjects' Knowl
edge of Diabetic's Self-Care Program . . 138
vii
CHAPTER I
THE PROBLEM
Introduction
This investigation studied the communication .
process in the context of an information theory framework
and, more specifically, the physician-patient communica
tion system in a medical setting. In the typical
physician-patient communication system the physician
transmits information about medical prescription to the
patient, but receives little or no feedback from the
patient regarding the accuracy of the patient's interpre
tations of his medical prescription. The physician
therefore has a limited opportunity to assess or correct
the messages which have been erroneously decoded or__^ .
received by the patient. This lack of a feedback loop
between physician and patient is a frequently-reported
source of interference in effective physician-patient
communication. Providing patients with feedback should
enable them to verify the accuracy of their interpreta-
1
2
tions of the information transmitted, thereby increasing
the accuracy in communication of medical prescription.
The goal of communication from a physician to a
patient is adequate reception of a maximum amount of
information by the patient. When transposed to a communi
cation system frame of reference, information is maximized
when the amount of uncertainty reduced by feedback is
maximized. It has therefore been further predicted that
feedback is more informative the more uncertainty it
reduces. The effects of informative feedback will vary
with the reinforcing qualities of the feedback. Positive
feedback on a response high in uncertainty will increase
the probability of recurrence of that response more than
positive feedback on a response low in uncertainty.
Conversely, negative feedback on a response low in uncer
tainty will lead to greater avoidance of that response
than negative feedback on a response high in uncertainty.
Support for both predictions can be found in the experi
mental literature. The second prediction has been tested
only under the condition where the amount of uncertainty
has been experimentally manipulated.
In the present study, diabetic patients were given
informative feedback relevant to a diabetic's self-care
program. The feedback given patients was systematically
varied and the data were analyzed in a manner designed to
assess the effects of feedback on four types of patient
responses. Informative feedback was given to diabetic
patients on items which the patients had previously
answered correctly and had also expressed a high amount
of certainty that their response was correct; on items
which were correct and with low expressed certainty; on
items which were incorrect and with high expressed cer
tainty as to the correctness of the response; and on
items which were incorrect and with low expressed cer
tainty.
Background of the Problem
Communication between physician and patient is
usually crucial to the success of a treatment program.
Communication of information from the patient is necessary
in order to enable the physician to diagnose and prescribe
treatment. Communication of information from the physi
cian to the patient is necessary to enable the patient to
follow the prescriptions of the physician. The published
opinion of the medical profession is that physicians and
patients do not communicate effectively.
Both the physician and the patient deplore this
lack of communication. Gee (1960) polled 50 per cent of
the medical school graduates of 1950 who were practicing
medicine in 1960. Forty-two per cent of the physicians
responding revealed the sentiment that the most deficient
experience in medical school was the practical experience
in physician-patient relationships. Skipper (1963) inter
viewed 86 hospitalized patients and concluded that the
patients considered communication extremely important.
Furthermore, the patients' most frequent criticism of
their medical care was the "poor explanation" provided.
Physicians most often place the blame for poor communica
tion on the patient (see Geib [1962], Moser [1964], Ort
[1964], Pollitzer [1963], Van Dellen [1963]). They report
such patient shortcomings as not listening, being anxious
and not understanding. The problem does appear to be two
fold for, as Ley (1966) summarizes, "investigations have
shown that from 29 to 65 per cent of patients are not
satisfied with the information given them. . . . Somewhere
between 20 and 52 per cent of patients fail to follow the
advice given" (p. 69).
Objective measurement of the patient's understand
ing of the information presented has occurred infrequently
and usually in the study of ward teaching rounds. Romano
(1941) interviewed 100 patients before and after rounds.
More than one half of the patients stated that they had
understood the essential substance of the discussion.
A much smaller number of patients were able to produce
objective evidence of such understanding and, in fact,
there was considerable misinterpretation. Hayes (1960),
Preuss (1958), Sapolsky (1965), and Sell (1960) similarly
report a considerable amount of misunderstanding on the
part of patients regarding the physician's communications,
and, as Hayes (1960) concludes:
As soon as possible after the examination of a
patient a member of the house staff should return
to the bedside, answer any questions, correct mis
interpretations and, if necessary, translate what
transpired in terms that the patient can understand
(p. 1307).
Beaser (1956) reports an effort to assess the
diabetic patient's knowledge of his disease. In 1952, the
Subcommittee on patient education of the Diabetes Community
Services of Boston questioned 238 diabetics. Ten multiple
choice questions were used which gave a representative
though not complete survey of the patient's knowledge.
"Results showed that all were distinctively deficient in
knowledge of their disease" (p. 168).
A consistent shortcoming of all findings is the
complete lack of statistical data. The statements by
Romano (1941) that "a much smaller number" (p. 666)
1
demonstrated understanding and by Beaser (1956) that the
patients were "distinctively deficient in knowledge"
(p. 147) limit potential comparisons between groups and
programs. Universal agreement exists that effective
physician-patient communication is lacking in spite of
the lack of quantification of results.
Most writers contend that the improvement of com
munication is the responsibility of the physician.
Pollitzer (1963) states that the physician does not tell
his listener what the patient is ready and anxious to
hear. He concludes that communication between physician
and patient is a two-way street, but that the physician
is the only one to walk it. Moser (1964) asserts that
the physician is capable of and responsible for the com
munication v .th patients. Van Dellen (1963) emphasizes
that the patient should be educated in some degree. The
physician should provide a correction of facts to elimi
nate misconceptions and should give information in
understandable terms.
u
Few experimental studies deal with physician-patient
communication in spite of the concern about physician-
patient communication in the literature. The existing
investigations have supported the contention that the
patient benefits from increased communication. For
example, Wessler and Silberg (1953) and Edwards, McAdams
and Crane (1953) have shown the striking importance of
self-care in preventing or postponing necrosis and infec
tion of the legs in diabetic patients and even in those
diabetics with advanced peripheral vascular disease.
Janis (1958) has shown that patients who were
given information about their operations before the pro
cedure remembered the operation and its sequelae more
favorably than those who were not so well informed.
Nahum (1964) reports that the knowledge of what is about
to happen in operations creates greater calmness in
patients, in contrast to the results obtained from a
control group denied such knowledge.
Egbert (1963) reports that patients who had been
informed by an anesthetist before an operation about the
events which were to occur on the day of operation and
about the anesthetic to be administered were not drowsy
and were more likely to be calm on the day of operation.
The study involved 449 patients and compared two types of
pre-operative visit (supportive and informative) with the
value of sodium pentobarbital. Egbert reports that it was
not possible to keep the pre-operative visits distinctly
supportive or informative. If a patient sought informa
tion in the supportive situation, the physician felt
obligated to provide it, and if the patient appeared to
be in need of support in the informative situation, the
physician was supportive.- In consequence, significant
differences between the two types of pre-operative visits
were not found.
Egbert (1964) in a second study has shown that
pre-operative information and education has had vital
effects upon the amount of post-operative care and medi
cine needed by patients. Fifty-one patients were not told
about post-operative pain (C Group). Forty-six patients
in the "special care group" were told about the pain and
what could be done about it. Providing patients with pre
operative education resulted in the patients needing less
morphine, manifesting less anxiety, and leaving the
hospital, on the average, two and one-half days earlier.
Egbert's studies support the general proposition that
Information Is useful to the patient, but have confounded
other variables with Information. In the first study
Egbert was unable to separate the effects of giving
Information from those of supportive behavior toward the
patient. In tjhe second study he did not even attempt to
distinguish supportive behavior from information. Further,
the experimental group had information about what to do
about the pain, whereas this information was not available
to the control subjects.
Programmed learning is an expanding area of
interest which may be destined to have a major impact on
physician-patient communication. Programmed instruction
has been initiated with diabetic patients. McDonald and
Kaufman (1963), Skiff (1965), and Spiegel (1965) have all
reported on the development of "Taking Care of Diabetes,"
the first program designed for diabetic patients. Of the
184 patients invited to participate in this initial
investigation, 40 per cent did not complete all the pro
cedures. The results, reported for those who completed
the program, indicated that 77 per cent showed some gain
10
In Information. Unfortunately, there is no Indication
of the amount of Information gain or If the results were
significant.
Other articles which discuss the "Taking Care of
Diabetes Program" and Its value to the diabetic patient
are Kaufinan (1964) , Kaufman (1965) , and Meadows (1965) .
The program has been used at St. Frances Hospital in
Peoria, Illinois; Slnal Hospital, Baltimore; and Mobile
Infirmary, Alabama. The program has been praised highly
though not adequately evaluated in all three instances.
The program has been criticized for its length (it takes
several hours to complete) , and because patients with
insufficient reading ability, inadequate vision, or other
physical incapacities cannot utilize the teaching machine
without assistance. Donald Etzweler (1965) has proposed
a systematic evaluation of the "Taking Care of Diabetes
Program" but the results have not yet been published.
In summary, there seems to be a published consensus
that physician-patient communication is poor; that often
the fault lies with the patient and that responsibility
for improving communication lies with the physician.
Although the work of such investigators as Janis (1958)
11
and Egbert (1963, 1964) establishes that some information
is better than no information, only in the field of pro
grammed learning have the studies dealt directly with the
problem of improving communication.
Theoretical Framework
It may be useful to conceptualize as a communica
tion breakdown those instances where the information
received by the patient is minimal or misinformative,
whatever idiosyncracies of the physician or the patient
or the physician-patient relationship may be responsible
for the inadequate communication. Modifications of the
technical form of the communication, as derived from
communication theory, are perhaps most readily attainable
as well as most likely to generate improvement in communi
cation between the physician and his patient.
The formal development of Communication Theory may
be dated from the publication of Shannon's Mathematical
Theory of Communication in 1949. Shannon's diagramatic
approach to and mathematical model of communication were
a culmination of the efforts of many contributors.
Shannon himself credits the work of Nyquist (1928) and
12
Hartley (1928) for providing a basis for his mathematical
model and the general diagramatic approach had been pre
viously used by such theorists as Bott (1930) and
Scripture (1931) .
David Middleton (1965) , in Topics in Communication
Theory. succinctly expresses the essence of Shannon's
communication theory which conceptualizes communication
as.a process involving the transmission of information
between a single source and a single receiver: "Informa-
/ •
tion is used here in the technical sense of different
degrees of certainty and uncertainty, and not necessarily
in the broader sense of information as meaning" (p. 1).
Information Theory provides a framework for dis
cussing a communication system in which the amount of
information transmitted in a message is determined by the
amount of uncertainty that the message reduces. Measures
of uncertainty can be applied whenever we have an event
selected from a set of alternative, mutually exclusive
events, with a probability assigned to each of them. In
the diagramatic approach utilized by Shannon, there is not
only a certain degree of uncertainty about what will be
received at the output end of the communication channel
13
but there is also a degree o£ uncertainty about what went
into the input. In a perfect communications system there
will be a one-to-one correspondence between input and
output. In psychology, the two events which correspond
to the input and output of a communication channel are
the stimulus and response. It has been demonstrated
abundantly (Miller, 1956, and Broadbent, 1958) that the
response is affected by the probability of occurrence of
a stimulus. The degree of uncertainty at the input end
(stimulus) therefore affects the degree of uncertainty
at the output end (response).
One difficulty with applying Information Theory to
psychological data is the necessary shift in the measure-
i
ment of uncertainty. In application of Shannon's work,
the uncertainty measure has two properties. It reaches
a maximum when all the probabilities of occurrence are
equal and when the probabilities are equal it increases
with the number of alternative classes to which the
signal would belong. These quantities are objectively
measured by the communication engineer. The psychologist,
on the other hand, is often dependent on subjective proba
bility. The subjective probability of an event is the
strength of the subject's expectation that an event will
14
occur. The relationship between objective and subjective
probability is complex and cannot be reduced to a simple
formula of correspondence, but linear relationships have
- 'J
been found by Philip (1947), Sheford (1959), Stevens (1957),
Toda (1951), and Toda (1955). Recognizing the statistical
distinction between objective and subjective probability,
it has been possible to broaden the application of
Information Theory. This has been done most notably by
Berlyne (1960) in his work on conflict, arousal and
curiosity.
