PUBLIC HEALTH BRIEFS
skills in the proper ratio according to AHA standards. The fact that only 1 per cent of all trainees correctly performed all behaviors indicates that a major dichotomy exists not only between the cognitive knowledge and performance skills but also between the preliminary and functional performance techniques. Even more alarming, 88 per cent of the trainees felt confident in their ability to administer CPR. At the present time, there are no rigid pass/fail criteria for Basic Life Support courses. Consequently, trainees certified for completing the course feel that they are capable of effectively administering CPR, regardless of their actual performance ability. At the very least, this study emphasizes the importance of establishing more objective pass/fail criteria for Basic Life Support CPR instruction and underscores the need for more specific assessment of trainee knowledge and performance skills. A quantitative evaluation procedure which is easy to administer would strengthen lay CPR instruction programs. As more and more CPR training programs are launched throughout the United States, the importance and timeliness of further research is emphasized. Many questions remain unanswered: Are the recommended standards of CPR performance too difficult for the average lay individual to attain? If so, should the standards be modified, and to what degree? What specific areas of CPR training need reinforcement through additional manikin practice and/or supplemental literature? Is the Recording Resusci Anne an appropriate simulator of a person? Further, questions concerning the retention of knowledge and psychomotor skills must be answered: Are mandatory refresher courses needed? And, how can they be appropriately implemented? Although this study documents that lay CPR instructors are capable of providing for and facilitating the transfer of cognitive and selected performance skills, a more systematic approach to lay CPR training is needed. The concept of lay
CPR instruction should not be abandoned, but rather refined to incorporate a standardized evaluation of trainee performance and to stress attainment and retention of adequate functional psychomotor performance skills.
ACKNOWLEDGMENTS This project was conducted by the Public Education Section of the National Heart and Blood Vessel Research and Demonstration Center, Baylor College of Medicine, Houston, Texas, a grant supported project of the National Heart, Lung, and Blood Institute, National Institutes of Health, Grant No. HL 17269. The authors wish to thank The Junior League of Houston and the American Heart Association, Houston Chapter, for their outstanding cooperation and assistance in conducting the study. Also, we wish to thank Robert M. Chamberlain, PhD, for his assistance on the earlier drafts of this manuscript.
REFERENCES 1. American Heart Association, National Academy of SciencesNational Research Council. Standards for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). Journal of the American Medical Association 227 (Supplement): 833-866, 1974. 2. Katser, A. D., Norman, G. C., and The AHA Task Force on CPR Instructional Material. CPR, Cardiopulmonary Resuscitation: Overview 1. American Heart Association: 1-10, 1975. 3. Lund, I., and Skulberg, A. Cardiopulmonary resuscitation by lay people. The Lancet 2:702-704, 1976. 4. Cobb, L. A., Alvarez, H., III, Kopass, M. K. A rapid response system for out-of-hospital cardiac emergencies. Medical Clinics of North America 60 (2):283-293, 1976. 5. Alvarez, H., III, Cobb, L. A. Experiences with CPR training of the general public. Proceedings of the National Conference on Standards for Cardiopulmonary Resuscitation and Emergency Cardiac Care, American Heart Association, 33-37, 1975. 6. Vanderschmidt, H., Burnap, T. K., Thwaites, J. K. Evaluation of cardiopulmonary resuscitation course for secondary schools. Medical Care 13 (9):763-774, 1975. 7. Pyramid Films: New Pulse of Life, University of Southern California School of Medicine, Los Angeles, CA, 1975.
Application of a Data Collection Method To Ensure Confidentiality ROGER B. WHITE, MSW, DRPH A study to estimate the incidence and prevalance of child abuse and neglect among a Native American population was recently conducted. The double blind data collection method described assisted in obtaining data access from Address reprint requests to Dr. Roger B. White, Assistant Professor, Department of Maternal and Child Health, Johns Hopkins University, School of Hygiene and Public Health, 615 N. Wolfe St., Baltimore, MD 21205. This paper, submitted to the Journal January 17, 1977, was revised and accepted for publication May 31, 1977.
