medical drama research paper

• Research article
• Open access
• Published: 26 September 2021

TV medical dramas: health sciences students’ viewing habits and potential for teaching issues related to bioethics and professionalism

• Irene Cambra-Badii   ORCID: orcid.org/0000-0003-1233-3243 1 , 2 ,
• Elisabet Moyano 2 ,
• Irene Ortega 3 ,
• Josep-E Baños 4 &
• Mariano Sentí 2  

BMC Medical Education volume  21 , Article number:  509 ( 2021 ) Cite this article

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Medical dramas have been popular since their inception, especially among medical students. We hypothesized that the recent increase in the availability of TV medical series through online streaming platforms has probably changed health science students’ viewing habits as well as the representation of bioethical conflicts and health professionals.

We invited undergraduate students of medicine, nursing, and human biology to complete a self-administered questionnaire about their viewing habits and perceptions of the depictions of bioethical issues and professionalism in TV medical series.

Of the 355 respondents, 98.6 % had watched TV in the last year, 93.5 % watched TV series, and 49.6 % watched medical dramas more than once a week. The most-viewed medical dramas were The Good Doctor , House MD , and Grey’s Anatomy . The most-remembered bioethical topics were medical errors, inappropriate professional behaviors, and death. Most students considered that ideals of professionalism were depicted positively and professionals were portrayed as intelligent, professionally qualified, and competent.

Conclusions

Medical dramas are very popular with health science students and are potentially useful as teaching tools for discussing issues related to bioethics and professionalism.

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TV medical dramas have been very popular since their inception [ 1 , 2 , 3 , 4 , 5 ]. Although most TV medical dramas are produced in the United States and depict situations in the American health system, they are consumed globally. Medical dramas are mainly watched for entertainment and relaxation [ 6 ]; they are followed by many medical and nursing students [ 7 , 8 , 9 , 10 ] as well as by clinicians [ 11 ].

These fictional narratives provide concrete medical situations and are often regarded as a source of health information by viewers [ 1 , 12 ]. Several authors have suggested that medical dramas are a potential tool for teaching students in health sciences disciplines [ 2 , 5 , 13 , 14 ]. Baños et al. [ 15 ] analyzed the usefulness of House MD for teaching clinical pharmacology. Jerrentrup et al. [ 3 ] also proposed House MD to teach about rare diseases and diagnostic strategies. Williams et al. [ 16 ] pointed out several potential uses of House MD , Scrubs , and Grey’s Anatomy to teach medical problems, medical system issues, psychosocial issues, and relationships with the patient’s family. Wong et al. [ 17 ] successfully used two excerpts from House MD and one from Grey´s Anatomy to teach doctor-patient communication skills, while McNeilly and Wengel [ 18 ] used ER for teaching psychotherapeutic techniques to medical students. Hirt et al. [ 19 ] suggested Northern Exposure , Cardiac Arrest , ER , Scrubs , House MD , Doc Martin , Grey’s Anatomy , and Nurse Jackie in a brief guide for health sciences educators to teach various themes such as mentorship, hospital environments, teaching and learning, and professionalism.

Specifically for analyzing and teaching professionalism and bioethical issues, medical dramas were especially explored in the last decade. Czarny et al. [ 20 ] performed a content analysis of 50 episodes of Grey’s Anatomy and House MD during the 2005–2006 television season and found 79 depictions of bioethical issues classified under 11 topics, including consent, ethically questionable departures from standard practice, death and dying, and confidentiality. Cambra Badii et al. [ 21 ] performed a content analysis of the first season of The Good Doctor and found 179 situations that can be used to teach bioethics. Arawi [ 22 ] proposed to work with Grey’s Anatomy and House MD vignettes to teach biomedical ethics, and Pavlov and Dalquist [ 23 ] used Grey’s Anatomy to teach communication and professionalism. Moreover, Spike [ 24 ] pointed out the bioethical issues involved in a doctor–patient communication and medical errors in Scrubs .

The portrayals of health professionals that appear in medical dramas are also interesting, because they were changing over the years [ 5 , 14 , 25 ]. Chory-Assad and Tamborini [ 26 , 27 ] demonstrated the decline in positive portrayals of physicians in television since the 1990 s, and Czarny et al. [ 20 ] showed up clearly anomalous portrayals of professionalism in House MD and Grey’s Anatomy .

These portrayals can be used to analyze or discuss professionalism because they offers positive models of behavior, like Miranda Bailey and Derek Sheperd from Grey’s Anatomy , or Allison Cameron and James Wilson from House MD [ 9 ]. Even complex and negative models, like Doctor House in House MD , can be useful to teach professionalism, but in this case, from his mistakes [ 9 , 20 ]. Seminal studies of television viewing habits of health sciences students have provided interesting information about health sciences students’ TV viewing habits [ 7 , 9 , 10 ]. However, in the last 10 years, the growing popularity of online platforms such as Netflix, HBO, Hulu, and Amazon Prime has drastically changed the way that TV series are produced and consumed [ 28 ]. It is likely that these developments have changed health sciences students’ TV viewing habits, and it is possible that they have also affected their impressions of bioethical issues and the portrayal of healthcare professionals in medical series.

Taking into account the previous literature and the expansion of series and online platforms, we hypothesized that health sciences students watch medical dramas almost daily, that they remember ethical dilemmas and how they were portrayed, and that they follow positive and negative role models, so medical dramas might therefore be useful for teaching them bioethics and professionalism. In this study, we sought to determine (a) health science students’ television viewing habits, (b) which medical dramas they have recently viewed, (c) their motives for watching medical dramas, (d) the ethical issues portrayed in the dramas that they recall, and (e) the characteristics of the health professionals’ portrayed in the dramas that determine whether students’ consider them positive or negative role models.

Study population

This study surveyed all undergraduate students of medicine, nursing, and human biology at our University during the 2018–2019 academic year. Inclusion criteria were participation in classroom activities at the time of the survey and consent to participate in the study. Exclusion criteria were not explicitly established other than the lack of compliance with inclusion criteria. The final sample population included all students enrolled in the 6-year Bachelor of Medicine program, in the first 3 years of the 4-year Bachelor in Nursing program, and in all years of the 4-year Bachelor in Human Biology. Fourth-year nursing students were not included because the fourth year of this program is dedicated to clinical training and does not include classroom activities. Medical students begin clinical training in the fourth year, but continue to have classroom activities thereafter, and students of human biology do not undergo clinical training.

Study design

We adapted Czarny’s medical TV drama survey [ 10 ], designed to gather data on basic demographic characteristics, general TV and TV medical drama viewing habits, impressions of bioethical and professionalism issues in medical dramas, and sources of information on bioethical issues (Additional file 1 ).

Medical dramas considered in the study were ER , House MD , Grey’s Anatomy , NipTuck and Scrubs like in previous studies [ 7 , 9 , 10 ]. We have added the most newest medical dramas aired in Spain at the time of the survey, The Good Doctor and The Resident . Students could add other medical dramas in an open field. We modified some questions about TV shows and the characters that students most and least wish to resemble in their professional lives to make them open-ended and adding some questions about the reasons for watching medical series [ 6 ] and the portrayal of doctors and nurses in medical dramas [ 26 ].

To ascertain whether the wording or the questions should be changed, we pilot-tested the survey on ten members of the research team. They were experienced researchers in the field of biomedical research education and members of the Group for Educative Research in Health Sciences of our university. Based on this feedback, we reformatted the survey to improve clarity.

Data collection

We used the Google Forms platform to draft the questionnaire and conduct the survey; participants could complete the questionnaire between February 13 and April 8, 2019. We ensured that each respondent provided only one response by controlling the login in Google Forms in the different classrooms, while guaranteeing anonymity.

The study was performed according to the principles of the Declaration of Helsinki. Data confidentiality was ensured according to local legislation on the protection of personal data.

Before starting the survey, students were read an information sheet explaining the background, aims, and procedure of the study, and they were informed that the bioethics committee had approved the study protocol and that participation was voluntary.

Data analysis

We used descriptive statistics to summarize participants’ demographic characteristics and data obtained from the survey. To compare categorical variables between groups (men vs. women; medical students vs. nursing students vs. human biology students; preclinical vs. clinical medical students), we used chi-square tests.

In analyzing our data, we dichotomized responses for three items. For the frequency of viewing medical series, we grouped all responses indicating viewing > 1 under the category “frequently” [ 9 ]. For questions answered on a five-item Likert scale (those regarding the reasons for viewing medical dramas and the representation of ethical issues), the responses “totally agree” and “agree” were grouped together into the category “yes”, and the responses “neither agree nor disagree”, “disagree”, and “strongly disagree” were grouped into the category “no”. Similarly, the responses about the appropriateness of the depiction of each of the different ethical issues in the medical series, the responses “barely” and “below acceptable” were grouped together into the category “poorly represented”, while the responses “appropriate” and “very appropriate” were grouped together as “well represented”.

All tests were two-tailed, and statistical significance was set at 0.05. Microsoft Office Excel 2007 and SPSS (version 16) were used for all analyses.

A total of 355 of 918 students participated in the survey; responses were obtained from 124/339 (36.6 %) of eligible medical students, 143/381 (37.5 %) of eligible nursing students, and 88/198 (44.4 %) of eligible human biology students (Table  1 ). Women accounted for 78.5 % of the respondents, and the proportion of women participants was similar in the three programs, coinciding with the distribution of women in the three programs. Mean age did not differ between groups of students from the different programs, although the age range was broader in the group of nursing students than in the other two groups.

Television viewing habits

Nearly all respondents (98.6 %) reported watching TV in the last year; the most-watched shows were TV series (93.5 %), followed by movies (86.8 %), news (67.9 %), and sports (34.7 %) (Table  2 ). There were no differences between genders except women in the nursing program watched less news and sports ( p  < 0.05).

Nearly half (49.6 %) the students watched medical dramas. There were no differences in the frequency of viewing among the different programs.

The most common way of watching medical dramas was through online platforms (listed by 78.1 % of respondents: of whom 41.7 % used Netflix, 23.7 % used Movistar, 9.9 % used HBO, and 2.8 % used Amazon), followed by regular TV episodes (24.2 %), regular TV reruns (16.3 %), pirate streaming (11.5 %), and DVD (1.4 %).

In the last year, the most-watched medical dramas were The Good Doctor (47 %), House MD (41.4 %), and Grey’s Anatomy (38 %), followed by The Resident (7.9 %), ER (6.8 %), and Scrubs (5.9 %). No series included in the open field “other medical series” reached a significant frequency to be included in the analysis, but Chicago Med , Code Black and Nurse Jackie were mentioned a total of 16 times.

Gender differences were observed only for Grey’s Anatomy , watched by 44.7 % of women but only 13.1 % of men. The difference was even greater among medical students (46.5 % of women vs. 8.3 % men, p  < 0.001). No differences were found in the medical dramas watched between students’ in different years within academic programs.

Asked whether they discuss medical aspects of the series with their friends, 57.8 % of all participants responded affirmatively. The reasons most often given for watching medical dramas were entertainment (96.6 %) and medical information (89.2 %), followed by habitual pastime/companionship (76.5 %), and relaxation (68 %).

Ethical issues

Most students (56.9 %) considered that the medical series did not adequately portray the bioethical issues that appear in clinical practice. The bioethical issues remembered best were medical errors (66.5 %), inappropriate professional behavior (58.3 %), and death (59.4 %), followed by confidentiality (49 %), quality or value of life (48.2 %), infectious diseases (45.9 %), and access to and equity in health care (40.8 %). The least-mentioned issues were harassment (29.3 %), education for healthcare professionals (25.6 %), non-therapeutic methods (24.8 %), and human research (22.3 %) (Table  3 ).

The ethical issues that were considered the best portrayed in the medical dramas differed among the groups. Medical students most often listed death (65.9 %), infectious diseases (62.7 %), and quality or value of life (62.1 %); nursing students most often listed organ transplantation (67 %), death (62.5 %), and quality or value of life (59.3 %); and human biology students most often listed death (84 %), infectious diseases (81.6 %), and organ transplantation (80.9 %).

Similarly, the ethical issues considered badly represented listed by medical students were non-therapeutic medical uses (65.1 %), human research (64.3 %), and education of health professionals (58.8 %); those listed by nursing students were human research (64.1 %), access to and equity in health care (63.2 %), and non-therapeutic medical uses (62.5 %); and those listed by human biology students were access to and equity in health care (65.9 %), human research (59.5 %), and harassment (51.1 %).

There were no significant differences between clinical and preclinical medical students regarding the representation of bioethical issues: 45.2 % of preclinical students and 54.8 % of clinical students responded that these issues were well represented.

Sources of bioethical information

The information about bioethics that students received during their university education came mostly in compulsory subjects (52.4 %), followed by extracurricular activities (5.1 %), and elective subjects (2.3 %); 15.5 % of respondents stated that they had received no information from the university about bioethical issues.

The sources of information on bioethics considered most important were the university (91.3 %) and scientific journals (86.8 %), followed by friends (76.4 %) and medical dramas (63.6 %). The sources considered less important were ecclesiastical staff, religious values, ​​and blogs. There were no differences between genders. There were no differences between fields of study, except medical students gave significantly lower importance to scientific journals and religious values.

Portrayals of health professionals

Most students believed that all ideals of professionalism were depicted positively in medical dramas. Doctors were portrayed positively in medical dramas; respondents referred to their intelligence (97.3 %), professional qualification (93.6 %), and competence (90.5 %). Nurses were also portrayed positively; respondents most often referred to their kindness (75.8 %), empathy (74.5 %), and caring (74.3 %).

The survey asked about which characters the students aspire to be like in their professional careers, and they responded none (9.9 %), Dr. Meredith Grey (from Grey’s Anatomy ) (5.6 %), and Dr. Gregory House (from House MD ) (2.5 %). Students of human biology tended to want to resemble Dr. House more than medical students and nurses.

The characters they least aspired to be like were Dr. Gregory House (from House MD ) (18.6 %) and Cristina Yang (1.4 %) and April Kepner (1.1 %) (both from Grey’s Anatomy ). The most-chosen negative characteristics were lack of intelligence (55.1 %), lack of professional qualification (53.1 %), and lack of competence (42.2 %).