A concept which has had a profound effect on
communication theory and behavior theory in general is
that of feedback. Credit is given by Wiener (1948) and/or
Ashby (1956) for its present conceptualization. It is
defined as the alteration of a system's input by its
output and implies a closed system feedback loop. In
Wiener’s (1948) terms, learning is in its essence a form
of feedback. The feedback principle means that behavior
is scanned for its result and that the success or failure
of result modifies future behavior. The feedback concept
is an integral part of communication theory and is utilized
by information theorists as the major mechanism for
improving communication.
Statement of the Problem
The communicative process between the physician
and patient can be described within the Information Theory
framework. The physician transmits certain messages and
the patient receives and acts upon them. Typically lacking
from physician-patient communication is an opportunity for
the physician to evaluate the accuracy of reception of his
messages by the patient in order that he may correct
inaccuracies with additional feedback. Seldom is the
patient informed of the accuracy of his interpretations
and actions. The need for feedback was essentially what
Hayes (1960), Preuss (1958), Sapolsky (1965), and Sell
(1960) were suggesting when they recommended that clarifi
cation and re interpretation be made to the patient follow
ing ward rounds. It is therefore hypothesized that
informative feedback to the patient will increase the
accuracy in communication of medical prescription. More
specifically, however, communication theory defines
information in terms of uncertainty. It can be deduced
that feedback which reduces a high degree of uncertainty
contains more information than feedback which reduces a
small amount or no uncertainty. In terms of the present
16
study, feedback to the patient on responses which he
indicates are highly uncertain will contain more informa
tion and thus enhance communication more than feedback
on responses of which the patient is certain. It is
therefore hypothesized that feedback on responses high in
uncertainty is more informative than feedback on responses
low in uncertainty.
The reinforcement qualities of feedback must also
be taken into account, in addition to a consideration of
its informative aspects. Feedback which informs the sub
ject that his previous response was correct is positively
reinforcing. Feedback which indicates that the subject's
response is incorrect is negatively reinforcing. In
consequence, the second hypothesis may be refined in order
to take cognizance of the distinction between the rein
forcing and informat ion- communicating qualities of feed-
back. That is, positive feedback on a response high in
uncertainty should increase the probability of that
response more than positive feedback on a response low
in uncertainty. Conversely, negative feedback on a
response low in uncertainty should lead to greater avoid
ance of that response than negative feedback on a response
17
high in uncertainty.
These hypotheses were tested at Los Angeles County -
University of Southern California Medical Center using
80 diabetic patients as subjects. , There were three con
trol groups and one experimental group with 20 subjects in
each. The design of the study was as follows:
The Post-Test Control Group assessed the amount of
learning provided by the general hospital experience:
the doctor, nursing staff, etc. A post-test, in a recall
format, was administered to measure the subject's knowl
edge of a diabetic's self-care program.
The Pre- and Post-Test Control Group assessed the
amount of learning provided by exposure to the pre-test
procedure and the consequent effects of practice and of
alerting the subject as to the information to be obtained.
The 20 subjects in this group received a pre-test and 36
hours later a post-test, both tests requiring recall of
the subject's medical prescription.
The Instruction Booklet Control Group assessed the
amount of learning provided by exposure to an instruction
booklet which was administered to the subjects. Patients
18
In this group were given the pre-test, two administrations
of the instruction booklet, and a post-test. The instruc
tion booklet contained 32 multiple choice questions. No
feedback was inserted into this booklet, although the
items to be included were determined in the same manner
as for the Experimental Group.
The Experimental Group received the same number of
trials as the Instruction Booklet Control Group, but the
groups "differed in that the instruction booklet for the
experimental subjects included informative feedback in the
form of a statement of the correct responses printed on
the page immediately following each question. The instruc
tion booklet contained 32 items, 8 of which the subject
had initially answered correctly and with high certainty,
8 of which were initially correct and with low certainty,
8 of which were initially incorrect and with high certain
ty as to the correctness of the response, and 8 of which
were incorrect and with low certainty.
The first hypothesis, that informative feedback to
the patient will increase the accuracy in communication
of medical prescription, leads to the prediction that the
subjects in the Experimental Group will learn significantly
19
more Information about their medical prescription than
subjects in the three control groups.
The second and third hypotheses are relevant only
to the Experimental Group and the predicted differential
effects of informative feedback on the four types of items
in the instruction booklet. It is predicted that there
will be more correct responses among those items which
were initially correct and low in certainty than among
those items which were initially correct and high in cer
tainty. This follows from the second hypothesis which
states that more information was provided by the feedback
on items which were low in certainty. For the items which
were previously incorrect, the prediction based on the
third hypothesis is that, following informative feedback,
there will be more avoidance of responses which were
>
initially incorrect and highly certain than avoidance
of responses which were initially incorrect and low in
the subject's certainty of the correctness of his response.
CHAPTER II
REVIEW OF THE LITERATURE
The Concept of Uncertainty
A review of the literature on the concept of
uncertainty reveals little experimental work. It has been
long recognized by the layman that some people are more
"self confident" than others. Personality theorists have
also speculated regarding the existence of a general
character trait of confidence of judgments or decisions.
As early as 1892, Fullerton and Cattell (1892) experi
mentally demonstrated that some observers are not confi
dent unless they are right, while others are often
confident when they are wrong.
A number of studies have addressed themselves to
the relationship between confidence of judgments and
correctness of responses. Peirce and Jastrow (1884)
reported that judgments of confidence were positively
related to the difference between two stimuli (lifted
weights) rather than the correctness of the responses.
20
21
Similar findings have been reported by Griffing (1895),
Hemmen (1911) , and Strong (1912) . Obrink (1963) tested
adult subjects on tasks of visual and auditory perception,
memory, attention, recognition and ability to draw conclu
sions and multiply; he also tested primary school children
with visual space discrimination and memory span tests.
Obrink found that the amount of confidence of correctness
reported by subjects for correct responses was highly
correlated with the certainty of correctness reported for
incorrect responses. Individuals who were confident when
right were confident when wrong. A subject's degree of
confidence changed only slightly for short intervals but
increased with intervals of time. Individual differences
in degree of confidence were striking, however, particu
larly in the range of moderately difficult test items.
No sex differences in confidence judgments were found.
Adults were decidedly less confident. Obrink concluded
that there was very little relationship between the
absolute achievement of the subjects and their level of
confidence.
Willingham (1958) reports findings similar to
Obrink'8, that is, the subjects who expressed frequent
judgments of confidence of their correctness when making
22
correct responses also expressed such judgments fre
quently when responding incorrectly. Willingham concluded
that confidence varies as a function of the distance
between the two stimuli on the psychological scale and is
independent of correctness, a conclusion very similar to
that reported by Peirce and Jastrow (1884).
An empirical fact is that the individual who
expresses a higher degree of confidence about the correct
ness of his response is no more likely to be right than
the individual who is unconfident. It is also true,
however, that answers given a high degree of confidence
of correctness are more likely to be accurate than items
not so judged.
Hollingworth (1913) analyzed the relationship
between correctness and extent of confidence of correct
ness of response with a 4 point scale ranging from "per
fectly confident" (A) to "mere guess" (D) and reports that
98 per cent of the "AM items were correct, 81 per cent of
the "B" responses, 77 per cent of the "C", and 59 per cent
of the "D" items. He also reports in a second experiment
using the same scale that the percentages were: A-92%,
B-73%, C-63%, and D-60%. Hemmon (1911) used the scale
23
on a different task and obtained the following results:
A-91%, B-75%, C-59%, D-41%. Trow (1923) in an experiment
involving 12 tasks obtained the following percentages:
A-90%, B-75%, C-60%, D-50%. It is evident that in spite
of the large individual differences in the use of a confi
dence scale, a high relationship exists for a group of
subjects between correctness and confidence of correctness.
The above material implies a belief on the part of
• i
investigators that a general trait of confidence exists.
The data collected to date, however, do not support the
assumption of a general trait of confidence in individuals.
Trow (1923) in his extensive study on the concept of confi
dence reports testing 42 subjects on 16 tests calling for
20 judgments upon which each subject's confidence was
obtained. Line discrimination, weight discrimination,
and memory span for digits are examples of the 12 tests
which could be scored in an objective manner. Ethical
judgments, causal judgments, belief, and judging of
poetry were the 4 tests which required subjective responses
and the subject's confidence in his responses. Trow
concluded that there was little relationship between
amount of confidence expressed by subjects on the objec
tive and subjective tasks. Trow concluded further that
24
the range of each subject's confidence on the different
tests was so great that no general trait of confidence
was observed. On the average, the difference between a
subject's highest and lowest ranking as to confidence in
the 16 tests was 32 ranks out of a possible difference of
41. The lowest range was 22 ranks and two subjects had
the highest possible range.
Wolff (1953) attempted to determine whether uncer
tainty is a behavioral phenomenon based on past experience
or a more general personality construct by obtaining the
subjective report of subject's certainty as well as an
objective behavioral measure in terms of the.amount of
information requested by the subject. He obtained no
significant correlation between the certainty measures on
five tasks and concluded that one's statement of certainty
and one's request for further information were both
related to the specific task performed.
If certainty is a task-determined trait, what are the
variables which determine or affect degree of certainty?
Lotsof (1959) attempted to demonstrate that one's verbal
statement of certainty was determined by past experience.
He individually tested nine groups of 10 subjects each.
25
Every subject was asked to guess which of two lights
would appear. The subjects indicated their choice by
pressing a button. The subject was then told whether he
was correct. "Correctness" was experimentally manipulated
so that the nine groups were given different amounts of
positive reinforcement. He informed subjects in Group I
that their responses were correct 16 per cent of the time;
subjects in Group IX received positive reinforcement 83
per cent of the time; and the remaining groups were rein
forced at intermediate levels within the range from 16 to
83 per cent. Analysis of the data revealed significant
differences in certainty of responses among the groups
and a strong association (correlation .93, p < .01)
between frequency of reinforcement and certainty of
response. Lotsof;'s results are in keeping with the
hypothesis that the higher the expectancy for success
the greater the amount of certainty ascribed to the
verbal response.
There has been at least two attempts to study the
personality of the highly confident individual in spite of
the data which seem to militate against the idea of confi
dence as a general personality trait. Calvin et al.
(1950) separated 90 subjects into those who were high and
those who were low in their certainty of prediction of
which light would follow a buzzer. He then analyzed the
TAT responses of subjects but found no significant differ
ences. Griffith (1958) pointed out that two types of
individuals, as defined by responses on the MMPI, could
be expected to vary systematically in the trait of confi
dence. Psychasthenic individuals are said to be marked
by vacillation, excessive doubt, worry, lack of confi
dence, and mild depression (see Hathaway and McKinley,
1951, p. 20, and Welsh and Dahlstrom, 1956, p. 81).
Hypomanic individuals, on the other hand, are said to be
active, enthusiastic, confident, aggressive and expansive
(see Hathaway and McKinley, 1951, p. 21, and Welsh and
Dahlstrom, 1956, p. 167). Specifically, Griffith
hypothesized that individuals with a psychasthenic pro
file would give significantly more doubtful judgments
than individuals with a hypomanic profile in a psycho
physical weight discrimination experiment. Furthermore,
individuals with dull profiles (between 30 and 60 only)
would be intermediate between these two. The results
supported the above hypothesis at the .05 level.
27
Whereas the above research has tended to show that
one's uncertainty is based on one's past experience,
there has also been an attempt to show that one's
response to a situation is influenced by one's certainty.
Postman, Jenkins, and Postman (1948) experimentally
compared recall and recognition and found that there are
more correct responses made in recognition than in recall.
David (1961) comments that Postman's results are predict
able from Information Theory because recognition involves
a finite number of choices, whereas recall involves an
unknown number. Davis devised a study using combinations
of numbers and letters, which supported the assumption
that the number of choices was functionally related to
the number of correct responses. Wiegand (1963) has also
shown that by manipulating stimulus certainty one can
alter the subject's ability to respond. Three studies
were performed to investigate the relationship between
stimulus uncertainty and simple reaction time, joint
stimulus response uncertainty and choice reaction time
and uncertainty in a complex information task and reac
tion time. In all three situations a linear relation
was found.
28
Another area of concern in the literature is that
of developing a scale to measure uncertainty, or merely
to determine if it can be reliably, scaled.
Foley (1959) observed that subjects in predicting
which of two stimuli would come next would respond some
times with "I think," "I am sure," etc. Foley decided to
evaluate the differences in meaning for these words. He
gave 38 subjects the following questionnaire:
Assuming the probability that an event X will
occur can be assigned a value ranging from 1
(X will not occur) to 10 (X will occur) . What value
would you assign to the following statements:
I am sure X will occur, I suppose X will occur,
T am certain X will occur, I think X will occur,
I am positive X will occur, (p. 614)
Foley found these words to connote different degrees of
subjective uncertainty and in the following order:
suppose, think, sure, certain, positive. Berry (1960)
replicated Foley's work with 162 men and women students
and concluded: .