AJPH November 1977, Vol. 67, No. 11
the federal, state, tribal and private agencies since it provided a means to protect individual identification. Application of this method required minor modifications to accomodate the various agency interpretations of the Federal Privacy Act (P.L. 93-579) or their own data confidentiality provisions. Two data collection instruments were devised, hereinafter referred to as the Patient Information Form (PIF) and the Master File Form (MFF). The PIF contained sociodemographic and medical data relevant to the study questions. 1095
PUBLIC HEALTH BRIEFS
Personally identifying data such as names, addresses, and date of birth were not included on the PIF form. Sequential case numbers for the study were assigned ranging from 0001 through 3999 in anticipation of no more than 4,000 cases
being reviewed. Master File Form (MFF) numbers ranging from 6001 to 9999 were randomly generated and paired to the PIF study instruments. Data collection packets included the PIF and MFF instruments as detachable units. Personally identifying information was included on the MFF although without reference to the data collection source, study status of the child, or PIF number. Since the study utilized comparison children from among pediatric outpatient programs, the headings of the MFF sheet revealed that this was a child health survey. Such a heading openly and briefly described a study focus and prevented those persons having access to the completed MFF (e.g. clerks, messengers, or secretaries) from determining if the child was seen as a result of abuse or neglect or if the child was a member of the comparison group. Data on the MFF included the child's full name, month, day and year of birth, sex, and mother's full name. (See Figure 1) To reduce the potential for rater variation and concomitant error, three data collectors were used within and between data sources.* Data collectors completed the instrument package and the MFF instruments were given to a designated agency administrator. Separation of the MFF and PIF instruments precluded any future reconstruction of personal identification. The MFF, now under control of the agency administrator, was forwarded to a previously agreed upon central administration representative for the courts, hospitals, or social service agencies. the PIF data, anonymous to individual identification, was transferred for data processing. Within medical facility settings it was not possible for the agency representative to determine if the child was abused, neglected, or part of the majority (94 per cent) representing comparison cases. Within court and social service agencies, the MFF instruments represented an abused or neglected child . . . information possessed by the agency prior to the study. Once all data collection had been completed from the 29 data centers, the previously agreed upon central administrative representatives met with the principal investigator to rearrange all Master File Forms. Since hospital, court, and social service cases had now been merged by this procedure *One agency supplied additional data collectors for abstracting their data with appropriate reliability of data methods employed.
1 096
and since case status and source were not identified on the MFF, the principal investigator was not in a position to act other than as a clerk in sorting cases solely for duplicate case removal. Three manual sorts of the MFF were required using child and mother names separately and date of birth. When sorting was completed, the forms were destroyed in the presence of agency representatives to ensure that the names were not available for subsequent use. Where duplicate cases were noted, only the randomized MFF number was recorded and subsequently computer matched to the PIF number. Since all cases were now identifiable only by randomly assigned number dyads, case specific identification data were not possible at this stage of data collection. In summary, what may appear as an elaborate system is quite elementary and provides for the retention of anonymity within a population and adds only the step of manual MFF sorting for duplicate removal purposes. This double blind data collection approach is conveniently used for reliability sub-studies since a method of selecting cases for re-rate at differing time intervals or by different raters can be easily handled. Blindness is maintained since original data are separated from the record source. Unused original data forms may be used and simply marked as a "re-rate". The duplicate removal phase is used to identify and match re-rated to original cases and the subsequent testing is handled by computer. Application of this technique undoubtedly can enable researchers to gain access where individual patient release of information is neither possible nor feasible while providing for the ethical and legal protection necessary for the patients. The compliance of this procedure to meeting various federal and state codes has been tested only in the circumstances of the study described.
Conclusion Even where federal, state, and local codes do not require it, this double blind method is an added protection. In addition to data confidentiality, this procedure provides assurance to the principal investigator and study staff that accidental viewing of data collection instruments could not be tied to the releasing of any information that could be construed as deleterious to an individual or family. Variations specific to individual study questions, various populations, and unique analytical procedures will require individual logistics for application. However, the goals of gaining access to data while deliberately providing anonymity to protect patient rights to privacy can be overcome by incorporating a double blind data collection method.