More than 12 years after Czarny et al.’s original survey of health science students’ TV viewing habits [ 10 ], we found that nearly all health sciences students had watched TV in the last year, corroborating the findings of other studies in the interim [ 7 , 9 ]. Moreover, TV medical dramas were the type of program that students’ watched most. This is a notable difference with Weaver and Wilson’s study [ 9 ], where medical dramas were the least-watched category (films were the most-watched category). This difference could be explained by the increased number of TV series and their availability through online platforms (e.g., Netflix); students now have greater freedom to choose what they want to see.

Nevertheless, the percentage of students who said they watch medical series (49.6 %) was much lower than in earlier studies (> 80 % in all), although we asked specifically about medical dramas, which can be considered a subgenre of medical programs. We cannot know whether these findings represent a change of health science students’ interests or whether they are a consequence of the proliferation of programs and series in various genres.

The medical drama that health science students watched most was The Good Doctor , one of the newest medical dramas (available since 2017). This series shows the life of a young autistic physician with savant syndrome who is starting his residency in surgery, and it includes many situations that involve bioethical issues [ 21 ]. The Good Doctor approaches medical issues from a different point of view than other popular medical dramas, and the originality of using an autistic resident as the main character probably adds to its appeal.

Two of the most-viewed series in previous surveys were also among the most popular in the current study: House MD , which aired from 2008 to 2012, and Grey’s Anatomy , which has aired from 2005 and is now in its 16th season. Why do students continue to watch these TV series? House MD is considered one of the best medical dramas with an iconic protagonist [ 3 , 7 , 8 , 9 , 10 , 17 , 29 ] and, like Grey’s Anatomy , it is distributed by Netflix, one of the most popular media-services providers, with 193 million subscribers around the world in 2020 [ 30 ]. Our study also corroborates the findings in previous research [ 9 , 10 ] that Grey’s Anatomy was the only medical drama for which there were differences in viewing between the sexes. A greater proportion of women than men watched this medical drama, perhaps because the main character is a woman and the storyline revolves around social and love relationships and the daily challenges of clinical practice in a hospital [ 13 ]. Nevertheless, the percentage of women who regularly follow Grey’s Anatomy in our survey (44.7 %) is clearly lower than in Czarny’s study (81 %) but close to and Weaver and Wilson’s (48.2 %) survey. The drop in the consumption of this medical drama could be due to the age of the series (it debuted in 2005) as well as to the wide availability of competing offerings. The series ER and Scrubs , found to be popular in previous research [ 7 , 8 , 9 ], were not among the most-watched programs in the present study, probably because they are not currently available on online viewing platforms.

The most important reasons for viewing medical dramas in our study were different from those in Lee and Taylor’s factor analysis of data from students enrolled in communications courses [ 6 ], where social interaction, relaxation, and entertainment motives were significant predictors of viewing time. In the current study, the salient motives were entertainment and medical information. The sources of information on bioethical issues considered most important in the current study are in line with those reported in previous studies [ 7 , 10 ], underlining the importance of the university and scientific journals. However, in the second line, friendships have replaced family. Medical dramas continued to hold the third place, as in Williams’ [ 7 ] and Czarny’s [ 10 ] studies, although it is interesting to note that whereas less than 50 % of respondents in their studies considered medical dramas an important source of information about bioethical issues, more than 60 % of those in our study considered these programs important.

Over half the respondents in our study considered that the ethical issues that appear in medical dramas were not adequately depicted. We can only speculate about the reasons for this finding, which is similar to that reported in previous investigations [ 7 , 9 , 10 ], although the study populations were different. Perhaps students consider that medical dramas are unrealistic. It is important to note that students recall the ethical issues portrayed in medical dramas even some time after viewing and consider that they are not correctly represented. Given that nearly half the students discuss medical issues with friends and that “social activity may facilitate the formation of new opinions and perceptions” [ 10 ], it seems that medical dramas play a role in forming views about bioethics and appropriate behavior for health professionals.

We analyzed the portrayal of medical doctors and nurses in medical dramas and the characteristics of these professionals that the students consider positive. Both professions were viewed positively. The characters in medical dramas have changed over the last 25 years, evolving from idealized representations of “medical heroes” to more complex representations of professionals with flaws and interpersonal problems, even to the point of including “antiheroes” [ 25 , 26 , 27 , 31 ]. These changes seem to point to an increased focus on negative characteristics of physicians in current medical dramas; as Chory-Assad and Tamborrini [ 26 , 27 ] demonstrated, positive portrayals of physicians in television programs have declined since the 1990 s. However, students of health sciences continue to consider that the protagonists of these TV series are positively represented.

It is striking that we found the least-represented characteristics of the physicians in medical dramas were empathy, emotional involvement, and kindness. Our results agree partially with those of Chory-Assad and Tamborrini’s earlier studies [ 26 , 27 ] although their analyses included the representation of doctors in different types of television programs, not only medical dramas. Like in our study, “competence” was an important characteristic of TV physicians in their studies; however, they found that “ethical character” and “regard for others” were also portrayed. These findings highlight a shift in emphasis toward knowledge derived from evidence-based medicine to the detriment of clinical skills needed to care for patients [ 32 ].

As in Weaver and Wilson’s study [ 9 ], the characters students would most like to resemble continue to be the protagonists of House MD and Grey’s Anatomy , the most-viewed medical dramas. Also, Dr. Gregory House ranked highly both as someone students most and least aspired to be like in their own careers. The importance of this character should not be underestimated: despite his questionable professionalism evident in his constant disregard for the rules and avoidance of contact with his patients [ 33 , 34 ], health sciences students value House’s knowledge and intelligence [ 3 , 29 ].

The characters that respondents from all three programs of study said they would most like to resemble were all medical doctors. The fact that respondents did not choose any nursing characters invites speculation about the roles of doctors and nurses in TV medical dramas. Whereas the characteristics most often cited to describe physicians in these series were intelligence, professional qualification, and competence, those most often cited to describe nurses were friendliness, empathy, and caring. These portrayals have been analyzed various times in relation with the different roles of physicians and nurses as well as with poor, incorrect, or misleading portrayals of nursing role models [ 8 , 35 ] in which stereotypes abound, especially in relation to gender roles [ 36 ]. Nurses are rarely the protagonists of medical dramas and are even “invisible” in many TV dramas [ 37 ]; moreover, nurses are often wrongly characterized as only females and as underlings who are not involved in decision making.

Our results show that medical dramas could be useful for teaching bioethics. Because these programs are seen by many students, have an interesting and entertaining format, depict bioethical conflicts that students remember and characters they want to resemble, TV medical dramas can be considered a valuable tool to help students reflect on bioethics. Many TV series present diverse situations in each episode that can be used to teach ethics, although it is essential to analyze the content and to establish the suitability of the material for each pedagogical objective [ 38 , 39 ].

Students’ interest in medical dramas suggests that these programs can also be considered in developing new teaching strategies. These materials can be useful for exploring transversal issues, such as medical professionalism, doctor-patient relationship, bioethics, and communication skills [ 2 , 16 , 19 ]. Medical dramas can also be considered part of the hidden and informal curricula of medical ethics [ 40 , 41 , 42 ], which is at least as important as formal education in ethics [ 10 ]. Given the importance of compulsory subjects in health sciences degrees in teaching of bioethics, incorporating medical dramas into these classes could be a good approach to exploiting this material.

Students can absorb the educational messages in medical dramas when they view them for entertainment. In fact, even though they were not created specifically for education, these programs can be seen as an entertainment-education tool [ 43 , 44 ]. In entertainment-education shows, viewers are exposed to educational content in entertainment contexts, using visual language that is easy to understand and triggers emotional engagement [ 45 ]. The enhanced emotional engagement and cognitive development [ 5 ] and moral imagination make students more sensitive to training [ 22 ]. Previous investigations about entertainment-education medical dramas and social learning theory indicate that these programs can increase knowledge about health matters, for example about early breast cancer detection [ 46 ].

Albert Bandura’s social learning theory [ 47 , 48 , 49 ] indicates that people can learn behaviors vicariously by watching and thinking about characters’ behaviors. In entertainment-education medical drama, the characters can serve as positive or negative models to teach desirable professional behavior [ 9 , 10 ].

Rather than merely passive observers, health science students are active viewers who notice positive and also negative characteristics of physicians and nurses. In this sense, students can decide whether characters’ behavior should be emulated or criticized, as well as which characters might serve as positive or negative role models. Also, students point out that bioethical dilemmas are sometimes poorly represented (overall, students most often mentioned inadequate representation of bioethical issues related to human research, non-therapeutic methods, and equity of access to healthcare) and this implies that they critically see portrayal of bioethical dilemmas and the character actions in resolving these dilemmas. As Spike points out [ 24 ], these TV series adhere to the Hollywood paradigm of morality tale and may be valuable aids to thinking about ethics and professionalism. Although it is difficult to determine the effects of medical dramas on students’ attitudes, our study confirms their popularity.

Some authors consider that TV series can have negative influences on students because they could be unrealistic or even potentially harmful and dangerous [ 34 , 50 ], basically because of unreal or inaccurate depictions of hospital procedures and professional practice; however, we consider that rather than focusing on the authenticity of medical procedures, teaching based on medical series should focus on the plausibility of the situations that are presented [ 51 ]. The issues depicted in medical dramas are useful for exploring moral judgments beyond verisimilitude [ 29 ], although they may not be very useful for teaching practical skills [ 50 ] except to criticize mistakes. In any case, studies comparing the pedagogical efficacy of medical dramas and other narrative resources could provide valuable information.

Future research must apply a systematic approach to evaluate the pedagogical impact of medical dramas. Although there are some previous experiences [ 17 , 18 , 22 ], there is a lack of systematization in the development of these activities and in the measurements of empirical results; moreover, the approach to the pedagogical interpretation of this impact should also be considered systematically, for example using Kirkpatrick’s learning levels [ 52 , 53 ].

The large number of health science students that watch TV series and medical dramas in particular strongly suggests that students find these programs attractive, which in turn makes them attractive for teaching If we interpret this association according to Kirkpatrick’s learning levels, it seems clear that the use of series in teaching of health sciences would easily fulfill the first level, of reaction. A positive reaction to the teaching activities is essential: although it does not guarantee learning by itself, it serves to validate the experience [ 52 ]. Future studies should evaluate teaching experiences through short- and long-term outcomes, measuring not only student satisfaction (Kirkpatrick’s first level), but also knowledge acquisition (Kirkpatrick’s second level) and even skills acquisition on the behavioral level (Kirkpatrick’s third level). This is especially important in relation to teaching bioethical issues that health science students already observe, remember, and criticize from medical series. These medical dramas could model behavior. It is striking that the most-remembered ethical issue was medical errors, followed by inappropriate professional behavior. As we pointed out above, these are opportunities to learn through good or bad models, so they can be included in classes to teach patient safety or other specific subjects with an appropriate evaluation method. We recommend strict measurement of the effectiveness of teaching activities as well as comparison with standard pedagogical methods.

As Law et al. [ 43 ] pointed out, it would be important to take into account long-term evaluations to address Kirkpatrick’s third (behavior) and fourth (results) learning levels. This approach involves not only measuring how medical dramas can lead to knowledge and skills acquisition, but also how this acquisition can be translated into students’ behavior in concrete situations, such as in workplace-based assessments or simulations about patient care, when they have to remember and reproduce for the action themselves.

Finally, some limitations of our study should be outlined. First, it was limited to a sample of health sciences students of some disciplines at a single university. Our study can be expanded in future research to include more students from the same university or students at various universities on different continents. Moreover, only about 50% of the students responded, probably because participation was voluntary, but we consider that was adequate to obtain sound conclusions. In fact, getting good responses to surveys is a challenging issue. Besides, the majority of respondents were women but this was expected as most of students of health sciences in our country are female.

It would be interesting to explore the effects of cognitive maturity on students’ responses; however, this important issue should be considered in a study specifically designed to determine the effect of cognitive maturity in each group of students. Also, it could be interesting to analyze the impact of local TV series to analyze bioethical issues outside the context of the United States [ 50 , 54 ], and to analyze the impact of non-fictional programs. Moreover, it could be interesting to analyze the possible influence of medical dramas in young professionals’ attitudes and behaviors [ 8 , 11 ] as well as the possible impact on young people’s desire to become healthcare professionals.

We conclude that medical dramas are of considerable importance and relevance to students. Nearly all health sciences students watched television in the last year, and nearly half of them students watched medical dramas frequently. Students remember bioethical issues discussed in television series, and most students believed that all ideals of professionalism were depicted positively in medical dramas.

The results of the current study show the effects of the huge increase in the availability of TV medical series through online platforms on the viewing habits of health science students. These students are big consumers of TV series, especially on new platforms. These resources are very accessible, allowing students to watch episodes of current or previously broadcast series as often as they like and as many times as they like. Students can view them on various devices (televisions, computers, tablets, smart phones, etc.), alone or with their friends and families.

Medical dramas can be useful for teaching issues related to bioethical questions and professional practice in health sciences. Depending on their educational objectives, teaching initiatives could use an entire season, an episode, or a shorter edited clip. It is important to undertake new studies to analyze students’ viewing habits and educational proposals to exploit medical dramas. Information about students’ interests, the series they watch, the bioethical conflicts that they remember can help in designing teaching activities, and information about the efficacy of these adjuvant teaching methods can help in improving them.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

We wish to thank María Dolores Bardallo Porras, Director of the Escola Superior d’Infermeria del Mar , a center associated with Pompeu Fabra University, and Meritxell Girvent, Director of Studies, Faculty of Medicine, Pompeu Fabra University.

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Research Group Education in Health Sciences, Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain

Irene Cambra-Badii, Elisabet Moyano & Mariano Sentí

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Irene Ortega

School of Medicine, Universitat de Vic – Universitat Central de Catalunya, Vic, Spain

Josep-E Baños

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ICB, EM and JEB designed the study protocol; ICB and IO carried out the survey, ICB, IO, MS and JEB managed the data and performed the statistical analysis; ICB, EM and JEB wrote the manuscript. All the authors have read and approved the final manuscript.