The present data not only substantiate Foley's
ordering of subjective probabilities, but offer
evidence that the ordering is stable over a
variety of conditions and subjects, (p. 640)
Adams (1957, 1958) reports two studies in which
he taught subjects, by giving informative feedback, to
make their confidence judgments conform to their
performance. In the first study (1957), subjects were
asked to identify words flashed on a tachistoscope and
to indicate on a scale from 0 to 100 the probability of
correctness. The material provided the subjects explained
that an estimated probability of 10 per cent meant that
the subject expected his response to be correct 10 per
cent of the time. Feedback was not given as to the cor
rectness of any individual response but as to the correct
ness of the subject's confidence scale. Subjects improved
significantly both in seeing the words correctly and in
confidence judgments. Adams (1958) replicated this find
ing in another experiment where the task was stating
whether a pair of words were synonyms, antonyms, or
unrelated.
These are two experimental studies in the litera
ture which deal directly with the area of uncertainty
and the value of informative feedback. The fact that
uncertainty is experimentally induced is the most impor
tant distinction between these two studies and the present
work.
Shelly (1961) reports three experiments based upon
a paired associates paradigm. Switch pulling and visual
figure (angles) were paired. The task for the subject was
30
to learn which switch to pull when shown a visual figure.
A lamp would light in front of the correct switch after
they had responded. In the experimental situation the
amount of information or conversely the amount of noise
was varied by changing the number of "noisy events."
That is, sometimes more than one lamp would come on.
Shelly concluded that the prediction that noise reduces
initial learning rate proportionately to the amount of
noise can serve as a first approximation. In some
experimental groups there were four alternative switches,
in others eight. Shelly found consistent differences
between the effects of noise in the four and eight
alternative conditions. It was more effective in depress
ing performance in the four alternative condition. In __
essence, Shelly had manipulated the subject's uncertainty
by changing the number of "noisy events" and found, as
Information Theory would predict, a decrease in per
formance .
Mosel (1961) directly tested the hypothesis that
the greater the subject's uncertainty concerning his
response the greater the amount of information contained
in knowledge of results. Mosel also used the paired
31
associates paradigm. He defined uncertainty In terms
of the number of available responses. Mosel used two
groups of 10 subjects each. Each subject was to guess the
correct consonant-vowel-consonant (c-v-c) triad to be
associated with two digits. Subjects were told that their
guess was correct, regardless of which one was chosen.
Thus, both groups received the same knowledge of results
for the same performance. Group I, however, received one
bit of Information, since the feedback reduced uncertainty
arising from a choice between two alternatives. Group II
received three bits of Information, since their uncer
tainty arose from a choice between eight alternatives.
The hypothesis predicted that Group II would receive more
information and hence would learn more consonant-vowel-
consonants than Group I. The total number of c-v-c triads
correctly recalled was 22 for Group I and 31 for Group II,
which confirmed the hypothesis at the .05 level.
In summary, the research on uncertainty has hot
been extensive but has led to certain conclusions. Uncer
tainty is based oh past experience in a given situation
(is task-determined) . Furthermore, the greater the amount
of uncertainty the greater the negative effect upon per
formance. It would appear that one's verbal statement of
32
uncertainty can be accurately and consistently scaled.
Finally, there is some experimental evidence to indicate
that the greater the uncertainty reduced by feedback
the greater the learning.
The Concept of Feedback
Whereas the concept of uncertainty suffers from a
lack of experimental attention, the concept of feedback
o
has been deluged with it. Many of the variables which
have been experimentally manipulated and studied are not
relevant to our present concern. For a comprehensive
review of motor skills learning, one should read
Bilodeau (1961). Bilodeau's article also covers the
problem of immediate versus delayed feedback, as does
that of Ammons (1956). Another variable covered exten
sively in the literature has been the problem of con
founding of time between response end and knowledge of
results or time between knowledge of results and next
response. This has led to a literary dispute between
Bilodeau (1965) and Dyal (1964, 1965). Several authors
have suggested methods for dealing with the problem. See
Becker (1963), Bilodeau (1958, 1961), Bourne (1963),
33
Denny (1960), Nobel (1958), and Weinberg (1964). Another
Interest has been with the effects of misinformation
feedback. See, for example, Bourne (1963), Goodnow
(1955), Goodnow and Postman (1955), and Piskin (1960).
Determining the optimal amount of feedback to be
administered is an effort which has commanded a great
deal of experimental attention. Amsel (1960), Jenkins
and Stanley (1950), and McGuigan (1960) have shown that
100 per cent knowledge of results is optimal in the
acquisition of a response, since performance will
stabilize sooner. However, recent studies suggest that
presenting 100 per cent knowledge of results may not
produce the most efficient learning. Holland (1960)
compared post-test scores of groups receiving continuous
knowledge of results and no knowledge of results to
frames in the Holland-Skinner program and found no
differences. Hough and Revsin (1963) found no differ
ences between a teaching machine group receiving 100 per
cent knowledge of results (KR) and two programmed test
groups, one receiving 100 per cent KR and the other no KR.
See also Moore and Smith (1961, 1964) . The above findings
would be interpreted by Information Theory as a case
in which KR is redundant and consequently does not
enhance learning.
Chansky (1960) reports the effects of four types
of teacher feedback on acquisition and recall. Students
were asked to learn the age expectancy for eight items
from the Vineland Social Maturity Scale. There were
four groups. One group was given continuous information
(subject told correct response after each trial). The
second group was continuously graded (subject told if
right or wrong and at end of trial given a grade) .
Intermittent information was given to the third group
(right or wrong for half of the trials and correct
answer provided). The fourth group was given intermittent
grading (right or wrong for half and given grade at end).
Acquisition was significantly faster after continuous
information; however, recall did not differ significantly.
The mean number of acquisition trials were 5.61, 6.82,
13.29, and 31,52, respectively. The mean number of
recall responses were 3.40, 3.79, 3.56, and 2.94, respec
tively. When one's purpose is the retention of informa
tion by the subject, Chansky concludes: "Clearly the
most economic method is intermittent information" (p.
Krumboltz and Weisman (1962), using a different
problem area, obtained similar results. That is, inter
mittent confirmation was most efficient. Rosenstock
(1966) modified Krumboltz and Weisman's design to be sure
that each concept had an equal amount of confirmation
and also found that different schedules of KR did not
significantly affect results onpost-tests. Siegel (1965)
i
has studied the effect of schedules and specificity of
knowledge of results on retention with two experiments.
The first task was the Thorndike Line Estimating Tech
nique. Knowledge of results was given continuously
\
every fourth trial and every eighth trial. One hundred
acquisition trials per day were scheduled on four con
secutive days, and retention was measured after 1, 2, 4,
and 8 weeks. The second experiment used the Medicon
Hand Dynamometer and involved estimating 40 pounds, plus
or minus 5 pounds. Five-schedules of presentation of
KR consisted of continuous knowledge of results every
second, fourth, sixth, and eighth trial. Retention was
measured 1, 2, 4, and 8 weeks after acquisition. The
results in both experiments indicate that skill acquisi
tion varied with knowledge of results schedule (slower
with less KR), but retention remained the same.
36
That feedback enhances learning is an established
empirical finding which is not in dispute. The focus in
the literature appears to center around the effects of
various experimental manipulations of feedback. A problem
has been the separation of the rewarding and informative
aspects of feedback. Studies have shown that organisms
prefer information about an outcome, even when the informa
tion has no apparent instrumental value, as when cues
inform the subject of an outcome but the subject is unable
overtly to change the immediacy, probability or magnitude
of the outcome. See Lockhard (1963), Perkins (1963),
Pervin (1963, 1965), and Prokasy (1956). This preference
has been attributed to the consequent reduction in uncer
tainty by Lansetta and Driscoll (1966). From the informa
tion theorist's point-of view, the amount, of information
in a reinforcing event must be controlled. One can make
predictions about the effects of stimuli with differing
informational levels.
The work on the "information hypothesis" is an
* example of such predictions. Egger and Miller (1962)
performed an experiment to test the view that the strength
of the acquired reinforcement value of a neutral stimulus
37
is proportional to its informative value. An informative
or non-redundant predictor is a cue for primary rein
forcement which has not been preceded by a cue imparting
the same information. The authors tested this hypothesis
with 88 Albino Rats in a Skinner Box. Their results indi
cated that the reinforcing value of the stimulus was
stronger when it was not redundant (a redundant cue gives
no new information). These results were found, despite
the more distal association with primary reward of the
informative cue. McKeever and Forrin (1966) also tried
to test the formulation which holds that the first pre
dictor in a sequence of predictors becomes a more effec-
. tive secondary reinforcer despite a more distal associa
tion with primary reward. Contrary to Egger and Miller's
findings, the study produced no information effect.
However, it also failed to find the traditional goal
gradient effect associated with Hull (1943) , which has
been confirmed by extensive empirical data.
Tversky (1966) has tried experimentally to separate
the informative and rewarding aspects of feedback. In his
study the subject had a choice between two alternatives
at each trial: to observe the outcome, whether the left
or right light would come on, with no payoff; to predict
38
the outcome with nor information but with the possibility
of positive payoff given at the end of the experiment.
On each of 1,000 trials the subject chose between two
acts: possible five cents, or feedback. All subjects
deviated from optimal strategy by seeking far too much
information (approximately ten times the amount required) .
If one assumes that information reduces uncertainty and
that this is a valued outcome, then Tversky has not
separated feedback's informative and rewarding properties
but compared the relative strengths of reinforcement by
reducing uncertainty and reinforcement by paying the
subject a nickel.
In summary, the concept of feedback has received
a great deal of attention. The emphasis has not been on
proving that feedback enhances learning; this appears to
be an accepted empirical fact. The majority of work has
been to manipulate the many variables associated with the
presentation and timing of feedback in order to determine
the optimal use of knowledge of results. In addition,
there has been some effort to deal with the informative
nature of feedback as it is distinct from its reinforcing
quality.
CHAPTER III
METHODOLOGY
Subjects
The subjects (Ss), 48 females and 32 males, were
all hospitalized diabetic patients at Los Angeles County -
University of Southern California Medical Center.
Diabetics were chosen as the subject population because
they must acquire a great deal of self-treatment informa
tion. The Sub-Committee on.Teaching of Diabetics in
Hospitals of the American Diabetic Association has stated:
"An essential part of treating the condition is teaching
the patient how to live with it" (McDonald and Kaufman,
1963, p. 209).
The subjects ranged in age from 15 to 71, the mean
age being forty-four. The subjects were given the Verbal
Comprehension Test from the Employment Aptitude Survey
(Ruch and Ruch, 1963). The scores ranged from zero to
27.3, with a mean of 9.9. The females, with a mean of 9.7,
39
8cored at the 1 per cent level when compared with the
highest female job classification (secretary) and at the
15 per cent level when compared with the lowest female job
classification (junior clerk). The males, with a mean of
10.2, scored at the 10 per cent level when compared with
the norms for the highest male job classification (Manu
facturing Company Wide Norms) and at the 30 per cent level
when compared with the lowest job classification (General
Productive Male Population). There were no significant
differences in Verbal Comprehension Test scores between
the various experimental and control groups.
The subjects were selected to participate in the
study by the ward residents. Each morning (Monday through
Thursday) the research assistant would obtain from two
residents the names of three patients who were available
for the experiment. Six patients were referred each day
so that four patients were always present on the ward.
Patients were sometimes not available because they were
being x-rayed in class, subjects for ward rounds, etc.
Residents referred patients who were well enough to be
interviewed; who would be in the hospital for the follow
ing two days; who were on some form of diabetic medication,
either Insulin (58 Ss) or oral agents (22 Ss) ; and who
41
spoke English. (See Appendix A for the Instructions to
the Residents.) The assignment of patients to the
different experimental groups was random and prearranged,
one patient being assigned to each group each day. The
research assistant was given previous instructions as to
which resident's patient was to be assigned to which
group.