AJPH November 1977, Vol. 67, No. 11
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PUBLIC HEALTH BRIEFS
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AJPH November 1977, Vol. 67, No. 1 1
_ 0
1097
skills in the proper ratio according to AHA standards. The fact that only 1 per cent of all trainees correctly performed all behaviors indicates that a major dichotomy exists not only between the cognitive knowledge and performance skills but also between the preliminary and functional performance techniques. Even more alarming, 88 per cent of the trainees felt confident in their ability to administer CPR. At the present time, there are no rigid pass/fail criteria for Basic Life Support courses. Consequently, trainees certified for completing the course feel that they are capable of effectively administering CPR, regardless of their actual performance ability. At the very least, this study emphasizes the importance of establishing more objective pass/fail criteria for Basic Life Support CPR instruction and underscores the need for more specific assessment of trainee knowledge and performance skills. A quantitative evaluation procedure which is easy to administer would strengthen lay CPR instruction programs. As more and more CPR training programs are launched throughout the United States, the importance and timeliness of further research is emphasized. Many questions remain unanswered: Are the recommended standards of CPR performance too difficult for the average lay individual to attain? If so, should the standards be modified, and to what degree? What specific areas of CPR training need reinforcement through additional manikin practice and/or supplemental literature? Is the Recording Resusci Anne an appropriate simulator of a person? Further, questions concerning the retention of knowledge and psychomotor skills must be answered: Are mandatory refresher courses needed? And, how can they be appropriately implemented? Although this study documents that lay CPR instructors are capable of providing for and facilitating the transfer of cognitive and selected performance skills, a more systematic approach to lay CPR training is needed. The concept of lay
CPR instruction should not be abandoned, but rather refined to incorporate a standardized evaluation of trainee performance and to stress attainment and retention of adequate functional psychomotor performance skills.
ACKNOWLEDGMENTS This project was conducted by the Public Education Section of the National Heart and Blood Vessel Research and Demonstration Center, Baylor College of Medicine, Houston, Texas, a grant supported project of the National Heart, Lung, and Blood Institute, National Institutes of Health, Grant No. HL 17269. The authors wish to thank The Junior League of Houston and the American Heart Association, Houston Chapter, for their outstanding cooperation and assistance in conducting the study. Also, we wish to thank Robert M. Chamberlain, PhD, for his assistance on the earlier drafts of this manuscript.
REFERENCES 1. American Heart Association, National Academy of SciencesNational Research Council. Standards for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). Journal of the American Medical Association 227 (Supplement): 833-866, 1974. 2. Katser, A. D., Norman, G. C., and The AHA Task Force on CPR Instructional Material. CPR, Cardiopulmonary Resuscitation: Overview 1. American Heart Association: 1-10, 1975. 3. Lund, I., and Skulberg, A. Cardiopulmonary resuscitation by lay people. The Lancet 2:702-704, 1976. 4. Cobb, L. A., Alvarez, H., III, Kopass, M. K. A rapid response system for out-of-hospital cardiac emergencies. Medical Clinics of North America 60 (2):283-293, 1976. 5. Alvarez, H., III, Cobb, L. A. Experiences with CPR training of the general public. Proceedings of the National Conference on Standards for Cardiopulmonary Resuscitation and Emergency Cardiac Care, American Heart Association, 33-37, 1975. 6. Vanderschmidt, H., Burnap, T. K., Thwaites, J. K. Evaluation of cardiopulmonary resuscitation course for secondary schools. Medical Care 13 (9):763-774, 1975. 7. Pyramid Films: New Pulse of Life, University of Southern California School of Medicine, Los Angeles, CA, 1975.
Application of a Data Collection Method To Ensure Confidentiality ROGER B. WHITE, MSW, DRPH A study to estimate the incidence and prevalance of child abuse and neglect among a Native American population was recently conducted. The double blind data collection method described assisted in obtaining data access from Address reprint requests to Dr. Roger B. White, Assistant Professor, Department of Maternal and Child Health, Johns Hopkins University, School of Hygiene and Public Health, 615 N. Wolfe St., Baltimore, MD 21205. This paper, submitted to the Journal January 17, 1977, was revised and accepted for publication May 31, 1977.
