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Open Access Research article

Exploring laypeople’s epistemic beliefs about medicine – a factor-analytic survey study

Dorothe Kienhues* and Rainer Bromme

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Department of Psychology, University of Muenster, Fliednerstrasse 21, Muenster, 49149, Germany

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Citation and License

BMC Public Health 2012, 12:759  doi:10.1186/1471-2458-12-759


The electronic version of this article is the complete one and can be found online at: http://www.biomedcentral.com/1471-2458/12/759


Received:9 September 2011
Accepted:3 September 2012
Published:10 September 2012

© 2012 Kienhues and Bromme; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

The aim of this study was to develop an instrument to measure laypeople’s beliefs about the nature of medical knowledge and knowing (the EBAM). Such beliefs should be a target of increased research interest because they influence how people handle medical information, for example in shared decision making.

Methods

An online survey was completed by 284 participants. Items assessed different aspects of laypeople’s epistemic beliefs about medicine and explicitly focused on the appearance of medical knowledge in everyday life and the evaluation of different sources as a way to justify knowledge.

Results

Factor analysis yielded a five-factor solution for the instrument. Dimensions covered by the instrument are certainty of medical knowledge, credibility of medical textbooks, credibility of medical information on the Internet, justification of medical knowledge, and preliminarity of medical knowledge.

Conclusions

Results indicate that laypeople have meaningful beliefs about the nature of medical knowledge and the trustworthiness of different sources. The instrument developed seems promising for measuring laypeople’s epistemic beliefs about medicine, which may help to increase patients’ compliance in medical decision making.

Background

This article describes the rationale and empirical testing of an instrument to measure laypeople’s epistemic beliefs about medicine (EBAM).

Why are laypeople’s epistemic beliefs about medicine important and of interest for health psychology issues? For shared decision making and for patients’ treatment adherence, it is necessary for patients to understand the complexity and, at times, uncertainty of medical knowledge [1,2]. Imagine a male patient diagnosed with high cholesterol. His general practitioner has made clear that he should avoid eating butter and red meat and that it might be of value to take some medication to lower the cholesterol level. The patient will probably search for additional information on what to do on the Internet [3] (Google finds about 104.000.000 results for the keyword “cholesterol”). There, he will come across web pages with statements on the dangerousness as well as on the harmlessness of eating butter. He will find web pages that advertise a specific drug to lower cholesterol and Internet forums where patients describe (adventurous) alternative ways in how they control high cholesterol. In other words, he will be confronted with a plenitude of information and a multitude of opinions on a specific health-related problem. As a result, forming a conclusion about his future behavior will be quite difficult and the treatment of cholesterol may in his view be a complex and ill-structured problem (which it might also be in experts’ view [4]). The patient will have to undertake the task to assess which information is more important and valid than other information, how conflicts between various perspectives of knowledge can be solved, and how conflicting evidence could be integrated into a viable framework of personal understanding and decision making. He will have to cope with the fact that there are alternative treatments, differing interpretations of symptoms or even several interpretations of the underlying pathophysiological explanations of illnesses and risks. How the patient assesses the controversies (both on his own and in the next consultation with the doctor), in how far he accepts that people disagree on what is the best solution, how he reconciles his own ideas with those of experts and whether he takes advice from his doctor is influenced by the beliefs he holds about the nature of medical knowledge and knowing, called epistemic beliefs.

Of course, whether the patient will take advice from his doctor and in how far he is willing to participate in the decision making process, is not only influenced by epistemic beliefs but also by many other factors, e.g. the patients’ degree of anxiety, age or even their numeracy skills [5]. Furthermore, various characteristics of the doctor will play a role, e.g. his general consultation skills [6] but also in how far he appears to be trustworthy and competent [7] (and this evaluation of trustworthiness and competence might again be influenced by epistemic beliefs, see below).

Most problems patients are confronted with in medical decision making require knowledge and expertise which goes far beyond laypeople’s understanding. That is, patients depend on experts' explanations and advice and are not able to acquire the knowledge and skills which would be necessary to directly assess the experts' knowledge claims. However, patients will probably have a more general idea about what constitutes trustworthy and reliable knowledge claims, how one can obtain knowledge, or how to identify credible sources for (medical) information. That is, patients can refer to their epistemic beliefs when they need to reflect critically about medical information, evaluate what to believe, and which knowledge claim to support [8,9]. Epistemic beliefs are furthermore seen to function as an “apprehension structure” [10]: they allow for an anticipation of the knowledge to be learnt or to be dealt with, which includes for example an expectation of the complexity of a topic and of how much is already known about a topic.