Research Assistant
The test materials were presented individually to
each subject by a research assistant who was herself a
diabetic and who was familiar with the information she
was presenting, while at the same time naive as to the
hypotheses being tested. The research assistant was
aware of the different treatments for each group, but
was not informed regarding the behavioral changes pre
dicted. The two weeks preceding the beginning of the
experiment were spent in training the assistant, by super
vising 40 interviews with 10 different subjects, and role
playing so that she would be familiar with the materials
and methods of presentation. (See Appendix B for the
Instructions to the Research Assistant which designated,
in advance, the assignment of patients to groups, and
42
which of ten test booklets, each containing a different
random order of questions, to present to each subject.
Materials
Test Booklet
A 60-item recall test which depicted the topics
relating to self-care in diabetes, in cartoon form, was
constructed in order to assess the patient's knowledge
of correct self-care with respect to diet (20 questions),
urine testing (18 questions), medication (4 questions),
acute reactions (9 questions), and personal hygiene (9
questions). The test was individually presented to each
subject. The subjects were requested to respond verbally.
Three criteria served as a basis for the selection
of items of information used to test the effectiveness of
feedback. The first criterion was the practical relevance
of information to the patient's self-care program. For
example, the Experimenter, in consultation with the medical
l
staff at Los Angeles County - University of Southern
California Medical Center, decided it was not necessary
for a patient to be aware of such abstract information
as the fact that Insulin is manufactured in the Isles of
43
Langerhans, but that it was important for his selection
of an appropriate diet that he know that orange joice is
a carbohydrate. Second, the Experimenter excluded all
questions which were not relevant to all patients to be
studied. For example, patients on Insulin should know
how to use a syringe, but other patients need not. The
Experimenter used as a third criterion for the inclusion
of a test item in the study, the availability of one,
rather than more than one, correct answer. Questions
which could have several different correct answers were
excluded or refined. Following a review of the literature
provided for diabetic patients, approximately 100 ques
tions which met the first criterion of relevance to the
patient's self-care program were selected. The 60 items
included in the study were determined by applying the
second and third criteria. (See Appendix C for the list
of 60 questions.)
In order to insure that the materials were clear
and informative, 60 concepts to be used in the Test
Booklet went through some seven or eight revisions by the
Experimenter, on the basis of interviews with 20 patients
and consultation with the staff at the Medical Center.
44
For example, the dietitian supplied a list of foods most
commonly eaten by Medical Center patients.
The importance of writing at the patient's level
has been a subject of great concern to the medical pro
fession. Knutson (1952, 1952, 1955) has discussed the
evaluation of medical literature in general terms.
Thrush and Lanese (1962), using the Dale-Chall Readability
Formula (1948) , specifically measured the readability of
literature designed for diabetic patients from 21 teaching
hospitals across the nation by selecting 143 passages and
computing the grade levels. Thrush and Lanese estimate
that literature designed for hospital patients should be
at the seventh grade level. They found, however, that the
materials presently in use ranged in grade level from
sixth to sixteenth, with an average grade level of 9.9.
They concluded that the literature designed to be read
by diabetics was not communicative because of its too-high
readability level. Thrush and Lanese suggested that the
materials be rewritten and, in the case of technical words,
descriptive sentences and illustrations be-used.
Application of the Dale-Chall Readability Formula
to the questions composing the test items used in the
45
present investigation revealed that the readability level
was at the seventh-to-eighth grade level. When the words
“urine*' and "diabetes*'/"diabetic" were excluded, the level
was found to be fifth grade. (See Appendix D for Dale-
Chall Formula.)
All 60 questions were illustrated in cartoon form
in order to increase still further the communicative value
of the test. The most extensive review of single versus
multiple channel communication is that of Frank Hartman
(1961), who generally concludes that information is com
municated more completely by pictures than by either
print or auditory channels. Furthermore, summation of
cues or facilitation which increases learning occurs when
all three channels (pictorial, print and auditory) are
used and the information is redundant. The present
investigation combined all three channels by having the
questions in cartoon form, printed, and at the same time
read aloud to the subjects.
An effort was made to make the cartoons appropriate
for the specific subject population at the Medical Center
by portraying some of the figures in the cartoons as
Caucasian, some as Negro, and some as ethnically non-
46
identifiable. Responses of the subjects suggested that
the cartoons were in general well liked and many subjects
asked to keep the booklets. Moreover, in some cases, the
subjects maintained interest in the study through three
hours of interviews over a two-day period. This lack of
resistance on the part of the patients may be attributed
in large part to the interest created by the cartoons.
Certainty Scale
The following was printed below the cartoon illus
trating each question:
Circle the word which best describes how you
feel about the correctness of your answer:
suppose think sure certain positive
The research assistant read this aloud to the subject
who then responded verbally.
Foley (1959) and Berry (1960) have previously
demonstrated the reliability scaling of the words "sup
pose," "think," "sure," "certain," and "positive," and
these five words were used for the certainty scale.
Twelve patients answered 20 questions about diabetes
twice within a three-hour period and indicated their cer
tainty as to the correctness of their responses. An
47
analysis of these data indicates that the scale has a
demonstrated reliability of 89.9, which is significant
at the .01 level. Table 1 describes the amount of change
occurring in certainty judgments between the first and
second administration of the scale for the patients
described above. It may be observed that the same
response is selected on both the first and second adminis
trations of the scale in almost 50 per cent of the judg
ments and only in 5 per cent do the ratings shift the
complete range of possible responses.
Instruction Booklet
In order to test the hypotheses regarding feedback
and certainty with cartoons, an Instruction Booklet was
developed. The questions in the Instruction Booklet were
presented in a multiple choice format, whereas the Test
Booklet had required the subject to recall the correct
response. The Test Booklet contained 60 questions, 32 of
which were selected for inclusion in the Instruction
Booklet. The criterion used for including a question in
the Instruction Booklet was based on a subject's response
to that question on the pre-test and, in consequence, the
content of the Instruction Booklet varied for each subject.
i
48
TABLE 1
CHANGES IN DEGREE OF CERTAINTY AFTER FIRST
AND SECOND ADMINISTRATION
Ratings £ % Cum. %
Remaining the same 83 49.11 49..11
Differing 1 degree 38 22.49 71..60
Differing 2 degrees 23 13.61 85..21
Differing 3 degrees 15 8.87 94..08
Differing 4 degrees 10 5.92 100,.00
The 32 questions were selected in the following manner:
8 of the questions the subject had previously answered
correctly and with high certainty as to the correctness
of the answers; 8 were correct and with low certainty;
8 were incorrect and with high certainty as to the cor-
rectness of the answers; and 8 were incorrect and with
low certainty. Subjects answering fewer than 16 questions
correctly (4 subjects) or more than 44 correctly (5 sub-
/
jects) were excluded from the study.
Two forms of the Instruction Booklet were designed
(see Appendix C for a list of the multiple-choice ques
tions and answers) . This required that 6 wrong answers
be determined for each of the 60 questions. Essentially,
the Experimenter, in consultation with the Medical Center
personnel, accomplished this by the method of free asso
ciation. The correct answer for 2 of the questions
(Diet I and Insulin I) varied with the medical prescrip
tion of the patient. In these two instances, the number
of alternate forms increased, since there were 8 possible
correct answers, although for an individual subject only
50
The multiple-choice questions were presented to
10 patients at the Medical Center. Alterations in the
choices were made on the basis of the information provided
the Experimenter by the patients1 general responses to
the questions, rather than according to a statistical
procedure. For example, to the question: "What should
you eat when you're sick?*' a low sodium diet had been
an alternate choice. This, however, was confusing to
subjects who were indeed on a low sodium diet.
Procedure
Subjects were assigned to one of four groups
which differed in the following manner:
The Post-Test Control Group
A Test Booklet (post-test) and the Employment
Aptitude Survey (EAS) Verbal Comprehension Test were
administered to subjects in the afternoon of the day
following the subjects' referral by a resident.
The Pre- and Post-Test Control Group
A Test Booklet (pre-test) and the EAS Verbal Com
prehension Test were administered to subjects in the
51
morning of the day the subject was referred by the
resident. Subjects received no further special attention
until the following afternoon when the Test Booklet
(post-test) was administered.
The Instruction Booklet Control Group
The pre- and post-tests and the Verbal Comprehen
sion Test were administered in the same manner and at the
same time as for the Pre- and Post-Test Control Group.
The subjects were also presented the two forms of the
Instruction Booklet on the first afternoon and second
morning of their participation in the experiment. The
32 items included in the booklet were determined in the
same manner as for the Experimental Group. However, no
feedback pages were inserted into the booklet.
Experimental Group
The pre- and post-tests and the Verbal Comprehen
sion Test were administered in the same manner as for the
Instruction Booklet Control Group. The subjects were also
presented with the two forms of the Instruction Booklet
in which was included informative feedback in the form of
a page on which the correct response was printed.
52
In all four groups, the research assistant presented
the materials to each subject individually. All subjects
were first given an opportunity to look at the cartoons
and to read the questions in the Test Booklets and/or
Instruction Booklets. The research assistant also read
each question aloud to each subject and recorded the
subject's response. Thus, the research assistant saw
the subjects from one to four times, depending on their
group. Time for administration of the Test Booklet
ranged from one-half hour to one hour. Time for adminis
tration of the Instruction Booklet ranged from 20 to 30
minutes.
f
CHAPTER IV
RESULTS
Table 2 presents the mean number of correct
responses and standard deviation of scores on the pre-
and post-tests. The raw scores which are tabulated in
Appendix E represent the number of questions answered
correctly.
Hypothesis I
Hypothesis I predicted that subjects in the group
receiving knowledge of the accuracy of their responses
to questions pertaining to a diabetic's self-care program
would perform significantly better than would subjects in
the three control groups.
\
Subjects in the Pre- and Post-Test Control Group,
the Instruction Booklet Control Group, and the Experimental
Group were given both a pre-test and a post-test of their
knowledge of medical prescription. An analysis of
variance (Edwards, 1957) was conducted of the subject's
53
54
TABLE 2
MEAN NUMBER OF CORRECT RESPONSES AND STANDARD
DEVIATION OF SCORES ON PRE- AND POST-TESTS
Total Items
Mean S. D.
Pre Post Pre Post
Feedback Items
Mean S.D.
Post Post
Post-Test
Control
Group
Pre- and
Post-Test
Control
Group
Instruction
Booklet
Control
Group 33.5
Experi
mental
Group
27 7.88
34.75 37.4 7.72 8.48 18.4 2.97
41.1 8.46 11.58 22.4 5.12
31.7 42.3 7.27 9.12 24.5 4.41
55
performance scores, tested under three conditions, with
two trials each. The results are presented in Table 3.
The post-test performance scores were significantly
higher (p < .001) than the pre-test scores, indicating
that learning had occurred. The interaction between the
pre- and the post-test scores and the three conditions
was also significant (p < .01).
Second, the gain in performance from pre-test to
post-test was analyzed by computing a single difference
score for each subject and submitting the array of scores
to an analysis of variance (Table 4) . The raw scores as
tabulated are displayed in Appendix E. In Table 5 the
results of a one-tail multiple t-Test for the difference
among the three difference score means are presented.
The Simple Randomized Analysis of Variance (Lindquist,
1953) indicates a significant difference (p < .001)
between the two control groups and the Experimental Group.
The direction of this difference (Table 5) indicates that
the Experimental Group learned significantly more than the
Instruction Booklet Control Group (p < .05) and signifi
cantly more than the Pre- and Post-Test Control Group
(p < .0005). Subjects in the Instruction Booklet Control
Group learned significantly more than subjects in the Pre-
56
TABLE 3
ANALYSIS OF VARIANCE OF PRE- AND POST-TEST SCORES
OF SUBJECTS IN EXPERIMENTAL AND CONTROL GROUPS
Source df MS F
Between Groups 2 16.41 .11291
Between Subjects 57 145.33
Total Between Subjects 59
Between Trials Pre-Post 1 1,449.38 107.04**
Interaction Trials x Methods 2 161.02 11.89*
Interaction: Pooled Subjects
x Trials 57 13.54
Total Within Subjects 60
Total 119
*p < .01
**p < .001
57
TABLE 4
ANALYSIS OF VARIANCE OF THE DIFFERENCES BETWEEN
PRE- AND POST-TESTS FOR SUBJECTS IN
EXPERIMENTAL AND CONTROL GROUPS
Source df MS F
Total 59 35.43
Between Groups 2 322.35 12.71*
Within Groups 57 25.37
*p < .001
58
TABLE 5
MULTIPLE t-TEST COMPARING DIFFERENCE SCORE MEANS
FOR EXPERIMENTAL GROUP AND CONTROL GROUPS
Pre- and vs. Instruction Critical
Post-Test Booklet Difference 4.22**
Control Control Obtained
Group Group Difference 4.95
Pre- and vs. Experimental Critical
Post-Test Group Difference 5.50***
Control
'
Obtained .