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Television viewing habits survey

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Cambra-Badii, I., Moyano, E., Ortega, I. et al. TV medical dramas: health sciences students’ viewing habits and potential for teaching issues related to bioethics and professionalism. BMC Med Educ 21 , 509 (2021). https://doi.org/10.1186/s12909-021-02947-7

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DOI : https://doi.org/10.1186/s12909-021-02947-7

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Medical Dramas and Viewer Perception of Health: Testing Cultivation Effects

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Jae Eun Chung, Medical Dramas and Viewer Perception of Health: Testing Cultivation Effects, Human Communication Research , Volume 40, Issue 3, 1 July 2014, Pages 333–349, https://doi.org/10.1111/hcre.12026

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By using a national representative sample ( N = 11,555), the current study tested cultivation theory and aimed at understanding the relationship between medical drama watching and viewer perception and beliefs related to health. Findings suggest that heavy viewers of medical dramas tend to underestimate the gravity of chronic illnesses such as cancer and cardiovascular disease and undermine the importance of tackling these issues. Heavier viewers of medical dramas, compared to lighter viewers, also tend to take a more fatalistic perspective about cancer. Theoretical implications for cultivation theory and practical implications for health policy makers and drama producers are discussed.

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TV medical dramas: health sciences students' viewing habits and potential for teaching issues related to bioethics and professionalism

Affiliations.

• 1 Chair in Bioethics, Universitat de Vic - Universitat Central de Catalunya, Carrer Miquel Marti i Pol, 1, 08500, Vic, Spain. [email protected].
• 2 Research Group Education in Health Sciences, Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain. [email protected].
• 3 Research Group Education in Health Sciences, Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain.
• 4 School of Health and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain.
• 5 School of Medicine, Universitat de Vic - Universitat Central de Catalunya, Vic, Spain.
• PMID: 34565375
• PMCID: PMC8474903
• DOI: 10.1186/s12909-021-02947-7

Background: Medical dramas have been popular since their inception, especially among medical students. We hypothesized that the recent increase in the availability of TV medical series through online streaming platforms has probably changed health science students' viewing habits as well as the representation of bioethical conflicts and health professionals.

Methods: We invited undergraduate students of medicine, nursing, and human biology to complete a self-administered questionnaire about their viewing habits and perceptions of the depictions of bioethical issues and professionalism in TV medical series.

Results: Of the 355 respondents, 98.6 % had watched TV in the last year, 93.5 % watched TV series, and 49.6 % watched medical dramas more than once a week. The most-viewed medical dramas were The Good Doctor, House MD, and Grey's Anatomy. The most-remembered bioethical topics were medical errors, inappropriate professional behaviors, and death. Most students considered that ideals of professionalism were depicted positively and professionals were portrayed as intelligent, professionally qualified, and competent.

Conclusions: Medical dramas are very popular with health science students and are potentially useful as teaching tools for discussing issues related to bioethics and professionalism.

Keywords: Bioethics; Health sciences students; Medical Dramas; Professionalism; Television.

© 2021. The Author(s).

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Conflict of interest statement

The authors declare that they have no competing interests.

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Based on a 'True' Story? How Medical Dramas Mislead You

Related content:

Grey's Anatomy is an awful program. Overly dramatic, scientifically inaccurate , and saturated with political messaging , the show is more propaganda than quality television. I can't stand it. Naturally, my wife watches it religiously.

The joys of marriage aside, I caught a snippet of a 2020 episode titled “A Hard Pill to Swallow” the other night. The episode originally aired two years ago, on the tail end of the EVALI panic, initially ( and wrongly ) blamed on nicotine vaping products. [1] Following the CDC and a wide swath of media reports at the time, Grey's Anatomy told a scaremongering story about the dangers of vaping. According to one summary of the episode :

Meredith and Cormac [two of the show's lead characters] team up to help a 17-year-old swimmer who starts spewing up blood. Eventually, they figure out Kai has been vaping — his lungs look like a 60-year-old smoker’s — and Grey’s proceeds to give us a heavy-handed Special Episode about why vaping is evil … It just felt very PSA-directly-to-camera.

There's something especially obnoxious about an industry as debauched as Hollywood lecturing anybody about healthy living. What makes the moral preening even worse is that the producers of Grey's Anatomy badly misrepresented the science to their audience of nearly four million viewers.

This points to a much broader issue with television shows in this genre: Hollywood's portrayal of modern medicine has misinformed the public about important health issues and undermined trust in physicians—all for the sake of entertainment.

Anti-vaping fairy tales

The assertion that a vaping teenager's lungs could even remotely resemble those of a 60-year-old smoker is preposterous. A high school student hasn't been exposed to anywhere near as many carcinogens as a lifelong smoker. The Grey's Anatomy writers should have Googled “ risk assessment ” before penning this episode. Such a homework assignment may have led them to an important concept widely employed by public health agencies: Risk = Hazard (times) Exposure.

Studies investigating the potential harms of vaping have nicely illustrated why this idea is so important. Since aerosols emitted by e-cigarettes contain far fewer harmful chemicals than tobacco smoke, vaping can't possibly pose the same level of risk as smoking. Additionally, vaping seems to mitigate some of the damage caused by tobacco use. There is evidence, for example, that vaping “may reverse some of the harm resulting from tobacco smoking in COPD patients,” according to one 2018 study.

This isn't academic nitpicking on my part; misleading the public about vaping has deadly consequences. A 2021 study published in BMJ Open found that smokers were less likely to switch to e-cigarettes after viewing tweets suggesting that vaping and smoking are equally harmful. “These findings suggest that misinformation about e-cigarette harms may influence some adult smokers’ decisions to consider using e-cigarettes,” the authors concluded.

TV patients more likely to die

Medical dramas haven't just misled the public about the benefits of vaping. At least three studies published over roughly the last decade have found that these shows tend to exaggerate the likelihood that a patient will die. According to a 2014 analysis :

Several empirical studies have examined the depiction of patient survival and outcomes of care in medical dramas. A study of three popular medical shows—ER, Chicago Hope and Grey’s Anatomy—showed mortality rates of fictional patients in television hospitals to be nine times higher than that of patients in real-world hospitals [emphasis mine].

Fans who watch many hours of these shows are more inclined to believe that real patients can do little to prevent serious illness and effective treatments are “bound to fail,” the authors added. Since 60 percent of Americans live with at least one preventable, treatable chronic disease, this is the worst possible message TV could send.

Heavy viewers of medical dramas in this study were also more likely to misunderstand which diseases pose the greatest threats to their health. Although cardiovascular disease and cancer cause the majority of deaths in the US, these programs tend to focus on “atypical” conditions—like a tree growing inside a patient's lung. The authors warned that this under-representation could “lead to the erosion of public support to address issues relating to cancer and cardiovascular disease.”

It gets worse, though. After reviewing the existing literature, the researchers surveyed a nationally representative sample of 11,555 adults ages 18 and older. Respondents who spent more time watching medical dramas were more likely to endorse the following statements:

“It seems like almost everything causes cancer.”

• “There are so many recommendations about preventing cancer, it’s hard to know which ones to follow.”

Like the results of earlier research, these examples are concerning because they may distort how people think about their well-being and the health care they receive. “For example,” the authors noted, “confusion and fatalistic views resulting from cumulative viewing of medical dramas may prevent individuals from seeking health professionals when their health is at risk.”

TV doctors: unethical jerks

Multiple studies have also shown that television profoundly influences how we think about physicians. “Heavy viewers of medical dramas compared to light viewers perceived doctors to be more unethical, tense, and inconsiderate,” the authors of a 2003 paper reported. This may be expected in situations where people have limited access to health care. But according to one 1995 study, even adults who regularly see a doctor tend to believe television depictions over their own experience with a health care provider. The researchers concluded :

Compared with physician perceptions of the profession, television portrays physicians, and the public perceives them, as more powerful, as imbued with greater income, status, and strength. In addition … television depicts physicians, and the public perceives them, as lower in character, meaning less moral, right, unselfish, good, and honest.

What to do?

In an ideal world, Hollywood would clean up its act and stop lying to people for the sake of ratings. But we don't live in that universe. Perhaps the second-best solution is to consume medical dramas as we do any other indulgence—in moderation. The occasional cocktail or dessert won't wreck your health, and a little bit of drama-laden television won't blind you to the realities of modern health care.

Nevertheless, it's worth remembering that we're good at recalling information but not the source it came from. That means we're liable to confuse facts with expertly delivered dialogue from a fictional story. So, cultivate a little skepticism. Don't believe what actors say until you verify that it's true. Guard your mind against bad ideas; no one else will do it for you.

[1] Lung injury in these cases was caused by illegal devices used to vape THC oil. See Dr. Bloom's excellent story Can Chemistry Explain 'Vaping Lung'?

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Effectiveness of Drama-Based Intervention in Improving Mental Health and Well-Being: A Systematic Review and Meta-Analysis during the COVID-19 Pandemic and Post-Pandemic Period

1 Faculty of Creative Arts, University of Malaya, Kuala Lumpur 50603, Malaysia; [email protected]

Farideh Alizadeh

2 Drama Department, Faculty of Creative Arts, University of Malaya, Kuala Lumpur 50603, Malaysia

Wenjing Cui

3 Department of Health Management Centre, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250012, China; moc.latipsohuliq@gnijnewiuc

Associated Data

The data that support the findings of the study are available from the corresponding author, upon reasonable request.

As a creative form of psychotherapy, drama appears to assist individuals in the COVID-19 pandemic and post-pandemic period in altering crisis conditions and challenging negative perspectives. Drama-based intervention is presented as an option for addressing mental health issues in clinical and general populations by utilising various multidisciplinary sources, such as psychodrama and role playing. In this study, a systematic review and meta-analysis were employed to assess the impact of drama on mental health and well-being during the COVID-19 pandemic and post-pandemic. Four electronic databases (PubMed, Cochrane, Web of Science, and ScienceDirect) were extensively searched from December 2019 to October 2022. Quality assessment and Risk of Bias tool of the Cochrane Collaboration were performed. Using a random effect model, standardised mean difference (SMD) values and 95% confidence intervals (CI) were calculated. In the final analysis, 25 studies involving 797 participants were included. The study revealed that drama-based interventions have the potential to improve mental health (e.g., trauma-related disorders) and well-being (e.g., psychological well-being), which could position drama as an adjunctive method of mental health care. This original review offered the newer, more comprehensive recommendations for drama-based intervention based on evidence.

1. Introduction

The COVID-19 pandemic has severely disrupted people’s lives. In addition to the physical threat, the outbreak has sparked a worldwide mental health crisis. A number of variables, such as fear of infection, treatment ambiguity, financial loss, and social isolation, affected the mental health of the entire population [ 1 , 2 , 3 , 4 , 5 ]. The prevalence of depression and anxiety disorders increased by more than 25% in the first year of the pandemic [ 6 ]. Yet, the long-term effects of the COVID-19 pandemic are substantial and will persist for years. After the pandemic, people may experience behavioural changes and emotional anguish [ 7 , 8 ]. Anxiety (ranging from 6.5% to 63%), depression (4% to 31%), post-traumatic stress disorder (12.1% to 46.9%), and cognitive-functional difficulties (4.4% to 17.4%) were observed in persons following coronavirus infection, according to a review of 34 studies [ 9 ]. Moreover, current evidence reveals that mental health issues may arise after the pandemic, owing to the environmental stressors, the loss of loved ones, or the change in lifestyle; consequently, early interventions are suggested to improve post-pandemic mental health and support long-term recovery [ 10 , 11 , 12 , 13 ].

Mental health is an integral part of an individual’s overall health and well-being. People with better mental health may connect, function, cope, and flourish more effectively [ 14 ]. Self-efficacy, independence, and intellectual abilities are regarded as critical components of mental health and well-being [ 15 , 16 ]. Moreover, cognitive and communication abilities may help individuals in adapting to their environment and achieving life satisfaction [ 17 ]. Several therapies, such as art, exercise, social skills training, and mindfulness-based interventions, have been demonstrated to enhance positive life experiences, identity, and adaptive functioning [ 18 , 19 , 20 , 21 ]. Despite the fact that numerous studies have been undertaken on mental health intervention, there is a need for a diversity of strategies that may support, enable, and sustain mental health improvement innovation.

Drama-based intervention is a creative form of psychotherapy that promotes psychological growth and transformation through the systematic and intentional use of drama and theatre techniques. The concept of role in dramatic context is taken as the central position in various multidisciplinary sources, such as dramatic ritual, which link drama to the treatment phase [ 22 ]. By playing a wide repertoire of roles, individuals have learned skills and gained exposure to different perspectives in order to function as both human and social beings [ 23 ]. Methods including theatre games, improvisation, psychodrama, storytelling, puppetry, role reversal, playback theatre, and theatre of the oppressed are employed to change the state of illness and crisis, which is the essence of drama-based intervention [ 24 , 25 , 26 ].

In healthcare settings like clinics, care homes, and community centres, drama appears to support individuals, groups, and families by facilitating communication and challenging negative perspectives [ 27 ]. Previous findings highlighted the significance of drama activities in allowing clients to express and tolerate depressive emotions [ 28 , 29 , 30 ]. In the context of treating trauma-related issues, drama therapy innovations have been shown to benefit the recovery process by assisting patients in developing a positive self-image, confidence, and appreciation of aesthetics [ 30 , 31 , 32 ]. The effects of drama on people with intellectual and developmental problems have been the subject of multiple investigations at an inpatient psychiatric hospital. Clients’ levels of self-esteem, self-expression, and social skills were found to increase as a result of participating in drama [ 33 , 34 , 35 , 36 ]. The COVID-19 lockdown period can be difficult for some people, but a special online drama programme has been supplied to help people deal with issues including loneliness, isolation, and traumatic loss [ 37 , 38 , 39 , 40 ].