AJPH November 1977, Vol. 67, No. 11
the federal, state, tribal and private agencies since it provided a means to protect individual identification. Application of this method required minor modifications to accomodate the various agency interpretations of the Federal Privacy Act (P.L. 93-579) or their own data confidentiality provisions. Two data collection instruments were devised, hereinafter referred to as the Patient Information Form (PIF) and the Master File Form (MFF). The PIF contained sociodemographic and medical data relevant to the study questions. 1095
PUBLIC HEALTH BRIEFS
Personally identifying data such as names, addresses, and date of birth were not included on the PIF form. Sequential case numbers for the study were assigned ranging from 0001 through 3999 in anticipation of no more than 4,000 cases
being reviewed. Master File Form (MFF) numbers ranging from 6001 to 9999 were randomly generated and paired to the PIF study instruments. Data collection packets included the PIF and MFF instruments as detachable units. Personally identifying information was included on the MFF although without reference to the data collection source, study status of the child, or PIF number. Since the study utilized comparison children from among pediatric outpatient programs, the headings of the MFF sheet revealed that this was a child health survey. Such a heading openly and briefly described a study focus and prevented those persons having access to the completed MFF (e.g. clerks, messengers, or secretaries) from determining if the child was seen as a result of abuse or neglect or if the child was a member of the comparison group. Data on the MFF included the child's full name, month, day and year of birth, sex, and mother's full name. (See Figure 1) To reduce the potential for rater variation and concomitant error, three data collectors were used within and between data sources.* Data collectors completed the instrument package and the MFF instruments were given to a designated agency administrator. Separation of the MFF and PIF instruments precluded any future reconstruction of personal identification. The MFF, now under control of the agency administrator, was forwarded to a previously agreed upon central administration representative for the courts, hospitals, or social service agencies. the PIF data, anonymous to individual identification, was transferred for data processing. Within medical facility settings it was not possible for the agency representative to determine if the child was abused, neglected, or part of the majority (94 per cent) representing comparison cases. Within court and social service agencies, the MFF instruments represented an abused or neglected child . . . information possessed by the agency prior to the study. Once all data collection had been completed from the 29 data centers, the previously agreed upon central administrative representatives met with the principal investigator to rearrange all Master File Forms. Since hospital, court, and social service cases had now been merged by this procedure *One agency supplied additional data collectors for abstracting their data with appropriate reliability of data methods employed.
1 096
and since case status and source were not identified on the MFF, the principal investigator was not in a position to act other than as a clerk in sorting cases solely for duplicate case removal. Three manual sorts of the MFF were required using child and mother names separately and date of birth. When sorting was completed, the forms were destroyed in the presence of agency representatives to ensure that the names were not available for subsequent use. Where duplicate cases were noted, only the randomized MFF number was recorded and subsequently computer matched to the PIF number. Since all cases were now identifiable only by randomly assigned number dyads, case specific identification data were not possible at this stage of data collection. In summary, what may appear as an elaborate system is quite elementary and provides for the retention of anonymity within a population and adds only the step of manual MFF sorting for duplicate removal purposes. This double blind data collection approach is conveniently used for reliability sub-studies since a method of selecting cases for re-rate at differing time intervals or by different raters can be easily handled. Blindness is maintained since original data are separated from the record source. Unused original data forms may be used and simply marked as a "re-rate". The duplicate removal phase is used to identify and match re-rated to original cases and the subsequent testing is handled by computer. Application of this technique undoubtedly can enable researchers to gain access where individual patient release of information is neither possible nor feasible while providing for the ethical and legal protection necessary for the patients. The compliance of this procedure to meeting various federal and state codes has been tested only in the circumstances of the study described.
Conclusion Even where federal, state, and local codes do not require it, this double blind method is an added protection. In addition to data confidentiality, this procedure provides assurance to the principal investigator and study staff that accidental viewing of data collection instruments could not be tied to the releasing of any information that could be construed as deleterious to an individual or family. Variations specific to individual study questions, various populations, and unique analytical procedures will require individual logistics for application. However, the goals of gaining access to data while deliberately providing anonymity to protect patient rights to privacy can be overcome by incorporating a double blind data collection method.
AJPH November 1977, Vol. 67, No. 11
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AJPH November 1977, Vol. 67, No. 1 1
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