Group Difference 7.95
Instruction VS. Experimental Critical
Booklet Group Difference 2.65*
Control Obtained -
Group Difference 3.00
*P < .05, one tailed
**p < .005, one tailed
***P < .0005, one tailed
59
and Post-Test Control-Group (p < .005).
In the above analysis, comparisons are made between
the experimental and control group performances on the
entire 60-item test. Feedback was given for only 32
items, however, and Hypothesis I concerns itself most
explicitly with the effect of informative feedback on
performance. In order to test the hypothesis directly,
it was necessary to determine arbitrarily 32 pseudo
feedback items for the Pre- and Post-Test Control Group.
The same procedure as was used for the Instruction Booklet
Control Group and for the Experimental Group was used in
choosing these 32 pseudo-feedback items. Having specified
the feedback and pseudo-feedback items for each group, an
analysis of variance of the number of correct post-test
responses on the 32 feedback items was conducted. The
results indicated a significant difference (p < .001)
between the two Control Groups and the Experimental Group
(Table 6) . The direction of this difference is assessed
with a Multiple t-Test comparing the mean number of cor
rect post-test responses on the 32 feedback items. As is
presented in Table 7, the subjects in the Experimental
Group, having received informative feedback, learned
significantly more than did either the subjects in the
60
TABLE 6
ANALYSIS OF VARIANCE OF THE NUMBER OF CORRECT POST-TEST
RESPONSES TO THE 32 FEEDBACK ITEMS FOR SUBJECTS
IN EXPERIMENTAL AND CONTROL GROUPS
Source df MS F
Total 59 24.29
Between Groups 2 187.9 12.49*
Within Groups 57 15.04
*p < .001
61
TABLE 7
MULTIPLE t-TEST COMPARING MEAN NUMBER OF CORRECT
POST-TEST RESPONSES TO 32 FEEDBACK ITEMS FOR
SUBJECTS IN EXPERIMENTAL AND CONTROL GROUPS
Pre- and vs. Instruction Critical
Post-Test Booklet Difference 3.261**
Control Control Obtained
Group Group Difference 4.0
Pre- and vs. Experi Critical
Post-Test mental Difference 4.242***
Control Group - Obtained
. .. .
Group Difference 6.1
Instruction vs. Experi Critical
Booklet mental Difference 2.048*
Control
Group
Group Obtained
Difference 2.1
*P < .05, one tailed
**p < .005, one tailed
***p < .0005, one tailed
62
Instruction Booklet Control Group (p < .05) or the sub
jects in the Pre- and Post-Test Control Group (p < .0005) .
Furthermore, the subjects in the Instruction Booklet
Control Group learned significantly more than did the
subjects in the Pre- and Post-Test Control Group
(p < .005).
The 32 feedback items were arbitrarily selected
so that 16 items had been previously answered correctly
by the subjects, and 16 had been answered incorrectly.
The data were analyzed to determine the effects of feed
back on these two types of items. Table 8 presents the
results for the initially correct responses. The analysis
of variance indicates that the difference between the
Experimental and Control Groups was significant (p < .05).
The direction of this difference is reflected in Table 9
in which it is seen that subjects in the Experimental
Group responded with significantly more (p < .005) correct
answers on the post-test than did subjects in the Instruc
tion Booklet Control Group. Turning to an analysis of
variance of the 16 items which were initially answered
incorrectly (Table 10), the difference between the three
groups is also found to be significant (p < .001) .
63
TABLE 8
ANALYSIS OF VARIANCE OF THE NUMBER OF CORRECT POST-TEST
RESPONSES TO THE 16 PREVIOUSLY CORRECT FEEDBACK ITEMS
FOR SUBJECTS IN EXPERIMENTAL AND CONTROL GROUPS
Source df MS F
Total 59 1.68
Between Groups 2 5.72 3.71*
Within Groups 57 1.54
*p < .05
64
TABLE 9
MULTIPLE t-TEST COMPARING MEAN NUMBER OF CORRECT
POST-TEST RESPONSES TO 16 PREVIOUSLY CORRECT
FEEDBACK ITEMS FOR SUBJECTS IN EXPERIMENTAL
AND CONTROL GROUPS
Pre- and vs. Instruction Critical
Post-Test Booklet Difference .6567
Control Control Obtained
Group Group Difference .6*
Pre- and vs. Experi Critical
Post-Test mental ' Difference .6567
Control Group Obtained
Group Difference .55*
Instruction vs. Experi Critical
Booklet mental Difference 1.045**
Control Group Obtained
Group
*
Difference 1.15
*not significant
**p < .005, one tailed
65
TABLE 10
ANALYSIS OF VARIANCE OF THE NUMBER OF CORRECT
POST-TEST RESPONSES TO THE 16 PREVIOUSLY
INCORRECT FEEDBACK ITEMS FOR SUBJECTS
IN EXPERIMENTAL AND CONTROL GROUPS
Source df MS F
Total
-
59 19.24
Between Groups 2 181.6 14.11*
Within Groups 57 12.87
*p < .001
66
A study of this difference indicates that the Experimental
Group learned significantly more than did the Pre- and
Post-Test Control Group (p < .0005) and that the differ
ence between the Experimental Group and the Instruction
Booklet Control Group approached significance (.10 > p >
.05). Furthermore, in comparing the Instruction Booklet
Control Group and the Pre- and Post-Test Control Group,
the former group answered significantly more of the
initially incorrect items correctly (p < .0005). See
Table 11.
It was not possible to obtain a difference score
for subjects in the Post-Test Control Group, since they
were administered only a post-test. It was possible,
however, to compare the performance of the Post-Test
Control Group with the Experimental Group. Table 12
presents the analysis of variance of the post-test per
formance for the four groups. The difference between
the four groups was significant (p < .001). Table 13
reflects the direction of this difference. The perform
ance of the subjects in the Post-Test Control Group was
significantly less (p < .0005) than the performance of
all other subjects.
67
TABLE 11
MULTIPLE t-TEST COMPARING MEAN NUMBER OF CORRECT
POST-TEST RESPONSES TO 16 PREVIOUSLY INCORRECT
FEEDBACK ITEMS~~FOR SUBJECTS IN EXPERIMENTAL
AND CONTROL GROUPS
Pre- and vs. Instruction Critical
Post-Test Booklet Difference 3.923**
Control Control Observed
Group Group Difference 4.65
Pre- and vs. Experi Critical
Post-Test mental Difference 3.923**
Control Group Obtained
Group Difference 5.65
Instruction vs. Experi Critical .7691
Booklet mental Difference 1.894*
Control Group Obtained -
Group Difference 1.0
* .10 > p > .05, one tailed
**p < .0005, one tailed
68
TABLE 12
ANALYSIS OF VARIANCE OF THE NUMBER OF CORRECT
RESPONSES TO POST-TEST FOR SUBJECTS IN
EXPERIMENTAL AND CONTROL GROUPS
Source df MS F
Total 79
Between Groups 3 967 12.51*
Within Groups 76 77.3
*P < .001
69
TABLE 13
MULTIPLE t-TF.ST COMPARING NUMBER OF CORRECT RESPONSES
TO POST-TEST FOR SUBJECTS IN EXPERIMENTAL
AND CONTROL GROUPS
Pre- and vs. Instruction Critical
Post-Test Booklet Difference 9.50*
Control Control Obtained
Group Group Difference 10.4
Pre- and vs. Experi Critical
Post-Test mental Difference 9.50*
Control Group Obtained
Group Difference 14.1
Instruction vs. Experi Critical
Booklet mental Difference 9.50*
Control Group Obtained
Group Difference 15.3
* P < .0005, one tailed
The presentation of the Testing Booklet to the
Post-Test Control Group as a post-test was in essence
equivalent to the pre-test for the other groups, since
it represented the first administration of the Testing
Booklet. The only difference between the pre- and post
tests was the time of day when the material was presented
to the subjects. In consequence, the post-test perform
ance of the Post-Test Control Group was compared to the
pre-test performance of the other two control groups and
to the Experimental Group. Table 14 presents the analysis
of variance of the pre- and post-test performances of the
four groups. The difference between the four groups was
significant (p < .05). Table 15 indicates the direction
of this difference. The post-test performance of the
Post-Test Control Group was significantly less than the
pre-test performance of the Pre- and Post-Test Control
Group (p < .005), and less than that of both the Instruc
tion Booklet Control Group (p < .05) and the Experimental
Group (p < .05).
Hypothesis II
Hypothesis II led to the prediction that following
feedback there would be more correct responses among items
71
TABLE 14
ANALYSIS OF VARIANCE OF THE NUMBER OF CORRECT
POST-TEST RESPONSES FOR SUBJECTS IN THE
POST-TEST CONTROL GROUP, AND PRE-TEST
RESPONSES FOR ALL OTHER SUBJECTS
Source df MS F
Total 79 68.07
Between Groups 3 234.56 3.81*
Within Groups 76 61.49
*P < .05
72
TABLE 15
MULTIPLE t-TEST COMPARING MEAN NUMBER OF CORRECT
POST-TEST RESPONSES FOR THE POST-TEST CONTROL
GROUP WITH MEAN NUMBER OF CORRECT PRE-TEST
RESPONSES FOR ALL OTHER SUBJECTS
Post-Test
Control
Group
vs. Pre- and
Post-Test
Control
Group
Critical
Difference 6.
Obtained
Difference 7,
Post-Test
Control
Group
vs. Instruction
Booklet
Control— _
Group
Critical
Difference 4.
Obtained
Difference 6.
Post-Test
Control
Group
vs. Experi
mental
Group
Critical
Difference 4.
Obtained
Difference 5,
62**
75
14*
50*
14*
20*
*p < .05
**p < .005
73
which had initially been answered correctly and with.high
uncertainty as to the correctness of the answers than
on items which had initially been answered correctly and
with low uncertainty as to correctness. A Chi-Square,
presented in Table 16, was used to assess the data since
the array of scores was negatively skewed. The results
indicate that the difference was in the predicted direc
tion (.10 > p > .05), which lends support to this
hypothesis. Some investigators assert that the Central
Limit Theorem (Guilford,_JL965) justifies the use of a
Jt-Test, even in heavily skewed distributions. Performing
a £-Test on the present data yielded a T of 2.17, which
was significant at the .05 level.
Hypothesis 111
The third hypothesis led to the prediction that,
following feedback, there would be more changes in
responses among items which had initially been answered
incorrectly and with low uncertainty as to the correctness
of the answers than on items which had initially been
answered incorrectly and with high uncertainty as to the
correctness; consequently, the scores would represent
74
TABLE 16
CHI-SQUARE ASSESSING RELATIONSHIP OF DEGREE OF
UNCERTAINTY AND NUMBER OF ITEMS CORRECT
ON POST-TEST # WHEN ORIGINAL
ANSWER WAS CORRECT
Number of
Items Correct
Low
Uncertainty
High
Uncertainty Total
6 2 1 “ 3
7 10 4 14
8 8 15 23
Total 20 20 40
Chi-Square - 5.06 (.10 > P > .05)
changes in response rather than the number o£ correct
responses. This hypothesis was not supported. A Chi-
Square, presented in Table 17, was used to assess the
data. The results indicate that the difference was not
significant (.70 > p > .50). The direction of this diff
erence was contrary to that predicted by Hypothesis III.
Discarding the ten tie scores and performing a sign test
(Siegel, 1956), the number of subjects changing a greater
number of high uncertainty responses was still not signif
icant (p > .10). Again, by making reference to the
Central Limit Theorem (Guilford, 1965), which permits
the use of a t-Test on a heavily skewed distribution,
a jt-Test was performed, yielding a T of 2.9, which was
significant at the .01 level.