Preserving mental health and cultivating well-being could be considered as methods for enhancing humanity’s ability to overcome the short- and long-term consequences of the COVID-19 pandemic [ 41 ]. In this challenging moment, it is vital to continue documenting drama interventions on mental health issues as an innovative strategy to improve rehabilitation services and establish effective healthcare programmes. Such studies on drama and theatre as treatments would seem significant in promoting well-being. However, as Cheek-O’Donnell [ 42 ] points out, drama therapy is currently in the crucial stage of intervention research and empirical investigation. It is imperative that both academics and practitioners have access to evidence-based recommendations about the efficacy of drama-based interventions in improving mental health and well-being.

The quantitative procedures of meta-analysis utilise comparisons of numerical results from a few research studies to examine the usefulness of interventions given in a variety of studies [ 43 ]. In this paper, meta-analysis is employed to investigate the effect of drama as an intervention on mental health and well-being. It focuses on studies published after late December 2019, when the outbreak of the coronavirus disease 19 (COVID-19) was reported [ 44 ]. The paper explores the productive technique of implementing a drama-based intervention with various populations in order to assess the effect by drawing on the experiences and changes of participants. The aim of the study is to contribute to the systematisation of drama-based treatment and provide evidence-based recommendations for clinicians, drama practitioners, and researchers.

2. Materials and Methods

This systematic review and meta-analysis were conducted in accordance with the preferred reporting items for systematic reviews and the meta-analyses (PRISMA) statement [ 45 ]. The protocol was registered on the International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY). The registration number is INPLASY2022120030.

2.1. Search Strategy

Four databases (PubMed, Cochrane, Web of Science, and ScienceDirect) from December 2019 until October 2022 were used to search for potential studies. The following key terms were used: (1) “mental health” OR “psychological wellbeing”; OR (2) “mental health” OR “health, mental” OR “mental hygiene” OR “hygiene, mental” OR “psychological wellbeing” OR “psychological wellness” OR “psychological ill being” OR “ill being psychological” AND (3) “drama” OR “psychodrama” OR “role playing” OR (4) “drama” OR “dramas” OR “drama therapy” OR “therapy, drama” OR “dramatherapy” OR “playing, role” OR “playings, role” OR “role playings” AND (5) “from 2020–2022”. The detailed search strategy is shown in Table 1 (PubMed is used as an example).

Search strategy on PubMed.

2.2. Inclusion Criteria

The PICOS (population, intervention, comparison, outcomes, study design) framework has been applied to determine the scope of the research process. (1) Patients in need of mental health and well-being improvement; (2) experimental group with drama-based intervention; (3) control group with no treatment or routine care; (4) outcome indicators such as quality of life, psychological well-being, depression, anxiety, trauma-related disorders, cognitive functioning, communication skills, and self-esteem; and (5) studies with controlled group and pre/posttest that reported the effect of intervention.

2.3. Exclusion Criteria

(1) Studies without measurable results or outcomes that were not reported; (2) studies of case reports, vignettes, or conference abstracts; (3) studies with incomplete or unreported data; (4) meta-analysis and review.

2.4. Study Selection

All of the literature describing drama intervention or programme was screened. Initially, the titles of the literature were separately checked by two researchers for duplication, non-measurable outcome studies, review papers, conference papers, and protocols. If the article’s title and abstract suggested that a drama intervention or practice was implemented, the full text of the article was downloaded as a potentially eligible study. The entire text was then independently reviewed and identified for inclusion by both researchers. A consensus was reached with the third researcher to resolve any discrepancies.

2.5. Data extraction

A pre-selected eight-item data extraction form was used to record data for inclusion in the study under the following headings: (1) author, (2) year of publication, (3) country, (4) population, (5) mean age, (6) sample size, (7) intervention, and (8) outcome measure. The risk of bias in the included studies was utilising a quality instrument validated by The Cochrane Collaboration ® [ 46 ]. Three levels of bias were assigned to trials: high risk, low risk, and unclear risk [ 47 ]. The seven domains were evaluated: (1) random sequence generation, (2) allocation concealment, (3) blinding of the participants and personnel, (4) blinding of outcome assessment, (5) incomplete outcome data, (6) selective reporting, and (7) other sources of bias (the conflict of interests or funding sources). Intervention studies involving humans that require ethical approval must identify the approving authority and the corresponding code.

2.6. Data Analysis

The primary outcome was the size of the drama-based intervention’s effect on the experimental group relative to the control group, or the comparison of pre- and post-test. Review Manager (RevMan) version 5.4 was utilised to conduct a meta-analysis of the results’ effects. All of the outcome data in this meta-analysis were continuous and presented as means with standard deviations (SD). Mean differences (SMD) with 95% confidence intervals (CI) were used to figure out a meta-analysis. A random effects model was selected since the effect sizes were pooled [ 48 ]. A p -value below 0.05 was considered statistically significant. The I 2 and chi-square tests were used to determine the presence of heterogeneity. Effect size = 0.2 is considered a “small” effect size, 0.5 represents a “medium” effect size, and 0.8 is considered a “large” effect size according to Cohen’s guidelines [ 49 ].

3.1. Study Identification and Selection

A total of 452 studies were identified from the electronic database. Due to duplication, 141 articles were removed. Ninety-six irrelevant articles (e.g., unrelated to drama, mental health, and well-being) and fifty-nine articles without abstracts were also removed. The remaining 156 documents were reviewed in abstract, and 87 documents were excluded (for reasons including case reports, conference papers, or reviews). After that, 97 potentially eligible records were retrieved for full text, whereas 28 records were not able to be accessed in full text (e.g., publishers’ restrictions) and were therefore excluded. The remaining 69 studies were read in full text, and 44 documents were again excluded (for reasons including no drama intervention, no quantitative outcome measure, or incomplete data). Finally, 25 documents were included in this study. Figure 1 shows the result of the screening process.

Flow diagram of literature selection.

3.2. Characteristics of the Included Studies

In total, 25 studies with 797 participants were included. Ten studies were conducted in Europe, eight in the Middle East, four in Asia, and three in the United States. There were 10 distinct forms of drama intervention. The characteristics of the included studies are detailed in Table 2 .

Characteristics of the studies included in the meta-analysis.

Note. T: experimental group; C: control group; NA: unavailable; Freq: frequency; LoI: length of intervention; SAD: social anxiety disorder; SMI: serious mental illness; PTSD: post-traumatic stress disorder; ND: neurodevelopmental disorders; ADHD: attention-deficit/hyperactivity disorder; ASD: autism spectrum disorder; MDD: major depressive disorders. QLS: Quality of Life Scale; QLESS: Quality of Life Enjoyment and Satisfaction Scale; ADLS: Activity of Daily Living Scale; SLS: Satisfaction with Life Scale; PWS: Psychological Well-being Scale; MMSE: Mini-mental State Examination; BPRS: Brief Psychiatric Rating Scale; CSDD: Cornell Scale for Depression in Dementia; BDI: Beck Depression Inventory; GDS: Geriatric Depression Scale; PSS: Perceived Stress Scale; CDS: Calgary Depression Scale; SCAS: Spence Children’s Anxiety Scale; BAI: Beck Anxiety Inventory; LSAS: Liebowitz Social Anxiety Scale; CTQ: Childhood Trauma Questionnaire; SPSS: Severity of PTSD Symptoms Scale; PCL: PTSD Checklist; CBCL: Child Behaviour Checklist; WISC: Wechsler Intelligence Scale for Children; EMI: Ricketts’ Engagement, Maturity, and Innovativeness; SAI-R: Revised Spontaneity Assessment Inventory; CSCR: Child’s Skill Scale Rating; BRIEF-A: Behaviour Rating Inventory of Executive Function-Adult version; CBCL: Child Behaviour Checklist; QCST: Queendom Communication Skills Test; CSI: Communication Skills Inventory; BPSEIH: Bio-psycho-social Expressions of Incompatibility in Hospital; PACS: Parent-adolescent Communication Scale; SCS: Self-Compassion Scale; SEC: Self-esteem Scale; GSES: General Self-efficacy Scale; BAS: Body Appreciation Scale.

3.2.1. Sample Characteristics

Sample sizes ranged from 5 to 114 participants, with age (mean + SD) ranging from 7.08 (1.53) to 82.62 (7.92); the majority of participants were female. Participants with trauma-related depression were included in five studies. Caregivers of children with neurodevelopmental disorders, cerebral palsy, or who were at risk were included in three studies. Two studies on children with attention-deficit/hyperactivity disorder have been conducted. Other studies included participants with social anxiety disorder, community-dwelling, epilepsy, chronic schizophrenia, hearing-impaired adolescents, and dementia patients.

3.2.2. Intervention Characteristics

The primary interventions included were psychodrama (12 studies) and drama therapy (4 studies). Other interventions, such as theatre performance, playback theatre, sociodrama, and theatre of the oppressed, were included. The majority of sessions were conducted once per week over 6–24 weeks, with durations of 1.5–2.5 h. In studies involving older and younger participants, however, shorter time periods (40–60 min) were allocated. In addition, a six-month study was conducted every two months for a duration of four days. Most of the interventions were conducted by occupational therapists, whereas instructors for the inpatient programme were clinical psychiatrists or specialists.

3.2.3. Outcome Measures

The outcome measures consisted of eight mental-health-related components that were administered as follows: quality of life in nine comparisons, psychological well-being in five comparisons, depression in seven comparisons, anxiety in three comparisons, trauma-related disorders in seven comparisons, cognitive functioning in four comparisons, communication skill in four comparisons, and self-regard in five comparisons. Regarding study design, twelve studies were accurately described as controlled trials, including five randomised controlled trials (RCTs), while thirteen were experimental studies with pre- and post-test groups.

3.3. Risk of Bias Analysis

Risks of bias were judged based on the Cochrane guidance. Regarding random sequence generation, four studies were deemed high-risk due to the absence of randomization procedures [ 50 , 52 , 65 , 70 ]. In terms of allocation concealment, three studies were judged high-risk reported no use of concealment in the allocation procedure [ 65 , 66 , 70 ]. Two studies [ 52 , 66 ] were evaluated as high risk regarding participants and personnel blinding. Meanwhile, the lack of blinding in outcome assessment led to a high risk classification for one study [ 50 ]. Except for four studies where the information was not reported [ 51 , 60 , 62 , 64 ], all studies were evaluated as low risk for incomplete outcome data due to the low dropout rate throughout the intervention. Regarding selective reporting, seventeen studies were rated as low risk, and the remaining eight studies were judged to be unclear. Concerning other biases, three studies did not identify the conflict of interest [ 56 , 58 , 72 ], one reported the author received research honoraria [ 52 ], and one indicated the authors were on the board of an entity supporting the research [ 69 ]. Figure 2 and Figure 3 display specific features.

Risk of bias graph for included studies.

Risk of bias summary for each included study [ 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 ].

3.4. Meta-Analysis

All effects and heterogeneities for quality of life, psychological well-being, depression, anxiety, trauma-related disorders, communication skills, cognitive functioning, and self-regard were tested. The results are presented in Table 3 .

Effects and heterogeneity for comparisons between studies.

3.4.1. Effect on Quality of Life

A total of nine studies involving 213 participants provided the results of the meta-analysis regarding quality of life. On the basis of comparisons, significant difference in the use of drama-based intervention on quality of life was observed, with a considerable impact size (SMD = 1.26, 95% CI = 0.33 to 2.20, p = 0.008). However, the level of heterogeneity was substantial (I 2 = 91).

3.4.2. Effect on Psychological Well-Being

Psychological well-being was measured in five investigations with a total of 208 individuals. There was no statistically significant difference, and great heterogeneity (I 2 = 96) was displayed amongst studies. The effect size of the drama-based intervention was deemed to be substantial (SMD = 1.40, 95% CI −0.32 to 3.12, p = 0.11).

3.4.3. Effect on Depression

In seven investigations with 225 participants, the effect of a drama-based intervention for depression was evaluated. In the comparison of three controlled trials and four pre/post-test studies, significant differences were shown in favour of drama-based intervention in depression assessments (SMD = 0.70, 95% CI −0.03 to 1.42, p = 0.03). The I 2 value in this meta-analysis, however, was high (I 2 = 85).

3.4.4. Effect on Anxiety

Assessments of anxiety were included in three studies with a total sample size of 99. There were two controlled trials and one pre/post-test study in the comparison, revealing positive effect of drama-based intervention on anxiety but no statistically significant difference (SMD = 1.10, 95% CI −0.24 to 2.45, p = 0.11), with a high degree of heterogeneity (I 2 = 87) across studies.

3.4.5. Effect on Trauma-Related Disorders

To evaluate trauma-related disorders, four studies with 169 people were analysed. The comparison included one controlled trial and three pre/post-test investigations. Meta-analysis revealed a positive effect of drama-based intervention on trauma-related disorders (SMD = 0.70, 95% CI 0.23 to 1.17, p = 0.003), with a substantial heterogeneity (I 2 = 66).

3.4.6. Effect on Communication Skills

In four trials with a total of 86 participants, communication skills were assessed. The comparison included three controlled trials and one pre/post-test study. Meta-analysis found that drama-based intervention had a great impact on enhancing communication skills (SMD = 1.76, 95% CI −0.06 to 3.57), while there was no statistically significant difference ( p = 0.06), and the I 2 value was high (I 2 = 91).

3.4.7. Effect on Cognitive Functioning

Seven studies with 189 participants were used to measure cognitive functioning. There were three controlled trials and four pre/post-test studies in the comparison. Studies applying drama-based intervention on cognitive performance found the large impact size, with statistically significant difference (SMD = 2.50, 95% CI 0.77 to 4.23, p = 0.005). However, the level of heterogeneity was substantial in this meta-analysis (I 2 = 96).

3.4.8. Effect on Self-Regard

Self-regard was measured using data from five studies with 215 participants. In the comparison, there were two controlled trials and three pre/post-test investigations. Meta-analysis revealed that drama-based intervention had no statistically significant effect on self-esteem (SMD = 1.40, 95% CI −0.06 to 2.86, p = 0.06), and the I 2 value was high (I 2 = 95).