Follow-up Data
Follow-up data were collected during a subject's
first clinical appointment after discharge from the
Medical Center. This was accomplished by noting the
amount of sugar in the 24-hour urine specimens of the
patients. With 50 per cent of the subjects having had
76
TABLE 17
CHI-SQUARE ASSESSING RELATIONSHIP OF DEGREE OF
UNCERTAINTY AND NUMBER OF ANSWERS CHANGED
ON POST-TEST, WHEN ORIGINAL
ANSWER WAS INCORRECT
Number of Low High
Items Changed Uncertainty Uncertainty Total
1 2 1 3
2 0 1 1
3 1 0 1
4 0 0 0
5 2 1 3
6 7 4 11
7 3 4 7
8 5 9 14
Total 20 20 40
Chi-Square -4.78 (.70 > p > .50)
77
a clinic appointment scheduled to date, there appeared
to be no difference between the Experimental and Control
Groups.
CHAPTER V
DISCUSSION
Problem and Procedure
An adequate self-care program Is mandatory to
enable a diabetic to maintain control over his disability.
The necessity for self regulation of medication, diet,
and exercise in order to prevent relapse requires that
the patient grasp a great deal of medical information.
While recognizing the potential value of educating the
diabetic patient in self-care procedures, physicians
have generally expressed pessimism about the adequacy
of physician-patient communication in conveying the
necessary medical information to the patient. The
present investigation does not support such pessimism.
The results demonstrate clearly that patients acquire
a significant amount of information by the use of train
ing procedures which require a minimal amount of inter
vention on the part of the medical staff.
78
The Pre- and Post**Test Control Group represents
minimal intervention in the present study. The 60 ques
tions on diabetic self-care, presented to the patient
during the pre-test, informed the patient of the nature
of the information he was expected to acquire, either to
prepare for a second test or for the protection of his
own welfare. Presumably, the patient was thereby alerted
to what information he should seek from his environment.
Patients typically knew the correct responses to no more
than one-half of the self-care questions, and it is
plausible to assume that the pre-test, therefore, created
uncertainty or insecurity in the patients. Berlyne
(1960) asserts that the creation of uncertainty should
lead to information-seeking because the reduction of
uncertainty is positively reinforcing. Festinger (1957),
similarly, predicts information-seeking, assuming that the
pre-test would create cognitive dissonance in the patient
by informing him of his lack of knowledge. The results
support the proposition that the patients did acquire
information; on the post-test, the subjects in the Pre-
and Post-Test Control Group made a significantly greater
number of correct responses (p < .001) than did those in
the Post-Test Control Group who had not been given the
80
pre-test.
The self-care questions on the pre- and post-tests
required the patient to supply the correct response from
his own response repertoire (open-ended Items), and
therefore from a large or possibly Infinite number of
possible responses. The Items supplied Information to
the patient as to categories of response or Information
which would be important for him to explore, but did not
provide information relevant to the correct answer. The
multiple-choice self-care items used in the Instruction
Booklet, however, did provide information about correct
responses by reducing the number of relevant correct
responses to four rather than to the large number of
potentially correct answers when subjects were not pro
vided with any possibly-correct responses in the test
or training instruments. The alerting and seeking
responses assumed to be operating in the Pre- and Post-
Test Control Group can also be assumed to have operated
in the Instruction Booklet Control Group. The patients
in this group, -however, were also provided with the
correct answer in the form of one of the multiple choices
and the possibility of more self reinforcement, since the
81
task was to recognize the correct response, in contrast
to the subjects in the other control groups who were
required to recall the correct response. If one assumes
that subjects in the Instruction Booklet Control Group
were provided with a greater amount of information by
the multiple-choice format and a greater opportunity for
self reinforcement, then one would expect the patients
in this group to acquire a greater amount of information.
The results demonstrate that these subjects did indeed
learn more than the subjects in the Post-Test Control
Group (p < .0005), and more than the subjects in the
Pre- and Post-Test Control Group (p < .005).
Hypothesis I
Hypothesis I led to the prediction that subjects
in the Experimental Group would learn a significantly
greater amount of information than would the subjects
in the three control groups. The resultB support the
prediction that informative feedback enhances the communi
cation of medical information. The subjects in the
Experimental Group answered significantly more questions
correctly on the post-test than did subjects in any of
82
the three control groups, i.e., the Post-Test Control
Group (p < .005), the Pre- and Post-Test Control Group
(p < .0005), or the Instruction Booklet Control Group
(P < .05).
A comparison of the post-test performance of the
subjects in the Post-Test Control Group with the pre-test
performance of subjects in the other two control groups
and the Experimental Group, indicated a significant
difference (p < .05). This difference may be attributed
to the difference in timing for the pre- and post-tests
and a general fatigue factor. The pre-test was given in
/
the morning when patients were more alert, whereas the
posfr-test was given in the afternoon when patients were
generally more fatigued. This systematic difference in
timing would have the effect of depressing the present
results, since the post-test for all groups was given in
the afternoon. In consequence, it can be assumed that
the significant learning demonstrated by the performance
of the experimental subjects on the post-test is, if
anything, a minimal indication of the potential value
of informative feedback.
In the above analysis, the total post-test per-
formance of subjects in the Experimental Group was
compared with the total post-test performance of all
other subjects. Hypothesis 1 dealt most specifically,
however, with the effects of informative feedback which
was given on only 32 of the 60 test items. ' For this
reason, a set of pseudo-feedback items was chosen arbi
trarily for the subjects in the Pre- and Post-Test
Control Group, on the same basis as the items selected
for the Experimental Group so that the performance of
subjects on these 32 items could be compared with the
performance of subjects in the Instruction Booklet Con
trol Group and the Experimental Group. The subjects in
the Experimental Group did, as predicted, answer more
of the 32 feedback items correctly than did the subjects
in either the Pre- and Post-Test Control Group (p < .0005)
or the Instruction Booklet Control Group (p < .05) .
These results abundantly demonstrate the value of
informative feedback within the medical setting. The
Medical Center patients used as subjects in this study,
when measured by the Verbal Comprehension Test of the
Employment Aptitude Survey, were intellectually in the
lower 20 per cent of the general population. In spite
of their limited general abilities, the subjects acquired
84
a significantly greater amount of information about their
self-care program, thus validating the value of the
employment of informative feedback systems within the
hospital environment.
The 32 feedback items were arbitrarily selected
so that 16 feedback items had previously been answered
correctly and 16 incorrectly. Analyses of variance
indicated that both types of items were significantly
affected by informative feedback (P < .05 for previously
correct items; p < .001 for previously incorrect items).
In both situations the subjects in the Experimental Group
acquired the greater amount of medical information.
Two conclusions may'be drawn from the above
findings. First, with respect to feedback and correctness
of response, the subjects demonstrated significantly more
learning, even on those items which they had initially
answered correctly in the free-recall situation. This
indicates that learning does occur, even in this situa
tion, since positive reinforcement lowers the threshold
for the correct response and increases the probability
of correct response, Second, with respect to feedback
and incorrect responding, reinforcement theorists have
85
maintained that only positive reinforcement will lead to
learning. The present findings indicate, however, that
the information provided by the feedback outweighed the
aversiveness associated with being informed that one has
made an incorrect response.
Hypothesis II
Hypothesis II predicts that informative feedback
on items which were initially correct and with high uncer
tainty enhances learning more than does informative feed
back on items which were initially correct and with low
uncertainty. This prediction is based on the assumption
that the more informative the unit of feedback, the more
positive is the reinforcement for the subject. This
hypothesis was assessed by computing a Chi-Square compar
ing the degree of uncertainty and the number of items
correct on the post-test. The results lend support to
this hypothesis, since the Chi-Square approached signifi
cance (.10 > p > .05). A review of the data presented
in Table 16 reveals that the number of correct responses
was at a maximum (8 correct items) 23 times out of a
possible 40 responses. Moreover, 10 of the 20 subjects
86
in the Experimental Group has tie scores for the high
and low uncertainty items, and 8 scores differed in the
predicted direction. Increasing the tramber of initially
correct items for which informative feedback is adminis
tered may diminish the ceiling effect found in the present
data and thereby increase the probability of obtaining
a significant result. In earlier research concerned
primarily with the value and manipulation of feedback,
the informational level of a unit of feedback has been
largely ignored. The present results support the conclu
sion that one should maximize, the informational value of
feedback in order to maximize its reinforcement qualities.
Furthermore, investigators of feedback and feedback-related
phenomena should consider control of the informative value
of feedback to prevent confounding with other variables.
Hypothesis III
Hypothesis . Ill led to the prediction that the low**
uncertainty items would change more because informative
feedback in this situation is doubly aversive. That is,
the subject receives negative reinforcement by being in
formed that his previous response was incorrect and
thereby his uncertainty is increased rather than
decreased. One may compare feedback on incorrect and
low-uncertainty items to feedback on incorrect and high-
uncertainty items. Information indicating the incorrect
ness of a response is an assumed aversive stimulus, but
the amount of uncertainty is reduced rather than in
creased when the subject has responded with a high degree
of uncertainty. Since this situation is not doubly
aversive, it had been predicted that there would be less
avoidance of an initially highly uncertain response.
Hypothesis III was not supported by the findings
of the present investigation. For the initially incor
rect responses, the number of low-uncertainty items
changed on the post-test was not significantly lower
than the number of high-uncertainty items changed (Chi-
Square .70 > p > .50). A t>Test was performed and the
results were significant (p < .01), but in a direction
which was opposite to that predicted.
No significant difference was obtained between
the high- and low-uncertainty items when compared with
the number of correct responses on the post-test. Never
theless, there were significantly more changes in response
88
among the high-uncertainty items. An analysis of the
data reveals that the greatest change occurred on those
items to which the subjects had previously responded,
"I don't know."
The question posed by the present findings is
whether negative feedback on highly uncertain responses
is indeed aversive. It has been assumed that when the
subject responds with high uncertainty, he is indicating
little commitment to his response and when he responds
with "1 don't know," he is indicating no commitment. In
the present situation the subjects have indicated some
preference when they have responded with high uncertainty.
Brehi? and Cohen (1962) discuss the concept of commitment
and its relation to response change; they believe that
when subjects respond with high uncertainty, they are
not highly committed to their answers. Consequently, as
would be predicted by Dissonance Theory, responses would
readily change under the positive influence of the uncer
tainty reduction created by informative feedback. Brehm
and Cohen predict further that, with an increase in com
mitment, a subject's resistance to change would increase
and new information would be ignored or distorted.
89
Dissonance Theory, then, predicts that the subject would
resist changing a response to which he was highly com
mitted; on the other hand, Reinforcement Theory predicts
that the subject would avoid a response for which he had
already received negative reinforcement. The present
findings would lend support to the assumption that, in
fact, both variables could be operative in such a situa
tion. These findings suggest the advisability of explor
ing the interaction of dissonance and reinforcement by
expanding the uncertainty scale so that feedback could
be given on items of varying degrees of uncertainty.
Implications for Further Research
The results of the present investigation have
both practical and theoretical implications for future
study. The applicability to the medical setting of
Information Theory has been amply demonstrated. The
study also provides a design for improving medical com
munication which utilizes, simultaneously, three channels
of communication and informative feedback. Specifically,
the study provides information to the staff of the Los
Angeles County - University of Southern California Medical
Center concerning the amount of information patients
presently obtain from the hospital environment and speci
fies the areas in which there is greatest need for patient
education. It has been proposed to furnish the test of
the diabetic's self-care program developed for the present
study to the nursing and attending staff so that they may
assess the patients' knowledge of the material and may
correct any gaps in information, if necessary. The test
ing materials are being presented to the Medical Center
for use on the wards, in the hope that these materials
may be coordinated with the teaching programs presently
in use.
It can be assumed that the practical utility of
this form of communication has an even more generalized
applicability. Although the generalizability of this
type of communication system is not presently known, its
value should be explored, not only in other medical
settings where communication is relevant to the medical
disorder, but also in the diverse fields in which effec
tive communication is a common need.
The theoretical implications of this research are
relevant to future developments in reinforcement theory
91
and most specifically in programed instruction. Experi
menters in programed instruction have concluded that a
program is most effective when every unit of feedback
reduces a minimum of uncertainty. This conclusion springs
from an analysis of reinforcement theory which emphasizes
the need for positive reinforcement to produce learning.
In order to increase the likelihood of positive reinforce- .
ment, programs which make the subject certain of the
correctness of his response have been designed. This is
in contradistinction to Information Theory which holds
that the most informative feedback is that which reduces
a maximum of uncertainty. From a programer's point of
view, an optimum program is one in which the subject is
completely certain of the correctness of his answers;
but this creates a situation in which the knowledge of
results is redundant and no information is imparted by
feedback.
The results of the present investigation lend
support to the prediction that there is greater learning
when positive reinforcement is given on highly uncertain
items. In fact, there is some indication that negative
feedback is highly informative and not necessarily
92
aversive when there is little or no commitment to a
particular response on the part o£ the subject.
Following replication of these results, it would
seem to be of value to explore the possibility of increas
ing the effectiveness of programed instruction by using
a partial reinforcement schedule which was established
on the basis of the subject's certainty of response.
It would first be necessary to develop a precise certainty
scale. This could be accomplished by using a procedure
• i
similar to that followed by Adams (1957), who trained his
subjects to estimate accurately the probability that the
response was correct on a 10-point certainty scale.
This was accomplished by providing the subjects with
feedback. Once having obtained an accurate estimate of
the subject's degree of certainty, a series of investiga
tions could be conducted to assess the effects of feed
back which is varied in its positive and negative valence
and in the level of certainty felt by the subjects. Such
a series of investigations would assess the value of
giving positive reinforcement which is at the same time
informative. This would make it possible to determine
the point at which negative feedback is no longer aversive
because of its increased informative value.
93
* ~ ’1 a
Summary
This investigation, conducted at the Los Angeles
County - University of Southern California Medical Center,
analyzed the physician-patient communication system within
an Information Theory .framework. A frequently-reported
source of interference in effective physician-patient
communication is lack of feedback to the patient which
would enable him to verify the accuracy of his interpre
tations of the information transmitted to him. It was
hypothesised, therefore, that informative feedback to the
patient would increase accuracy in communication of
medical prescription.
The goal of communication from physician to patient
is the patient's adequate reception of a maximum amount
of information. In Information Theory, the amount of
information in a message is determined by the amount of
uncertainty that is reduced by the communication. It was
hypothesized further that feedback on responses high in
uncertainty would be more informative than feedback on
responses low in uncertainty.
The reinforcement qualities of feedback, as well
94
as its informative aspects, were considered. Feedback
which indicates that the subject's response was incorrect
is negatively reinforcing. Feedback which informs the
subject that his previous response was correct is posi
tively reinforcing. In consequence, it was hypothesized
that positive feedback on a response high in uncertainty
would increase the probability of recurrence of that
response more than would positive feedback on a response
more than would positive feedback on a response that is
low in uncertainty. Conversely, negative feedback on a
response low in uncertainty, it was hypothesized, would
lead to greater avoidance of that response than would
negative feedback on a response that is high in uncer
tainty.
The communication of self-care information to
diabetic patients was chosen as the area of study because
this area of communication, while complex, is vital to
the successful treatment of diabetes.
The following materials were developed:
1. A Testing Booklet comprising 60 self-care items,
presented in cartoon form, and requiring the subjects to
recall the correct response, as well as to estimate their
95
degree of certainty regarding the correctness of their
response. The Testing Booklet served as both a pre-test
and a post-test.
2. An Instruction Booklet which presented in
multiple-choice form 32 of the 60 self-care items con
tained in the Testing Booklet. The 32 concepts comprised
8 items which the subject had answered correctly and with
a high degree of certainty as to correctness of response;
8 items answered correctly, but with low certainty; 8
items answered incorrectly, but with high certainty that
they were correct; and 8 items answered incorrectly and
with low certainty as to correctness.
Eighty diabetic subjects were randomly divided
into four equal groups. Subjects in Control Group I
were administered a post-test. Subjects in Control
Group II were administered both a pre-test and a post
test. Subjects in Control Group III were administered
the pre-test, the Instruction Booklet, and the post-test.
Subjects in the Experimental Group received the same
treatment as those in Control Group III. Experimental
Group subjects also received informative feedback as to
the correctness of their responses.
96
The results Indicate that subjects in Control
Group II demonstrated significantly more knowledge on the
post-test than did subjects in Control Group I. Subjects
in Control Group III demonstrated significantly more
knowledge on the post-test than did subjects in Control
Group I or Control Group II. The performance of the
Experimental Group subjects was superior to that of any
of the other subjects.
The results lend support to the second hypothesis,
that positive feedback on items initially high in uncer
tainty enhances learning more than does positive feedback
on items low in uncertainty (.10 > p > .05). The third
hypothesis was not supported by the findings of this
investigation. Negative feedback produced as great a
change among the high-uncertainty as among the low-
uncertainty items.
In conclusion, this investigation demonstrates the
applicability and value of utilizing feedback in a medical
setting, and lends support to the hypothesis that the
effectiveness of feedback can be improved by increasing
its informational value.
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APPENDICES
APPENDIX A
INSTRUCTIONS TO THE RESIDENTS
112
INSTRUCTIONS TO RESIDENTS
Dr. ______
Please list the names of three patients who are
well enough to be Interviewed on_____________ and
____________ . They should be on Insulin or oral drugs.
Should speak and read English.
Thank you.
Sharon Deacon
APPENDIX B
INSTRUCTIONS TO THE RESEARCH ASSISTANT
114
INSTRUCTIONS TO THE RESEARCH ASSISTANT
Subj ect __________________
Identify this patient as Group I*, subject ______________
This will be Dr. ________ listed patient.
See this patient _______________ afternoon ;
give this patient a post-test using Set _______________
and a vocabulary test.
Subject ___________________
Identify this patient as Group II**, subject ____________
This will be Dr. _________ listed patient.
See this patient morning ___________and give
a pre-test using Set __________ and a vocabulary test.
On___________ afternoon__________, give this patient a
post-test using Set ___________ .
*The Post-Test Control Group was referred to as Group I.
**The Pre- and Post-Test Control Group was referred to
as Group II.
115
Subject ____ _________
Identify this patient as Group 111$ subject
This will be Dr. ___________________listed patient. See
this patient __________morning __________and give a_pre
test using set _________ and a vocabulary test. On
afternoon ■ give this patient Booklet A. On___
morning , give this patient booklet B. On
afternoon . give this patient a post-test using
set
Subject ____________
Identify this patient as Group IV, subject ________________.
This will be Dr. ' listed patient. See
this patient __________morning . and give a pre-test
using set_________ and a vocabulary test. On
afternoon_________ administer feedback booklet A.
On _________morning ___________, administer feedback
booklet B. On ________afternoon , give this
patient a post-test using set .
*The Instruction Booklet Control Group was referred to
as Group III.
**The Experimental Group was referred to as Group IV.
APPENDIX C
LIST OF QUESTIONS ON DIABETES
117
LIST OF QUESTIONS ON DIABETES*
DIET
1. How many calories a day has the doctor prescribed
for you?
a.
1
500 a.
2
1500 a.
3
2200 a.
4
800
b. 800 b. 2200 b. 3000 b. 2600
c. 1200 c. 500 c. 1500 c. 1500
d. 1000 d. 1800 d. 1200 d. 2200
5 6 7 8
a. 1500 a. 2600 a. 3000 a. 1500
b. 800 b. 1800 b. 1200 b. 2000
c. 2600 c. 3000 c. 800 c. 500
d. 3000 d. 1000 d. 2000 d. 2600
(Correct answer: Varies per patient's prescription)
2. Why are some foods grouped together on the same
exchange list?
a. because they are good a. because they are
for you high in protein
b. they have the same b. they cost about
food value the same
c. they are low in c. they have the same
carbohydrate food value
d. so you can eat more d. so you can use one
exchange list at
each meal
*The correct answer is underscored.
Why can't you substitute items from different food
exchange lists?
a.
1
you can exchange them a.
2
you eat only one kind
b. you change the number at a meal
of calories b. they don't go well to
c. they will make you fat gether
d. they are all proteins c. they are all fats
d. you change the number
of calories
Which exchange list has baked beans, crackers,
potatoes, oatmeal and corn?
a. vegetable A
b. milk
c. bread
d. fruit
a. fat
b. vegetable B
c. meat
d. bread
Which exchange list has bacon, cream cheese, nuts,
mayonnaise and olives?
a. milk
b. fat
c. vegetable B
d. bread
a. meat
b. fat
c. vegetable B
d. fruit
Which exchange list has peanut butter, eggs, cottage
cheese and hot dogs?
1 2
a. fat a. bread
b. meat b. vegetable
c. vegetable c. meat
d. bread d. fruit
How should the diabetic diet differ from the normal
diet?
a. not all foods included a. balanced diet and less
b. balanced diet and less carbohydrate
carbohydrate b. more calories
c. balanced diet and c. no sugar
fewer calories d. balanced diet and
d. more carbohydrate more fat
Rice, beans, potatoes and orange juice are all part
of what food family?
1 2
a. carbohydrate a. fat
b. protein b. fruit
c. vegetable c. carbohydrate
d. bread d. meat
Hot dogs, peanut butter, cottage cheese and hamburger
are all part of what food family?
1 2
a. fruit a. protein
b.
bread b. carbohydrate
c. vegetable c. fat
d. protein d. meat
Bacon, cream, nuts, and margarine are all part of
what food family?
a. fats
b. vegetable
c. fruits
d. meat
a. Carbohydrate
b. protein
c. fats
d. bread
120
11. How much food value is there in
or garlic?
1
a. none
b. a great deal
c. coffee has the most
d. depends on what you
eat with them
12. Why can you have as much
1
a. they are good for
you
b.. only a little
carbohydrate
c. you can't
d. they have no food
value
13. What diet is good when you
1
a. a bland diet
b. a regular diet
c. a liquid or soft diet
d. a diet high in protein
vinegar, coffee, tea
2
a. a lot
b. they are of different
food value
c. none
d. vinegar has the least
as you want of some foods?
2
a. they aren't expensive
b. they have no food
value
c. you' re not supposed to
d. only a little protein
are sick?
2
a. a diet high in fats
b. a diet high in carbo
hydrates
c. little or no food
d. a liquid or soft diet
14. Why should you measure your food?
1 2
a. to be sure you eat a. to be sure you eat
the proper amount the proper amount
b. so you won't waste b. so you know how much
food to buy
c. to avoid too many c. you don't have to
vitamins d. to keep from eating
d. to be sure you get fats
a lot of carbohydrates
121
15. In preparing a meal, when
your food?
1
a. during preparation
b. before buying food
c. before cooking
d. after cooking
should you measure
2
a. after cooking
b. you don't have to
c. before it is prepared
d. at end of day
16. If you fry your food what difference does it make in
calculating your diet?
a. add a fat exchange a,
b. eat less carbohydrate b,
c. nothing c,
d. add a vegetable d,
exchange
add a fat exchange
eat less protein
drink more milk
add a bread exchange
17. Why should you eat only the foods on the exchange
lists?
a. so you won't get fat a.
b. you don't have to
c. so you'll have no b.
carbohydrates
d. you know the food c.
value d.
so you can get a high
sodium diet
you know how much the
cost
you know the food value
so you'll have no
starch in diet
18. What happens to your blood sugar if you skip a meal?
1 2
a. you will spill sugar
b. nothing
c. it is increased
d. it is decreased
a. it is increased
slightly
b. it does not change
c. it is decreased
d. it depends on how
often you do
122
19* Why should you eat only the amount of food Indicated
on the food exchange lists?
a. to gain weight a. to avoid polyunsat
b. it depends on your urates
medication b. you don't have to
c. they contain the right c. in order to avoid
number of calories proteins
d. so you'll get a lot of d. they contain the right
carbohydrates number of calories
20. What happens to your blood sugar if you eat between
meals?
a.
1
it is increased a.
2
you'll stop spilling
b. it stays the same sugar
c. it is decreased b. it is decreased
d. protein level is slightly
increased c. it is increased
d. nothing
URINE TESTING
1. In testing your urine with tablets, how many drops
of water should you use?
1 2
a. two
b. five
c. eleven
d. seven
a. six
b. nine
c. one
d. five
123
2. In testing your urine with tablets, how many drops of
urine should you use?
1 2
3.
4.
5.
a. six a. two
b. nine b. five
c. one c. eleven
d. five d. seven
In testing your urine with tablets, when should you
add the tablet?
1 2
a. after the water a. before the urine
b. before the water and b. after the water and
urine urine
c. after two minutes c. after the urine
d. after the water and d. after one minute
urine
In testing your urine with tablets, when should you
read the color?
1 2
a. before adding tablet a. after adding water and
b. immediately urine
c. after it stops bubbling b. after it stops bubbling
d. after 10 minutes d. while tablet bubbles
d. after five minutes
In testing your urine with tablets, what does it mean
if it turns orange? _ _
1 2
a. no sugar a. acetone in your urine
b. a great deal of' sugar b. a great deal of sugar
c. no acetone in your c. very little sugar
urine d. urine is all right
d. Urine is o.k.