3.4.9. Overall Effect with Controlled Groups

Drama-based intervention had a positive effect with controlled groups on cognitive functioning (SMD = 1.58, 95% CI 0.62 to 2.54, p = 0.001). No statistically significant difference was observed between controlled groups on quality of life (SMD = 2.08, 95% CI −0.33 to 4.49, p = 0.09), psychological well-being (SMD = 1.69, 95% CI −0.45 to 3.83, p = 0.12), depression (SMD = 1.77, 95% CI −0.35 to 2.70, p = 0.13), trauma-related disorders (SMD = 0.14, 95% CI −0.46 to 0.74, p = 0.65), anxiety (SMD = 0.88, 95% CI −0.82 to 2.58, p = 0.31), communication skills (SMD = 1.11, 95% CI −0.68 to 2.90, p = 0.06), and self-regard (SMD = 2.83, 95% CI −0.90 to 6.56, p = 0.14). The largest positive effect size was self-regard, followed by quality of life, psychological well-being, depression, communication skills, cognitive functioning, anxiety, and trauma-related disorders. See Figure 4 .

Overall effectiveness of drama-based intervention with controlled groups.

3.4.10. Overall Effect with Pre/Posttest Groups

Drama-based intervention with pre/post-test groups was effective to reduce depression (SMD = 0.42, 95% CI 0.05 to 0.78, p = 0.03), anxiety (SMD = 1.74, 95% CI 0.16 to 3.32, p = 0.03), and trauma-related disorder (SMD = 0.90, 95% CI 0.52 to 1.28, p < 0.0001). It is also effective to improve quality of life (SMD = 0.86, 95% CI 0.06 to 1.67, p = 0.04), communication skills (SMD = 4.98, 95% CI 1.91 to 8.04, p = 0.001), and self-regard (SMD = 0.39, 95% CI 0.14 to 0.65, p = 0.002). No statistically significant difference was observed between pre/post-test groups on psychological well-being (SMD = 0.46, 95% CI −0.69 to 1.62, p = 0.43) and cognitive functioning (SMD = 3.47, 95% CI −1.02 to 7.97, p = 0.13). The largest effect size was communication skills, followed by cognitive functioning, anxiety, trauma-related disorder, quality of life, psychological well-being, depression and self-regard. See Figure 5 .

Overall effectiveness of drama-based intervention with pre/post-test groups.

3.5. Evaluation of Publication Bias

The symmetry of the funnel plot was utilised to determine the publication bias of the meta-analysis results [ 75 ].The funnel plot of standard errors by SMD was assessed according to its symmetry, and the results are presented in Figure 6 . The dotted line on each side of the figure represent the 95% confidence intervals. The middle line represents the effect of the meta-analysis as a whole. No apparent publication bias among the studies on quality of life, depression, anxiety, psychological well-being, cognitive functioning, trauma-related disorder, communication skills, and self-regard was observed, as indicated by visual observation of the funnel plots.

Funnel plots for visual assessment of the presence of publication bias.

4. Discussion

This systematic review and meta-analysis evaluated studies that employed drama-based interventions to promote mental health and well-being in the COVID-19 and post-pandemic periods. A total of 25 studies representing 797 participants were identified. Overall, drama-based interventions were shown to have the most consistent favourable effect on trauma-related disorders, cognitive functioning, quality of life, and depression. Moreover, the study found that drama may be considerably beneficial but not significant in increasing psychological well-being and communication skills. Regarding the duration of drama-based intervention, except for two studies that employed 64 [ 55 ] and 72 weeks [ 56 ], the majority of the publications indicated that drama as a supplemental treatment was viable and acceptable with durations of 8–12 weeks.

In terms of forms and techniques of drama-based intervention, psychodrama (12 studies) and drama therapy (4 studies) were the most prevalent ones included. Other forms like theatre performance, playback theatre, theatre of the oppressed, and sociodrama were also included. The included studies found that the psychodrama had a statistically significant beneficial effect on lowering anxiety levels [ 50 , 62 , 74 ] and enhancing communication skills [ 51 , 64 ]. The playback theatre had the greatest effect on psychological well-being [ 58 ]. In addition, drama therapy was more effective than other cognitive functioning programmes applied in selected studies [ 54 , 61 ]. Furthermore, the findings revealed a positive psychological effect of organised short-term playback theatre involvement in community-dwelling older persons, indicating that the community drama may provide the elderly with an opportunity to enhance their existing well-being [ 58 ].

Initial results from the meta-analysis showed that drama-based interventions were effective in reducing symptoms of trauma-related disorders, according to the outcomes of four included studies. This is consistent with the finding of Yu et al. [ 74 ], who discovered that antidepressants combined with psychodrama were more effective at enhancing the coping style of patients with childhood traumatic depression than combined with a general health education intervention, thus providing a new clinical intervention option. In addition, Miguel and Pino-Juste [ 63 ] demonstrated that the psychodrama method (warming-up, action, and sharing) had a positive effect on domestic violence victims. Other two included studies added to the evidence that psychodrama is beneficial for reducing PTSD in inpatient substance abuse treatment patients [ 55 , 56 ]. It might be due to the fact that drama is more likely to assist individuals in expressing their difficulties, discovering their conflicts, and then confronting them [ 76 , 77 ]. The advantages were underlined in this review.

Meanwhile, the meta-analysis of seven studies discovered a statistically significant and favourable effect of drama-based interventions on cognitive functioning. For instance, the psychodrama technique may assist youngsters with attention deficit/hyperactivity disorder (ADHD) to reduce their aggressive behaviour and concentration difficulties [ 62 ]. Furthermore, drama therapy can be utilised as an effective intervention to lower the expenses of ADHD treatment, particularly for strengthening working memory in adolescents with ADHD [ 59 ]. Using a dramatic diary and monologue, cognitive-behavioral psychodrama group therapy promoted critical thinking and decreased defensiveness in inadequately guarded male adolescents [ 53 ]. This may be because of the way that drama encourages individuals to express repressed tensions and emotions in a safe environment by fostering spontaneity, inventiveness, and rational reasoning [ 54 , 78 ].

Moreover, nine studies included in the review demonstrated that drama-based intervention improved the quality of life. According with the findings of meta-analysis, the results of Vlotinou et al. [ 73 ] implied that drama activities (e.g., emotional expression, role-playing) may improve life quality of people with epilepsy by addressing their fear and loss of control. Besides, Simsek et al. [ 68 ] showed that quality of life of caregivers of children with cerebral palsy can be enhanced by increasing hope and self-confidence through warm-up, action, and sharing stages in psychodrama. Further research added to the findings that drama intervention fostered more favourable views towards the illness and social environment by gaining empathy and allowing participants to perceive themselves in diverse roles [ 63 , 67 ].

Additionally, the review confirmed the significance of drama-based intervention in the treatment of depression. In a meta-analysis, the statistical significance of seven investigations was determined. For instance, the included study by Sevi et al. [ 67 ] indicated that psychodrama sessions (e.g., dramatic games) helped alleviate depressive symptoms in patients with chronic schizophrenia by boosting sharing, group interaction, and a sense of belonging. Besides, the finding of Keisari et al. [ 58 ] showed that playback theatre, which integrates dramatic expression with the exploration of life stories in a group creative process, had a positive psychological effect in community-dwelling older adults with depressive psychological distress. Several studies have added to the evidence that drama improves mental health and reduces depressive symptoms through self-reflection and personal development. The drama programme provided therapeutic benefit and acted as a vehicle for the participants’ positive transformation [ 50 , 52 , 60 ].

It is also noted that the results suggested that drama-based intervention was beneficial but not statistically significant for enhancing psychological well-being. For example, a psychodrama programme improved the psychological balance of adolescents who had experienced a traumatic incident; the correlations showed increased psychological progress [ 71 ]. Furthermore, the results may point to the potential role of drama-based intervention in improving communication skills. This is consistent with the findings of Jang et al. [ 57 ], who discovered that the sociodrama programme improved parent–child communication for mothers of children with neurodevelopmental disorders. In accordance with additional findings [ 51 , 64 , 65 ], participants gained abilities via interpersonal interactions in the dramatic activities.

The review consists of twelve controlled groups, including five randomised controlled trials (RCTs), and thirteen experimental studies with pre- and post-testing. Depression, anxiety, trauma-related disorder, quality of life, communication skills, and self-regard were all positively affected by a drama-based intervention supported by pre/post-testing, whereas the overall effect of intervention with controlled trials had only positive effects on cognitive functioning. The current findings revealed that controlled groups were insufficient to demonstrate the efficacy of drama interventions on mental health and well-being. It suggested that additional well-designed controlled trials comparing experimental and control groups are required to evaluate the impact of drama-based interventions. More RCTs, particularly those with high-quality designs, were also called to provide causal explanations for the difference between pre- and post-values.

Several studies included in this review suggested drama-based intervention was feasible to cope with the COVID-19 pandemic. Consistent with the findings, Giacomucci et al. [ 56 ] discovered that people with active trauma from COVID-19 who participated in drama sessions reported a reduction in depression and PTSD symptoms. Notably, the COVID-19 social distancing decreased social contact engagement and may be risk factors for isolation, anxiety, and depression [ 79 ]. A number of included studies have provided solutions that allowed social connectedness through drama activities and generated the stimulating senses of connection and empathy in others [ 52 , 58 , 67 ], thereby enabling individuals to address issues of shared concern and increased their ability to embrace challenge in the pandemic and post-pandemic period. During quarantine, Cheung et al. [ 52 ] provided people with severe mental illness with online drama intervention via Zoom, which was considered a feasible strategy in the setting of the epidemic. This study constructed a convincing case for the usefulness of drama intervention in the digital space and proposed a novel strategy for dealing with pandemic realities.

5. Strengths and Limitations

In this study, the techniques of systematic review and meta-analysis were used to analyse the effects of drama on mental health and well-being of various populations during the COVID-19 and post-pandemic eras. This is the first review and meta-analysis to critically examine the evidence for the use of drama in mental health care. The findings of the selected studies provided crucial evidence of the effectiveness of drama-based intervention on mental health issues. This original review on the treatment of drama throughout individuals who required mental health care by different drama programmes provided more recent and comprehensive evidence-based recommendations.

The limitations of the study should be acknowledged. First, the literature search was restricted to the publications of the COVID-19 and the post-pandemic period (from December 2019 to October 2022); thus, some theoretically significant earlier contributions may have been overlooked. The number of included papers was modest, and several of the studies had small sample sizes, which may have compromised the reliability of the meta-analytic conclusions. Besides, a stratified analysis was not possible due to the extensive range of participant characteristics. Moreover, several studies in the present evidence base were conducted in quasi-experiment groups, which were inadequate to advance knowledge of the effects of drama-based intervention. Furthermore, despite the researchers’ best attempts, heterogeneity between studies could not be avoided.

6. Conclusions

This review and meta-analysis concludes that drama has the potential to improve mental health (e.g., trauma-related disorders) and well-being (e.g., psychological well-being), positioning it as a supplement to mental health care during and after the COVID-19 pandemic. Drama-based intervention is increasingly offered in healthcare settings as part of a variety of complementary therapies. Future research may examine the effects of drama-based interventions on individuals with post-COVID-19 pandemic trauma to better comprehend the correlations between drama activity and therapeutic effect. To further understand how drama interventions may be utilised as psychological prescriptions, it is recommended that future study compare drama intervention to other therapeutic treatments and/or compare different forms of drama programme. Moreover, telehealth and other technological advances may help improve the efficacy of drama intervention, which might be studied in the future.

Acknowledgments

We thank all the reviewers for their assistance and support.

Funding Statement

This research received no external funding.

Author Contributions

Conceptualization, L.J. and F.A.; methodology, L.J.; software, W.C.; validation, L.J., F.A. and W.C.; formal analysis, L.J. and W.C.; investigation, F.A.; data curation, W.C.; writing—original draft preparation, L.J.; writing—review and editing, F.A.; visualization, W.C.; supervision, F.A.; project administration, F.A.; funding acquisition, F.A. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Ethical review and approval were waived for this study, as this study is a systematic review of previously published studies.

Informed Consent Statement

Patient consent was waived, as this study is a systematic review of previously published studies.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Jerome R. Cox Jr. Papers Open for Research

Did you know the PC was invented at Washington University?

Well, not that PC. The Programmed Console.

In the spring of 1965, Jerome R. Cox Jr. and Wesley A. Clark co-taught a graduate course in computer design in which teams of students designed working computers. One student, V.W. “Bill” Gerth, also wrote an interactive radiation treatment planning program. A demonstration piqued the interest of the Division of Research Resources at the National Institutes of Health (NIH), which subsequently directed funding to the Biomedical Computer Laboratory (BCL), a division of the School of Medicine, to further develop the concept.

Cox—who had founded BCL the previous spring—and colleagues in the Mallinckrodt Institute of Radiology went to work. He called the redesigned computer the Programmed Console, or PC, reflecting the unique way that users could interact directly with stored programs at a display console. Software was designed to enable radiologists to calculate the optimal position and intensity of radiation beams to treat a tumor, while minimizing damage to surrounding, healthy tissue. And with NIH support, BCL initiated a Radiation Treatment Planning (RTP) Project that supplied PCs to teams from six different institutions to evaluate and refine their use in radiation therapy over the course of several years.

Documents about the PC are among the many materials found in the recently processed papers of Dr. Jerome “Jerry” R. Cox Jr. (1925-2023). Acquired by the Becker Archives in 2022, this rich collection provides a window into Cox’s nearly five-decade career at Washington University, documenting his path-breaking work in biomedical computing and computer science and revealing a dedicated researcher, teacher, and advocate whose influence and impact extended far beyond the classroom.

Images excerpted from a BCL brochure explaining the research and training activities available to graduate students, circa 1965 (FC157-S13-ss01-B077-F05, Bernard Becker Medical Library Archives, Washington University in St. Louis).

A significant portion of the collection pertains to Cox’s tenure as director of BCL (1964-1975), when he played a pivotal role in Washington University’s journey toward becoming a leader in the application of computers to biomedicine. Cox had first joined the university’s faculty as a part-time assistant professor of electrical engineering in 1955, after accepting a position at the nearby Central Institute for the Deaf (CID). He moved on from CID to found BCL in April 1964. That same year, the LINC development team at MIT found itself in need a new institutional home, and Cox was instrumental in making sure they had one at Washington University. The LINC , or Laboratory INstrument Computer, was a small-for-its-time, mobile, and interactive computer designed with lab-based research in mind. The LINC team relocated to St. Louis in June 1964 and continued their work in the newly formed Computer Research Laboratory (CRL), which shared space with BCL on the Medical Campus. In 1967, with funding from a major NIH grant titled “A Resource for Biomedical Computing,” the Washington University Computer Laboratories (WUCL) formed around BCL and CRL’s successor, the Computer Systems Laboratory (CSL). Cox chaired WUCL until the completion of the grant in 1983. “Few laboratories in the nation,” a summary report noted, “have had as deep an impact on the evolution of computers in medicine and medical research as CSL and BCL.”

Another substantial portion of the collection documents Cox’s roles as the first chair of the Department of Computer Science (1975-1991) and as director of the Applied Research Laboratory (1991-1995). Much like his contributions to biomedical computing, Cox’s work on computer networking and the high-speed transmission of medical images during this time helped Washington University become a leader in those fields. It also prompted Cox to co-found Growth Networks Inc. in 1997, an effort to commercialize university-developed fast-packet chipset technology. Cisco Systems later acquired the successful company in 2000. Cox’s business ventures continued in 2007, when he founded Blendics, derived from Blended Integrated Circuit Systems. Blendics led to a cybersecurity spin-off, Q-Net Security Inc., in 2015. The collection contains a moderate amount of materials related to Cox’s entrepreneurial endeavors.

Cox’s writings and professional activities are also well-represented. In addition to manuscripts and drafts, the collection contains reprints of many of his published journal articles. Prominent among Cox’s professional activities was his role as co-founder and co-chair of Computers in Cardiology. The annual international conference brought together researchers applying computers to electrocardiography. Organizers also made sure attendees had a chance to explore the host cities. When Washington University hosted the gathering in 1976, the social calendar included a visit to the Missouri Botanical Gardens, a riverboat cruise, and a rooftop reception at the Chase Park Plaza Hotel. Cox served as co-chair until 1988, and the conference, now known as Computing in Cardiology , continues to be held today.

The Cox papers are open and accessible for research. In addition to the materials mentioned here, researchers can find administrative documents, correspondence, grant applications, research notes, patents, photographs, and more pertaining to his extensive work in auditory physiology, ECG analysis and processing, CT and PET scanning technologies, DNA mapping, information systems and database technologies, electronic radiology, digital communication networks, and asynchronous computing. The collection also contains a modest number of materials related to Cox’s personal life.

Certificate for U.S. Patent No. 3,217,321, Collision Avoidance System, November 9, 1965 (FC157-S06-B017-F10, Bernard Becker Medical Library Archives, Washington University in St. Louis). Cox’s work also led to patents related to tomography systems, video with high speed reconstruction and display of compressed images, and asynchronous computing.

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• Current Students

First study to measure toxic metals in tampons shows arsenic and lead, among other contaminants

• By Elise Proulx
• 3 min. read ▪ Published July 3
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Tampons from several brands that potentially millions of people use each month can contain toxic metals like lead, arsenic, and cadmium, a new study led by a UC Berkeley researcher has found.

Tampons are of particular concern as a potential source of exposure to chemicals, including metals, because the skin of the vagina has a higher potential for chemical absorption than skin elsewhere on the body. In addition, the products are used by a large percentage of the population on a monthly basis—50–80% of those who menstruate use tampons—for several hours at a time.

“Despite this large potential for public health concern, very little research has been done to measure chemicals in tampons,” said lead author Jenni A. Shearston , a postdoctoral scholar at the UC Berkeley School of Public Health and UC Berkeley’s Department of Environmental Science, Policy, & Management. “To our knowledge, this is the first paper to measure metals in tampons. Concerningly, we found concentrations of all metals we tested for, including toxic metals like arsenic and lead.”

Metals have been found to increase the risk of dementia, infertility, diabetes, and cancer. They can damage the liver, kidneys, and brain, as well as the cardiovascular, nervous, and endocrine systems. In addition, metals can harm maternal health and fetal development.

“Although toxic metals are ubiquitous and we are exposed to low levels at any given time, our study clearly shows that metals are also present in menstrual products, and that women might be at higher risk for exposure using these products,” said study co-author Kathrin Schilling , assistant professor at Columbia University Mailman School of Public Health.

Researchers evaluated levels of 16 metals (arsenic, barium, calcium, cadmium, cobalt, chromium, copper, iron, manganese, mercury, nickel, lead, selenium, strontium, vanadium, and zinc) in 30 tampons from 14 different brands. The metal concentrations varied by where the tampons were purchased (US vs. EU/UK), organic vs. non-organic, and store- vs. name-brand. However, they found that metals were present in all types of tampons; no category had consistently lower concentrations of all or most metals. Lead concentrations were higher in non-organic tampons but arsenic was higher in organic tampons.

Metals could make their way into tampons a number of ways: The cotton material could have absorbed the metals from water, air, soil, through a nearby contaminant (for example, if a cotton field was near a lead smelter), or some might be added intentionally during manufacturing as part of a pigment, whitener, antibacterial agent, or some other process in the factory producing the products.

“I really hope that manufacturers are required to test their products for metals, especially for toxic metals,” said Shearston. “It would be exciting to see the public call for this, or to ask for better labeling on tampons and other menstrual products.”

For the moment, it’s unclear if the metals detected by this study are contributing to any negative health effects. Future research will test how much of these metals can leach out of the tampons and be absorbed by the body; as well as measuring the presence of other chemicals in tampons.

Additional authors include: Kristen Upson of the College of Human Medicine, Michigan State University; Milo Gordon, Vivian Do, Olgica Balac, and Marianthi-Anna Kioumourtzoglou of Columbia University Mailman School of Public Health; and Khue Nguyen and Beizhan Yan of Lamont-Doherty Earth Observatory of Columbia University.

Funding was provided by the National Institute of Environmental Health Sciences; the National Heart, Lung, and Blood Institute; and the National Institute of Nursing Research.

In the Media:

• A study found toxic metals in popular tampon brands. Here’s what experts advise  – NPR
• Lead, Arsenic, Other Toxic Metals Found in Dozens of Tampon Products – Los Angeles Magazine
• Lead and other toxic metals found in tampons, study finds – The Atlanta Journal-Constitution
• Toxic Metal in Tampons Risks Brain’s Cognitive Function, Scientists Warn – Newsweek
• New study finds lead and arsenic in tampons. But don’t panic, experts say – TODAY
• Tampons contain toxic metals such as lead and arsenic, UC Berkeley study finds – San Francisco Chronicle
• Toxic Tampon Warning As Arsenic and Lead Found in Common Menstrual Products – Newsweek
• Some tampons found to contain LEAD and other toxic metals that could be absorbed into the body, alarming study suggests – Daily Mail

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This paper is in the following e-collection/theme issue:

Published on 11.7.2024 in Vol 26 (2024)

Comparison of the Response to an Electronic Versus a Traditional Informed Consent Procedure in Terms of Clinical Patient Characteristics: Observational Study

Authors of this article:

Original Paper

• Anna G M Zondag 1 , MSc   ; 
• Marieke J Hollestelle 2 , PhD   ; 
• Rieke van der Graaf 2 , PhD   ; 
• Hendrik M Nathoe 3 , MD, PhD   ; 
• Wouter W van Solinge 1 , PhD   ; 
• Michiel L Bots 2 , MD, PhD   ; 
• Robin W M Vernooij 2, 4 , PhD   ; 
• Saskia Haitjema 1 , MD, PhD   ; 
• UCC-CVRM study group 5

1 Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands

2 Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands

3 Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands

4 Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, Netherlands

5 See Acknowledgements

Corresponding Author:

Anna G M Zondag, MSc

Central Diagnostic Laboratory

University Medical Center Utrecht

Utrecht University

Heidelberglaan 100

Utrecht, 3584 CX

Netherlands

Phone: 31 631117922

Email: [email protected]

Background: Electronic informed consent (eIC) is increasingly used in clinical research due to several benefits including increased enrollment and improved efficiency. Within a learning health care system, a pilot was conducted with an eIC for linking data from electronic health records with national registries, general practitioners, and other hospitals.

Objective: We evaluated the eIC pilot by comparing the response to the eIC with the former traditional paper-based informed consent (IC). We assessed whether the use of eIC resulted in a different study population by comparing the clinical patient characteristics between the response categories of the eIC and former face-to-face IC procedure.

Methods: All patients with increased cardiovascular risk visiting the University Medical Center Utrecht, the Netherlands, were eligible for the learning health care system. From November 2021 to August 2022, an eIC was piloted at the cardiology outpatient clinic. Prior to the pilot, a traditional face-to-face paper-based IC approach was used. Responses (ie, consent, no consent, or nonresponse) were assessed and compared between the eIC and face-to-face IC cohorts. Clinical characteristics of consenting and nonresponding patients were compared between and within the eIC and the face-to-face cohorts using multivariable regression analyses.

Results: A total of 2254 patients were included in the face-to-face IC cohort and 885 patients in the eIC cohort. Full consent was more often obtained in the eIC than in the face-to-face cohort (415/885, 46.9% vs 876/2254, 38.9%, respectively). Apart from lower mean hemoglobin in the full consent group of the eIC cohort (8.5 vs 8.8; P =.0021), the characteristics of the full consenting patients did not differ between the eIC and face-to-face IC cohorts. In the eIC cohort, only age differed between the full consent and the nonresponse group (median 60 vs 56; P =.0002, respectively), whereas in the face-to-face IC cohort, the full consent group seemed healthier (ie, higher hemoglobin, lower glycated hemoglobin [HbA 1c ], lower C-reactive protein levels) than the nonresponse group.

Conclusions: More patients provided full consent using an eIC. In addition, the study population remained broadly similar. The face-to-face IC approach seemed to result in a healthier study population (ie, full consenting patients) than the patients without IC, while in the eIC cohort, the characteristics between consent groups were comparable. Thus, an eIC may lead to a better representation of the target population, increasing the generalizability of results.

Introduction

The use of electronic informed consent (eIC) procedures in clinical research is increasing due to several benefits, including increased enrollment and improved efficiency, by reducing the need for on-site research staff and the associated paperwork [ 1 - 3 ]. eICs have the potential to improve the patient experience (eg, patient understanding and confidence) of the informed consent (IC) process, in part because of the ability to include digital multimedia [ 4 , 5 ]. Alternatively, concerns were raised about whether eIC forms are easily accessible to an elderly population and those with limited digital literacy [ 6 ], making it more difficult to assess whether the patient has fully understood the IC form, one of the requirements for a valid IC [ 7 ]. Standardized best practices for eIC procedures are still lacking [ 5 , 8 ].

In 2014, the University Medical Center (UMC) Utrecht in the Netherlands initiated the Utrecht Cardiovascular Cohort-CardioVascular Risk Management (UCC-CVRM) as a learning health care system (LHS). The UCC-CVRM LHS aims to improve uniform assessment and registration of cardiovascular risk indicators, based on Dutch national guidelines, in electronic health records (EHRs) for all patients referred to the UMC Utrecht for cardiovascular evaluation [ 9 ]. In an LHS, care and research are integrated in such a way that health care activities are continuously analyzed and the knowledge gained from these analyses is used to improve care by changing health care practices [ 10 ]. In the case of UCC-CVRM LHS, a traditional face-to-face IC procedure was used for blood sample storage in a biobank and the reuse of routine care data for scientific research purposes including linkage of data from EHRs to national registries [ 9 ]. In 2020, during the COVID-19 pandemic, the UCC-CVRM steering committee evaluated the study including the IC procedure [ 11 , 12 ]. In short, less than half of the patients who were invited to participate, 41.5% (2378/5730), provided written IC [ 12 ]. Next, patients who did consent differed in clinical characteristics from those nonconsenting or nonresponding, clearly leading to a selection of patients not representable for all eligible patients. For example, consenting patients had a lower cardiovascular disease burden than nonconsenting patients [ 11 , 12 ]. In addition, structured registration of cardiovascular risk management (CVRM) indicators in the EHR was worse compared with consenting patients. This selection is detrimental to an LHS, as the population included in the LHS may be less representative of the target population as a whole [ 11 , 12 ]. Finally, eligible patients were not invited, mainly because of the time-consuming and unsustainable IC procedure due to changes in personnel and changes in priorities during peak periods (eg, the COVID-19 pandemic) [ 13 ].

Therefore, the UCC-CVRM steering committee decided to alter the approach. Identification of eligible patients for the LHS was to be automated and CVRM data, to be assessed regularly in patients at higher cardiovascular risk, were extracted from structured fields in the EHR. To still enable the linkage of this patient information to data from national registries, general practitioners (GPs), and other hospitals, an eIC procedure was piloted. This study aims to evaluate the eIC procedure by studying the response to the IC form. In addition, we aim to assess whether the change in the IC procedure leads to a different study population by investigating potential differences in clinical characteristics between the response categories of the eIC compared with the former face-to-face IC procedure.

We used the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement as a reporting guideline for this study.

Study Setting

Patients visiting the UMC Utrecht for the first time for the evaluation of cardiovascular disease or risk factors were eligible for inclusion in the UCC-CVRM LHS. The full rationale of UCC-CVRM has been described elsewhere [ 9 ]. The eIC pilot was conducted between November 2021 and August 2022. During this period, all patients (18 years and older) visiting the cardiology outpatient clinic for first-time evaluation automatically received an email. This email notified these patients about UCC-CVRM and the associated eIC form that was available for completion in the UMC Utrecht patient portal. The IC procedures of the face-to-face IC and eIC are illustrated in Figure 1 . The full details eIC form presented to the patients in the patient portal are included in Multimedia Appendix 1 .

In both the face-to-face IC and the eIC forms, IC was asked for linkage with national registries, GPs, and other hospitals through the following two statements: (1) I consent to future requests to link with various international or national registries, such as the Central Bureau of Statistics (also known as Statistics Netherlands) where all causes of death are registered, the Dutch Cancer Registration (NKR), where all people with cancer are registered, the National Basic Registration of Hospital Care (LBZ), where all hospital admissions are registered, the Foundation for Pharmaceutical Statistics (SFK), where all people who use medicines are registered, and other regional and national registries. (2) I consent to the retrieval of my medical information from my GP, my pharmacy, and any other hospitals where I have been treated in the past.