124
6. In testing your urine with tablets, what does it mean
if it turns green?
1 2
a. acetone in your urine a. a small amount of
b. no sugar sugar
c. a great deal of sugar b. you are spilling sugar
d. a small amount of c. no acetone in your
sugar urine
d. diabetes is out of
control
In testing your urine with tablets, what does it mean
if it turns blue?
1 2
a. diabetes is out of a. acetone in your urine
control b. a little sugar
b. no acetone in your c. you are spilling sugar
urine d. no sugar
c. a great deal of sugar
d. no sugar
8. When should you test your urine?
a.
1
at each urination a.
2
at bedtime
b. before meals b. one half hour after
c. after meals eating
d. when ill c. occasionally
d. before meals
9. Which urine after a meal should you not use when
testing for the next meal?
1 2
a. Urine taken just before a. first urine
eating b. urine taken 2 hours
b. second urine after eating
c. fresh urine c. last urine
d. first urine d. third urine
125
10. Why should you record the results of your urine test?
1 2
a. so you'll know if a. to keep a record for
you tested it your doctor
b. so you'll know if b. you don't have to all
it's bad the time
c. you don't have to c. so you'll know if it's
d. to keep a record for good
your doctor d. to record the color
11. When should you carry out an Acetone test?
a. every day
b. if there is sugar
in your urine
c. before each meal
d. occasionally
a. at bedtime
b. after each meal
c. never
d. if there is sugar in
your urine
12. How many drops of urine should you drop on an Acetone
tablet?
a. eleven
b. seven
c. five
d. one
a. one
b. ten
c. eight
d. twelve
13. What does it mean if the Acetone tablet turns a
deep purple?
1 2
a. you're in good a. you have acetone in
health your urine
b. you have very little b. urine is o.k.
sugar c. too much medication
c. you have acetone in d. no sugar in urine
your urine
d. you have no acetone
126
14. What does a lot of sugar in the urine indicate?
1 2
a. your medication is a. you may get a reaction
just right b. you haven't been
b. you've been exercising eating enough
too much c. diabetes is out of
c. diabetes is out of
-
control
control
d. you've had too much
d. you have acetone in medication
your urine
15. Why should you take a urine test? _ .
1 2
a. to test for kidney a. to write results on
trouble chart
b. to test for sugar b. to test for liver
c. you're supposed to trouble
d. to get blood count c. to test for gygar
d. to test bladder
16.
What should you do if you have acetone in your urine?
1 2
a. call your doctor a. exercise more
b. eat sugar b. eat starches
c. go to bed c. call your doctor
d. ignore it d. eat a liquid diet
17. How can the doctor be best informed on the progress
of home diabetic control?
1 2
a. he can't a. by the medication you
b. by talking to you take
c. by a written record b. by what you tell him
d. by taking a blood c. by testing your urine
test d. by a written record
127
18. If your urine always tests orange, what should you do?
a. nothing, that's good
b. go to bed
e. call your doctor
d. eat more
a.
b.
c.
d.
exercise
change your diet
ignore it
call your doctor
INSULIN
1. What is the name of the drug you take for your
diabetes?
(Answer: Varies per patient's prescription.)
1
a. Regular (CSI) Insulin
b. Lente Insulin
c. Orinaze
d. Diabinase
3
a. Lente Insulin
b. NPH Insulin
c. Dymelor
d. DBI
5
a. Diabinase
b. HPH Insulin
c. Dymelor
d. DBI
7
a. Dymelor
b. Regular (CSI) Insulin
c. Orinaze
d. Diabinase
2
a. Regular (CSI) Insulin
b. NPH Insulin
c. Dymelor
d. DBI
4
a. Orinaze
b. HPH Insulin
c. Dymelor
d. DBI
6
a. NPH Insulin
b. Lente Insulin
c. Orinaze
d. Diabinase
8
a. DBI
b. Regular (CSI) Insulin
c. Lente Insulin
d. Diabinase
128
What does the medicine you take for your diabetes
do to your blood sugar?
a. decreases protein level a.
b. increases it slightly b.
c. increases sodium content c.
d. decreases it d.
decreases it
nothing
increases it
causes high
cholesterol
What will happen if you forget to take your diabetic
medicine?
a. low blood sugar
b. spill sugar in your
urine
c. get a reaction
d. nothing
a* spill sugar in your
urine
b. you will act intoxi
cated
c. need more food
d. you'll become weak and
hungry
What will happen if you take too much diabetic
medicine?
a. spill sugar
b. diabetic coma
c. reaction
d. vomit
a. nothing
b. reaction
c. high blood sugar
d. you'll need less
carbohydrate
129
PERSONAL HYGIENE
1. What is the effect of exercise on your blood sugar
level?
1 2
a. speeds it up a. high sodium level
b. decreases it b. level remains the
c. fats are decreased c. increases it
d. level goes up and d. decreases it
down
2. What is the proper exercise prescription for a
diabetic?
1 2
a. exercise before eating a. normal and consistent
b. diabetic shouldn't exercise
c. exercise only in the
morning
d. normal and consistent
exercise
3. What should a diabetic do
callous?
1
mm
a. tell his doctor
b. put iodine on them
c. nothing
d. use corn pads
b. as little as possible
c. heavy exercise once
a day
d. exercise after taking
medication
when he has a corn or
2
a. bandage them
b. cut them off
c. file them
d. tell his doctor
4. What is the best way for a diabetic to treat cuts and
scrapes?
1 2
a. bandage them a. keep them clean
b. keep them from scabbing b. put iodine on them
c. keep them clean c. put adhesive tape on
d. ignore them d. put alcohol on them
130
5. Why keep the £eet as clean as the face?
a.
b.
c.
d.
so they look good
to help your circula
tion
to avoid infection
no special reason
a. to avoid having to
exercise
b. to avoid infection
c. you don*t have to
d. so you can wear
tighter shoes
6. Why should a diabetic check his feet each night?
a. it's not necessary
b. to see if his shoes
fit
c. no special reason
d. to check for sores
a. to check for sores
b. to see if they're
clean
c. check them if you have
a sore
d. to see if they need
medication
7. Why should a diabetic not soak his feet in hot water?
a.
b.
c.
d.
may burn them easily
he'll catch cold
his temperature may
go up
speeds circulation
too much
a. may burn them easily
b. he can if they're sore
c. increased blood sugar
level
d. it hardens toenails
8. How should your toenails
1
a. straight across
b. after soaking in hot
water
c. pointed
d. very very short
cut?
2
a. should be left very
long
b. straight across
c. rounded at ends
d. tear them off
131
9. What should you do If you find a sore on your foot?
1 2
a. soak your feet in a. ignore it
hot water b. put iodine on them
b. call your doctor c. call your doctor
c. bandage it d. wrap your feet in
d. wear heavy socks tape
ACUTE RE A C 1’IONS
What causes a diabetic to sweat,, become weak and
hungry, and act intoxicated?
1 2
a. too little exercise a. too much carbohydrate
b. high blood sugar b. eating between meals
c. too little protein c. low blood sugar
d. low blood sugar d. spilling sugar
What should be done immediately to treat a reaction?
1 2
a. exercise a. go to bed
b. don't eat b. eat sugar
c. eat sugar c. you can't do anything
d. take some medication d. eat some vegetables
How can you avoid reactions?
1 2
a. eat a lot of protein a. take more medication
b. avoid snacking b. eat fats
c. eat meals on time c. don't eat any starches
d. exercise d. eat meals on time
How can you prevent a reaction during excessive
exercise?
1
a. eat a little sugar
b. eat some meat
c. take more medication
d. don't eat before
exercising
2
a. avoid carbohydrates
b. eat a little sugar
c. exercise just after
taking medication
d. a diabetic can't
exercise
What causes diabetic coma?
1
a. skipping meals
b. too little insulin
c. too much insulin
d. low blood sugar
2
a. too much medication
b. too little insulin
c. not eating enough
d. exercise
What causes s diabetic to vomit, urinate frequently,
be thirsty, and breathe rapidly?
1
a. not eating enough
b. reaction
c. high blood sugar
d. exercise
How fast is the onset of a
1
a. several days
b. gradually
c. five hours
d. usually rapid
2
a. high blood sugar
b. too much medication
c. low blood sugar
d. fasting
reaction?
2
a. two days
b. four hours
c. usually rapid
d. six hours
133
8. How fast is the onset of a diabetic coma?
1
a. five minutes
b. gradual
c. one hour
d. rapidly
9. When a diabetic has had a
to his blood sugar?
1
a. it circulates faster
b. it has increased
c. it has fallen
d. he is spilling sugar
2
a. gradual
b. ten minutes
c. very rapid
d. two hour8
reaction, what has happened
2
a. the protein level has
decreased
b. nothing
c. it has fallen
d. it has increased
slightly
%
APPENDIX D
DALE-CHALL READABILITY FORMULA
135
TABLE 18
DALE-CHALL READABILITY FORMULA
APPLIED TO 60 QUESTIONS ON A DIABETIC'S
SELF-CARE PROGRAM
1. Number of words in sample 639
2. Number of sentences in sample 60
3. Number of words not on Dale list 80
4. Average sentence length 10.65
5. Dale score (3 * 1 x 100) 12.5
6. Multiply average sentence length by .0496 .5282
7. Multiply Dale score by .1579 1.974
8. Constant 3.6365
Formula « 6 + 7 + 8 + - 6.1384
Grade level « 6.0 to 6.9 ■ seventh and eighth grades
136
TABLE 19
DALE-CHALL READABILITY FORMULA APPLIED TO 60 QUESTIONS
ON A DIABETIC'S SELF-CARE PROGRAM WHILE EXCLUDING
THE WORDS "URINE*1 AND "DIABETES"/•'DIABETIC"
1. Number of words in sample 606
2. Number of sentences in sample 60
3. Number of words not on Dale list 47
4. Average sentence length 10.1
5. Dale score (3 - f 1 x 100) 7.75
6. Multiply average sentence length by
.0496 .50096
7. Multiply Dale score by .1579 1.223725
8. Constant 3.6365
Formula ■ 6 + 7 + 8 - 5.46
Grade level * 5.0 to 5.9 ■» fifth and sixth grades
APPENDIX E
RAW DATA
TABLE 20
138
RAW DATA
NUMBER OF CORRECT RESPONSES ON PRE- AND
POST-TEST OF SUBJECTS' KNOWLEDGE OF
DIABETIC'S SELF-CARE PROGRAM
Sub- Pre-Test Post-Test ^Score* * 06
io. II III IV I II III IV II III IV
1 41 26 38 36 48 24 47 7 -2 9
2 44 32 38 1 44 45 51 0 13 13
3 42 16 21 33 45 28 31 3 12 10
4 28 37 29 38 32 44 36 4 7 7
5 22 35 37 28 21 46 56 -1 11 19
6 39 37 39 16 44 50 54 5 13 15
7 44 40 30 22 45 42 39 1 2 9
8 32 42 35 24 34 59 44 2 17 9
9 33 43 16 17 41 59 35 8 16 19
10 27 33 23 21 28 44 39 1 11 16
11 37 34 31 41 37 46 53 0 12 22
12 40 41 35 19 41 51 37 1 10 2
13 44 24 30 39 50 29 37 6 5 7
14 31 25 22 37 35 26 24 4 1 2
15 28 39 33 19 27 44 37 -1 5 4
16 21 27 31 24 21 26 42 0 -1 11
17 30 42 41 25 38 46 53 8 4 12
18 29 16 38 23 37 21 47 8 5 9
19 36 41 25 31 34 53 31 —2 12 6
20 47 40 42 26 46 39 53 -1 -1 11
Column headings:
I - Post-Test Control Group
II ■ Pre- and Post-Test Control Group
III ■ Instruction Booklet Control Group
IV « Experimental Group
APPENDIX F
TESTING BOOKLET
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Asset Metadata
Creator
Deacon, Sharon Rae
(author)
Core Title
The Effects Of Feedback On The Communication Of Medical Prescription To Diabetic Patients
Degree
Doctor of Philosophy
Degree Program
Psychology
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
OAI-PMH Harvest,psychology, general
Language
English
Contributor
Digitized by ProQuest
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Advisor
Jacobs, Alfred (
committee chair
), McBath, James H. (
committee member
), Priest, Robert F. (
committee member
), Slucki, Henry (
committee member
)
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