Data Collection

We collected data from all patients aged 18 years or older referred to a cardiology outpatient clinic. We used the Utrecht Patient Oriented Database to collect data from the patients who participated in the eIC pilot, referred to as the “eIC cohort.” The Utrecht Patient Oriented Database comprises data on, among others, patient characteristics and laboratory tests for all patients treated at the UMC Utrecht since 2004 [ 14 ]. We collected routine care data related to the patient’s demographics and cardiovascular risk, namely blood pressure, BMI, and laboratory measurements (serum lipids, glycated hemoglobin [HbA 1c ], hemoglobin, and renal function). These data were also collected for the cardiology patients who were invited during the period in which a face-to-face IC procedure was in place, referred to as the “face-to-face IC cohort.” From the face-to-face IC cohort, only patients invited up until December 31, 2019, were included because the COVID-19 pandemic significantly hampered the face-to-face IC procedure.

All measurements were extracted from structured fields in the EHR. Blood pressure values were extracted from the EHR ±7 days from the date of the visit at the cardiology outpatient clinic. For other measurements, the closest value, within ±21 days of the visit date, was extracted. If no measurements were found within these cutoffs, the measurement was considered missing. An overview of missingness per variable is added as Multimedia Appendix 2 . Age was calculated by subtracting the date of the visit from the patient’s date of birth. The estimated glomerular filtration rate was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation and used as a measure of renal function [ 15 ].

Data Analyses

We presented the yield for both the eIC and face-to-face IC cohort as counts and the percentages of patients who, (1) consented to the linkage of their data with their GP, pharmacy, and other hospitals, and linkage with national registries (ie, “full consent”); (2) did not consent for the linkage of their data with their GP, pharmacy, and other hospitals, nor to the linkage with national registries (ie, “nonconsent”); (3) consented to only 1 of the 2; and (4) the percentage of patients who did not respond at all or provided an answer for only 1 of the 2 statements (ie, “nonresponse”). Due to the limited number of observations in some IC response groups (n<25), especially in the eIC cohort, other than the full consent (n=1291) and nonresponse (n=1477) group, further analyses were restricted to the full consent and nonresponse group only.

To assess differences in patient groups, characteristics of the patients with full consent were stratified by cohort (ie, eIC cohort vs face-to-face IC cohort). As a supplement, we also explored the characteristics of the nonresponders by cohort. Finally, we assessed the differences in patient characteristics between the response categories within each cohort (ie, full consent versus nonresponse).

Clinical characteristics were presented as means with corresponding SDs, medians with corresponding interquartile ranges, or counts and percentages, as appropriate. To quantify differences in characteristics between cohorts, or response categories within cohorts, we performed multivariable linear regression analyses, adjusted for age, categorized into 4 categories with an approximately equal number of observations (18 to 47, 48 to 60, 61 to 70, and 71 to 95 years old), and sex. The assumptions of linear regression (eg, approximate normal distribution of the error terms, homoscedasticity of errors) were assessed. Where needed, we used the Box-Cox method to estimate the most appropriate transformation of the dependent variable to stabilize the variance and improve the accuracy of our estimations [ 16 ]. Similarly, multivariable linear regression was used to assess the difference in age (as a continuous variable) between groups, adjusted for sex. Multivariable logistic regression was used to assess the difference in sex between the groups (ie, between the 2 cohorts and between the response categories within each cohort), adjusted for age (categorized into 4 categories with an approximately equal number of observations). As a sensitivity analysis, we repeated the adjusted regression analyses with age as a continuous variable, to assess whether the categorization led to different results.

We used the Bonferroni correction to reduce the risk of a type I error resulting from the multiple tests [ 17 ]. Thus, the α that we considered as cutoff, .05, was divided by the number of analyses (N=13) performed per comparison. Therefore, a P value ≤.0038 was considered statistically significant.

All statistical analyses were performed using R software (version 4.0.5; The R Foundation) [ 18 ].

Ethical Considerations

We obtained an additional ethical waiver (number 19/641) from the Research Ethics Committee Utrecht to examine the characteristics of patients in all IC response categories. Patients who objected to the use of their clinical data for research purposes via the UMC Utrecht opt-out procedure were excluded from this study. Data were pseudonymized and the patients did not receive any compensation for their participation in this study.

Yield of the IC Procedure

In total, 3139 patients participated in this study, of whom 885 (28.2%) participated in the eIC pilot cohort and 2254 (71.8%) in the face-to-face IC cohort ( Multimedia Appendix 3 ). Of all patients from the eIC cohort, 49.9% (442/885) completed the eIC form, 50.1% (443/885) did not respond. Of all patients who completed the eIC form, we obtained full consent for linkage with GPs, hospitals, and national registries from 93.9% (415/442) of the patients. In the face-to-face IC cohort, 54.1% (1220/2254) of all patients completed the IC form, and 45.9% (1034/2254) patients did not respond. The percentage of responding patients with full consent was higher in the eIC cohort as compared with the face-to-face IC cohort (415/442, 93.9% vs 876/1220, 71.8%, respectively).

Differences in Characteristics Between the eIC and Face-to-Face Cohorts

Overall, fully consenting patients had similar patient characteristics ( Table 1 ). Adjusted for sex and age, the eIC cohort had lower hemoglobin levels and higher HbA 1c levels than the face-to-face IC cohort, reaching the multiple testing threshold for statistical significance for hemoglobin ( P =.0021).

Similarly, we compared the (clinical) characteristics of the nonresponding patients between cohorts, shown in Multimedia Appendix 4 . Adjusted for sex, the nonresponders of the eIC cohort were significantly younger and had, adjusted for age and sex, lower c-reactive protein values than the nonresponders of the face-to-face cohort. No other differences were observed.

a eIC: electronic informed consent.

b F2F IC: face-to-face informed consent.

c Reference group.

d SAP: systolic arterial blood pressure.

e HbA 1c : glycated hemoglobin.

f HDL: high-density lipoprotein.

g LDL: low-density lipoprotein.

h CRP: c-reactive protein.

i eGFR CKD-EPI: estimated glomerular filtration rate calculated using the Chronic Kidney Disease Epidemiology Collaboration equation.

Differences in Characteristics Between Response Categories

Within each cohort, we assessed whether there were differences in characteristics between the response categories (ie, full consent vs nonresponse). In the eIC cohort, the nonresponse group was significantly younger than the full consent group ( Table 2 ). Other than that, the clinical characteristics of the full consent group were similar to those of the nonresponse group.

More differences were found between the response categories of the face-to-face IC cohort. Adjusted for age and sex, patients in the full consent group had higher hemoglobin, but lower HbA 1c and c-reactive protein values than the nonresponse group ( Table 3 ).

a Reference group.

b SAP: systolic arterial blood pressure.

c HbA 1c : glycated hemoglobin.

d HDL: high-density lipoprotein.

e LDL: low-density lipoprotein.

f CRP: c-reactive protein.

g eGFR CKD-EPI: estimated glomerular filtration rate calculated using the Chronic Kidney Disease Epidemiology Collaboration equation.

Sensitivity Analysis

We repeated the regression analyses adjusted for sex and age. In these regression analyses, age was maintained continuous instead of categorized, to assess whether the categorization of age led to different results. The results were similar ( Multimedia Appendix 5 ).

Principal Results

We showed that by using an eIC in an LHS, patients more often provided full consent to link their data to national registries, GPs, and other hospitals compared with a face-to-face IC procedure. The clinical characteristics of patients with full consent remained largely similar after changing the IC procedure to an eIC. Except for age, we did not find any differences between the response categories of the eIC cohort, whereas in the face-to-face cohort, several differences were found. These differences potentially suggest a higher (cardiovascular) disease burden in the nonresponse group compared with the full consent group, indicative of a potentially more pronounced selection in the face-to-face approach.

A possible explanation for the differences in characteristics between the response categories in the face-to-face cohort is that patients may have been too ill or frail to attend the physical appointment with the research nurse to discuss and sign the IC form, resulting in nonresponse. The inability to attend the appointment was probably less of an issue in the eIC cohort, as patients were able to access the eIC form remotely. The finding suggests that the use of eIC results in a study population (ie, those who give full consent) that is more representative of the full target population. Our findings agree with a previous study showing that providing computer-based clinical study information leads to more willingness to participate [ 19 ], as the increased willingness to participate is consistent with the higher full consent rates found in the eIC group compared with the face-to-face IC group in our study.

Frequently Mentioned Challenges of eICs in the Literature

Concerns have been raised about whether consent given via an eIC is truly an “informed” consent [ 8 ]. According to the principles of the Declaration of Helsinki [ 7 ], potential participants must be adequately informed about various aspects of the study, such as its purpose, sources of funding, the anticipated benefits and potential risks, and the right to refuse or withdraw consent to participate without giving a reason [ 7 ]. According to previous research, comprehension assessment is more challenging when an eIC procedure is used as there is no direct interaction between the potential participant and researcher [ 6 ]. As a result, patients might provide consent without fully understanding what they are consenting to, or, conversely, patients may be less likely to consent because of the lack of personal interaction with the researcher or clinician, especially those who were already doubtful about participating in the first place. However, our findings indicate that the latter might not have been the case in our pilot study, as we observed a higher percentage of patients with full consent in the eIC cohort compared with the face-to-face IC cohort.

Another frequently mentioned concern is that studies using an eIC procedure could become inaccessible to patients who lack the digital literacy needed to access and understand the eIC form [ 6 ]. In 2021, the Netherlands had the highest percentage (ie, 79%) of 17- to 74-year-olds with at least basic digital skills in Europe [ 20 ]. Therefore, incomprehension of the eIC due to limited digital literacy may appear less of an issue in our study. However, the percentage of persons with basic digital skills varied considerably by age, with older people being less literate [ 20 ]. A sensitivity analysis showed that the age distribution of responding patients was similar between the eIC and the face-to-face approach ( Multimedia Appendix 6 ), indicating that the eIC was not less accessible than the face-to-face IC for certain age groups. However, accessibility may be an issue for geriatric patients, who are generally older than cardiology patients and often have geriatric syndromes that sometimes affect comprehension and literacy [ 21 ]. These syndromes generally make it difficult to obtain IC from the elderly [ 21 ]. eIC could, therefore, also be seen as an opportunity. Unlike paper-based ICs, multiple formats can be used to inform the patient about the purpose of the eIC and to provide technical support, for example, by using instructional videos or audio. The use of multiple formats in IC forms for the elderly has been recommended by, among others, Barron et al [ 22 ]. Furthermore, UCC-CVRM’s eIC form is available in UMC Utrecht’s long-existing patient portal. In the portal, patients have the opportunity to, among others, ask questions to their clinician via an e-consult, which can be used if parts of the eIC are unclear [ 23 ]. Another possibility would be a hybrid format, allowing patients who prefer correspondence by regular mail to respond using a paper-based IC form. However, it is questionable whether this would be helpful and it would negate the positive aspects of the eIC highlighted in this study (eg, less pronounced selection).

Legislation and Regulation Regarding eIC

Since July 2022, eICs have been permitted in the Netherlands when certain conditions are met [ 24 ]. A total of 6 conditions are described in the guideline written by the Central Committee on Research Involving Human Subjects (Centrale Commissie Mensgebonden Onderzoek) and the Dutch Association of Medical Research Ethics Committees (Nederlandse Vereniging voor Medisch-Ethische toetsingscommissies) [ 25 ]. The most important conditions are (1) eIC must be appropriate for the study, meaning that the study is associated with low potential risk and burden for the patient, (2) the eIC process must be sufficiently reliable and confidential, guaranteed by an electronic system that is compliant to the Dutch General Data Protection Regulation (UAVG in Dutch) and ensures the validity of the electronic signatures, and (3) the eIC procedure must be described in the study protocol [ 24 , 25 ]. The implementation of an eIC seems appropriate in the case of the UCC-CVRM, as no potential risk or burden for the patient is involved. Furthermore, in the eIC of the UCC-CVRM, data security, identity verification, and the validity of the electronic signature are ensured by the Dutch digital ID, an identification method for accessing web-based services [ 26 ]. Regarding the third condition, an amendment to the UCC-CVRM approach, including the eIC, was submitted and approved by the Research Ethics Committee.

Clinical Implications

Based on the results of our study, the use of eIC to obtain IC might be a sustainable and adequate way to enable researchers to link with national registries, GPs, and other hospitals. The use of the eIC seemed to have resulted in a population with consent that is more similar to the target population compared with the face-to-face IC, which is of great importance in an LHS. Results from the LHS would be more generalizable to the target population, namely to all patients at higher cardiovascular risk. Yet, one may argue whether ≈50% response to both the electronic and face-to-face IC for an LHS approach is sufficient. In addition, it should be noted that the extractability of CVRM indicators from structured fields in the EHR was much lower in the eIC cohort compared with the face-to-face IC cohort. Groenhof et al [ 13 ] showed that the former, protocolized, face-to-face UCC-CVRM approach led to more systematic registration of the cardiovascular risk profile in the EHR, which had a positive effect on CVRM guideline adherence in consenting patients, compared with the situation before UCC-CVRM was introduced [ 13 ]. The substantial missingness in the eIC cohort of our study may suggest that these improvements are at risk when the approach is automated, as deviations from the initial protocol are made, potentially leading to suboptimal CVRM in clinical care.

Exploring the views and experiences of patients could help to further improve the eIC form. Therefore, we recommend further qualitative research into the accessibility and understandability of eICs used for similar purposes and in similar settings as the UCC-CVRM LHS from a patient’s perspective.

Strengths and Limitations

To the best of our knowledge, we are among the first to investigate the differences in clinical patient characteristics between response categories of an eIC compared with those of a traditional face-to-face IC, specifically in the context of a cardiovascular LHS in a large sample of patients. Our uniqueness, however, limits the ability to compare our findings to the literature, as most research on eIC has focused on user perspectives, experiences, and the ethical considerations of eICs. For example, Chen et al [ 5 ] showed that in most included studies, participants had a better understanding of the information when using an eIC compared with a traditional paper-based face-to-face IC, while others found no difference [ 5 ]. Nevertheless, they [ 5 ] and others [ 2 , 6 , 27 ] indicated that face-to-face interaction should remain part of the IC process, especially for more complex and higher-risk studies. However, as the UCC-CVRM LHS is not a complex or high-risk study, the face-to-face interaction may be less necessary. Furthermore, the nonresponders in the eIC cohort may not be fully comparable to the nonresponders in the face-to-face IC cohort because, in the eIC cohort, patients received the eIC after their appointment at the cardiology outpatient clinic, whereas in the face-to-face IC cohort, cardiology patients were identified as eligible and received information about the UCC-CVRM LHS prior to their appointment. This means that patients who, for example, canceled their appointment at the last minute would still be included in the face-to-face cohort as nonresponders. It may be that patients who did not attend their appointment at all had different characteristics to those who attended but did not respond to the eIC, potentially affecting the validity of the comparisons made. Finally, the eIC form was piloted in the patient population of the cardiology outpatient clinic only. Although our results indicated that there were only minor differences (ie, hemoglobin) between patients providing full consent using the eIC compared with the face-to-face IC, it remains to be seen whether this would still be the case after implementation of the eIC in other clinical departments.

Conclusions

To conclude, our findings suggest that using an eIC may lead to a better representation of the target population by consenting patients. This increases the generalizability of results from studies using the data collected within the LHS from consenting patients.

Acknowledgments

The Utrecht Cardiovascular Cohort-Cardiovascular Risk Management (UCC-CVRM) is primarily financed by the University Medical Center (UMC) Utrecht (contact information of UCC-CVRM is [email protected]). AGMZ was supported by a grant from the European Union’s Horizon 2020 research and innovation program (grant agreement number 101017331; ODIN). MJH and RvdG were supported by the ZonMw, ETHMIRE project (grant agreement number 91217027). The funding sources were not involved in the design of the study, the analysis and interpretation of the data, the writing of the manuscript, and the decision to submit the manuscript for publication. Members of the UCC-CVRM study group were the following: GJ de Borst, Department of Vascular Surgery; ML Bots (chair), Julius Center for Health Sciences and Primary Care; M Hollander, Julius Center for Health Sciences and Primary Care; MH Emmelot, Department of Geriatrics; PA de Jong, Department of Radiology; AT Lely, Department of Obstetrics/Gynecology; HM Nathoe, Department of Cardiology; IE Hoefer, Central Diagnostic Laboratory; NP van der Kaaij, Department of Cardiothoracic Surgery; YM Ruigrok, Department of Neurology; and MC Verhaar, Department of Nephrology and Hypertension, FLJ Visseren, Department of Vascular Medicine, University Medical Center Utrecht and Utrecht University.

Authors' Contributions

AGMZ, HMN, WWvS, MLB, SH, and RWMV contributed to the conceptualization of the project. AGMZ, RWMV, SH, WWvS, and MLB contributed to the methodology of the project. AGMZ analyzed the data and drafted the manuscript. AGMZ, MJH, RvdG, HMN, WWvS, MLB, SH, and RWMV contributed substantially to the interpretation of the data. The final manuscript was critically reviewed and edited by all authors. Approval of the final manuscript was obtained by all authors.

Conflicts of Interest

None declared.

The electronic informed consent form as presented in the patient portal of the UMC (University Medical Center) Utrecht (translated from Dutch to English).

Missingness per variable in count and percentage, by cohort and informed consent response strata.

Yield (ie, response to the informed consent invitation), by type of informed consent. eIC: electronic informed consent; GP: general practitioner.

Differences between patients who did not respond, by cohort, adjusted for age and sex.

Results of the sensitivity analysis in which age is treated as a continuous variable instead of categorical variable.

Age distribution of patients who completed the informed consent form, stratified by cohort.

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Abbreviations

Edited by A Mavragani; submitted 29.11.23; peer-reviewed by CMJ Wong, H Kondylakis; comments to author 28.02.24; revised version received 15.04.24; accepted 10.05.24; published 11.07.24.

©Anna G M Zondag, Marieke J Hollestelle, Rieke van der Graaf, Hendrik M Nathoe, Wouter W van Solinge, Michiel L Bots, Robin W M Vernooij, Saskia Haitjema, UCC-CVRM study group. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 11.07.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research (ISSN 1438-8871), is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.

• Introduction
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The dotted vertical line indicates the Dobbs v Jackson Women’s Health Organization decision.

eTable. Diagnosis and Billing Codes Used to Identify Tubal Ligation, Vasectomy, and Encounters for Evaluation and Management (E&M)

Data Sharing Statement

• Permanent Procedures to Prevent Pregnancy in US Jumped After Dobbs JAMA Medical News in Brief June 4, 2024 Emily Harris
• Error in Figure JAMA Health Forum Correction May 10, 2024

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Ellison JE , Brown-Podgorski BL , Morgan JR. Changes in Permanent Contraception Procedures Among Young Adults Following the Dobbs Decision. JAMA Health Forum. 2024;5(4):e240424. doi:10.1001/jamahealthforum.2024.0424

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Changes in Permanent Contraception Procedures Among Young Adults Following the Dobbs Decision

• 1 Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
• 2 Center for Innovative Research on Gender Health Equity, Department of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
• 3 Department of Health Law, Policy, & Management, Boston University School of Public Health, Boston, Massachusetts
• Medical News in Brief Permanent Procedures to Prevent Pregnancy in US Jumped After Dobbs Emily Harris JAMA
• Correction Error in Figure JAMA Health Forum

On June 24, 2022, the US Supreme Court’s decision in Dobbs v Jackson Women’s Health Organization overturned the constitutional right to abortion, permitting states to further restrict or ban abortion care. As of January 2024, 21 states have done so. 1 This structural barrier to exercising control over pregnancy and childbearing will indirectly affect contraceptive decision-making.

Early research has documented increased demand for permanent contraception in the months following Dobbs , including tubal sterilization and vasectomy. 2 , 3 This change may reflect fears of restricted access to abortion and/or contraception. However, no research, to our knowledge, has evaluated the differential effect of Dobbs on permanent contraception among men relative to women or among younger adults who are more likely to have an abortion and to experience sterilization regret. 4 , 5 We therefore evaluated changes in tubal ligation and vasectomy following Dobbs among younger adults.

We used data from the TriNetX platform for this cross-sectional study. These continuously updated medical record data are largely from academic medical centers and affiliated clinics in all 4 US census regions. We used an interrupted time series study design, fitting seasonally adjusted segmented autoregressive models to assess level and slope changes in procedure rates before (January 1, 2019, to May 31, 2022) and after (June 1, 2022, to September 30, 2023) Dobbs . Sensitivity analyses with a truncated pre- Dobbs observation window (April 1, 2021, to May 31, 2022) were conducted using Stata, version 17.1 (StataCorp LLC). This research was deemed exempt from review and the need for informed consent by the Boston University Institutional Review Board owing to the use of deidentifed patient data. We followed the ( STROBE ) reporting guideline.

Using monthly aggregate counts of tubal ligations and vasectomies, we calculated rates per 100 000 person-months among female and male patients aged 18 to 30 years. Individuals with an encounter for evaluation and management each month and no permanent contraception documented previously were included in the denominator. Visits for evaluation and management, tubal sterilization, and vasectomy procedures were identified using Current Procedural Terminology and International Statistical Classification of Diseases, Tenth Revision codes (eTable in Supplement 1 ). Two-sided P < .05 indicated statistical significance.

Observed permanent contraception procedure rates, estimates, and seasonally adjusted models for 22 063 348 person-months (36.9% male and 63.1% female) are presented in the Figure . Prior to Dobbs , the monthly permanent contraception rate increased by 2.84 and 1.03 procedures per 100 000 person-months among female and male patients, respectively ( Table ). Dobbs was associated with an immediate level increase of 58.02 procedures and 5.31 procedures per month among female patients. Among male patients, it was associated with a level increase of 26.99 procedures and no significant change in the number of procedures per month. Findings were robust to sensitivity analyses.

We observed an abrupt increase in permanent contraception procedures among adults aged 18 to 30 years following Dobbs . The increase in procedures for female patients was double that for male patients. These patterns offer insights into the gendered dynamics of permanent contraceptive use and may reflect the disproportionate health, social, and economic consequences of compulsory pregnancy on women and people with the capacity to become pregnant.

This study has several limitations. The TriNetX platform does not capture state or health care organization identifiers. We were therefore unable to assess the potential outcomes of state abortion policy or account for changes in the sample attributable to fluctuations in the organizations contributing data over the study period. Additionally, our findings do not provide insight into the differential experiences of Black, Indigenous, Hispanic, disabled, immigrant, and low-income women, who disproportionately encounter interference and coercion in their contraceptive decision-making. 6

The abrupt increase in permanent contraception rates may indicate a policy-induced change in contraceptive preferences. Dobbs may have also increased a sense of urgency among individuals who were interested in permanent contraception before the decision. Changes in contraceptive decision-making must be considered to understand the short- and long-term implications of Dobbs on reproductive autonomy.

Accepted for Publication: February 7, 2024.

Published: April 12, 2024. doi:10.1001/jamahealthforum.2024.0424

Correction: This article was corrected on May 10, 2024, to correct the y-axis label in the Figure.

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Ellison JE et al. JAMA Health Forum .

Corresponding Author: Jacqueline E. Ellison, PhD, 130 De Soto St, Pittsburgh, PA 15261 ( [email protected] ).

Author Contributions: Dr Ellison had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Ellison, Morgan.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Ellison, Brown-Podgorski.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Ellison, Morgan.

Administrative, technical, or material support: Ellison, Morgan.

Supervision: Ellison.

Conflict of Interest Disclosures: None reported.

Data Sharing Statement: See Supplement 2 .

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Fires and climate are changing. The science must change as well, says paper

by North Carolina State University

A new paper on the many ways wildfires affect people and the planet makes clear that as fires become more intense and frequent, the urgency for effective and proactive fire science grows. By addressing these challenges, the fire research community aims to better protect our planet and its inhabitants.

The paper appears in the Zenodo research repository.

Fire is a natural part of life on Earth, sustaining healthy and balanced ecosystems worldwide. But human activity and a changing climate are rapidly shifting both the frequency and severity of wildfire events, creating new risks to human and environmental health.

Recently, a group of scientists from 14 countries and across several disciplines—physical and social sciences, mathematics, statistics, remote sensing, fire communication and art, operational fire science , and fire management—gathered to discuss rapid changes in fire regimes and identify pathways to address these challenges.

The experts identified three grand challenges for fire science in the coming decades: understanding the role of fire in the carbon cycle , fire and extreme events , and the role of humans in fire.

"If we want to improve the assessment of future fire impacts on people and the planet, we need to start with a better understanding of how climate, land cover changes, and human land management practices drive fire distribution and severity in the coming decades," says Douglas Hamilton, assistant professor of marine, earth and atmospheric science at North Carolina State University.

Hamilton, together with Morgane Perron of University Brest, France and Joan Llort of the Barcelona Supercomputing Centre, Spain, initiated the working group FLARE (which stands for Fire Science Learning AcRoss the Earth System).

To address the grand challenges, the scientists identified three pressing research priorities: understanding the net carbon balance of fire, developing rapid response tools for wildfire events, and understanding fire's impact on society, especially marginalized and underrepresented populations.

The first priority, understanding the net carbon balance of fire, refers to understanding how fire's carbon release, ecological recovery from fire, climate change , ocean biology, and ice melt all interact and affect the Earth's carbon balance.

"Wildfires can significantly affect the global carbon cycle," says Chantelle Burton, senior climate scientist at the Met Office UK. "Fires in ecosystems that store large amounts of carbon, such as peatlands, permafrost and forests, can release vast quantities of CO 2 into the atmosphere. However, where that carbon ultimately ends up and its impact on future warming are harder to determine. Incorporating accurate fire-related carbon fluxes into Earth System Models is crucial for predicting climate outcomes and informing mitigation strategies, and it will require us to bring together experts from across the fire sciences."

The second priority, developing rapid response tools for wildfire events, refers to developing tools for more timely and responsive answers to critical questions during extreme fire events and providing an annual report on key policy and media questions.

"Our observational, statistical, and modeling tools for assessing and projecting fire are improving rapidly, but the problem of extreme fires always remains one step ahead of us," says Douglas Kelley, fire scientist at the UK Centre for Ecology & Hydrology (UKCEH). "To catch up, we need our tools to provide quick, robust answers to critical questions about climate impact, human causation, affected communities, and future risks. These answers need to be communicated clearly to non-specialists when they are most needed."

The third priority aims to explore how fires affect marginalized and underrepresented communities, emphasizing Indigenous populations and environmental justice.

"So how should we be using all the tools at our disposal to improve measurements and help create better models for predicting the downstream effects of each fire?" Hamilton asks. "And once we do that, how do we best communicate these findings to our communities? We wanted to create a roadmap for science, so that our collaborations focus on getting these answers faster than at present."

A main goal in the white paper is to be able to improve fire modeling, predictability, and mitigation on both regional and global scales, but Hamilton also hopes that FLARE will aid in fostering transdisciplinary science and in recruiting future fire scientists. "There simply are not enough scientists in this field to do the work," Hamilton says.

Sebastian Diez from Universidad del Desarrollo, Chile and part of International Global Atmospheric Chemistry's (IGAC) Early Career Committee further emphasizes the importance of global collaboration. "Researchers from the Global South face unique challenges that require locally adapted solutions," Diez says. "Strengthening research capabilities and resources in less affluent regions is imperative to effectively address the transdisciplinary challenges of fire science."

"Fire has always been there in the Earth system. What's new is how it is being affected by and affecting humans in the context of wider planetary change," says Sophie Hebden, Future Earth. "By bringing together the different global research networks of Future Earth, we were able to address these challenges across research silos and outline a transdisciplinary research agenda for the global fire community."

As fire events become more intense and frequent, the urgency for effective and proactive fire science grows. FLARE's next steps are to address these challenges collectively, as a unified fire research community, to better protect our planet and its inhabitants.

Provided by North Carolina State University

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