As outlined above, medical problem solving often does not result in one clear solution, and the lack of relevant information for the problem-solving process is common [11,12]. Because many health-related problems are contentious and lack clear-cut solutions, they can be described as ill-structured problems, that is, “problems about which reasonable people reasonably disagree” [13]. Research in non-medical disciplines suggests that epistemic beliefs play an important role in dealing with such problems [8,13]. Therefore, assessing laypeople’s epistemic beliefs about medicine is important.

As a result, patients’ epistemic beliefs play an important role in medical decision making. They can be seen as a “must” for the exercise of patient rights, as they can guide their medical decision making even though patients do not have a conceptual understanding of the problem at hand. However, also in the case that patients prefer a rather paternalistic decision making model, their epistemic beliefs will still play a role insofar as that they may guide the choice of the expert to be trusted.

Therefore, laypeople’s epistemic beliefs about medicine should become a topic for research in health psychology. Psychological research on epistemic beliefs provides a profound background for this target.

Research on epistemic beliefs

During the last two decades, epistemic beliefs have become a target of increased research interest in developmental and educational psychology [14-16]. Epistemology as one cornerstone of philosophy embodies questions about the processes by which human knowledge is justified as well as questions about the nature of knowledge [17]. This leads to the most often used definition of the construct epistemic beliefs which distinguishes between the nature of knowledge and the nature (or process) of knowing as the two core sets of concerns [18]. How one conceptualizes knowledge and how it changes over time are seen as aspects of the nature of knowledge, while considerations about where knowledge comes from and how to make justifications refer to beliefs about the nature of knowing. Epistemic beliefs range from a less advanced view to more advanced epistemologies and develop through life and from educational experiences [19,20]. Whereas a less advanced view includes beliefs such as that knowledge is certain and stable, either true or false, and can be handed down by an authority, a more advanced view is characterized by beliefs that knowledge is rather complex and relativistic, by accepting the uncertainty and changeability of truth, and acknowledging that knowledge is construed individually.

It is assumed that people possess both discipline-general and discipline-specific epistemic beliefs (beliefs about specific academic fields) concurrently [21-23]. Discipline-specific beliefs are presumed to play a predominant role when working on a discipline-specific problem, while discipline-general beliefs influence motivation and engagement [17,24].

For example, studies reveal the important role of epistemic beliefs in dealing with (scientific) controversies [25-27]. An exemplary study [26] investigated the influence of high school students’ epistemic understanding on the critical interpretation of a dual-position text. In this study, an initial test of epistemic understanding asked participants to indicate for pairs of contrasting statements whether they think that only one of the views described is right or whether both views could have some rightness and – depending on the response to this question (“if both could be right”) –whether one view could be better than the other. According to this initial test, participants were assigned to three groups of different epistemic positions: participants primarily holding a less advanced (seeing knowledge as absolute and either right or wrong), moderate (seeing knowledge as idiosyncratic, so that all positions are equally right), or more advanced view (seeing knowledge as derived from reason, so that some positions are more justified and sustainable than others). All participants read a scientific text about genetically modified food, introducing both the position in favor and against such food. After reading the text, participants were asked to write a conclusion to the text. Findings showed that students with more advanced and with moderate epistemic understanding reflected better on the inconclusive nature of the debate on transgenic food than students with less advanced beliefs.

Epistemic beliefs about medicine

To date, epistemic beliefs about medicine have rarely been considered in psychological or medical research [28]. This is in sharp contrast to the assumed importance of such beliefs (outlined above). Evidence-based medicine comes along with the need for advanced epistemic beliefs [29,30]. Epistemic beliefs about medicine should play a quite prominent role in everyday life, not least because “the life of every individual is ripe with opportunities for applying health related knowledge” [31].

After a thorough review of the literature, few studies explicitly assessed beliefs about the nature of medical knowledge and knowing, and these studies did not deal with laypeople. In one study [29], conceptions of medical knowledge in an exploratory interview study on second-year medical students were considered. Results show that most students started medical school with rather simplistic beliefs, for example, stating that if uncertainty existed in some aspects of medical knowledge, this uncertainty would only be temporary. Within their first two years in medical school, most students changed their understanding of medical knowledge with regard to its certainty and considered medical knowledge open to change or adaptation. That is, the experience that medical knowledge less black or white than assumed led students to question their former way of thinking about medical knowledge.

Another study [32] attempted to elicit and analyze general practice trainees’ and trainers’ beliefs about medical knowledge and knowing in a focus-group approach. It concluded that people’s epistemic beliefs are probably influential in the solution of medical problems.

In sum, the nature of medical knowledge and knowing is not yet well researched, especially with regard to laypeople’s beliefs. One first attempt to assess laypeople’s epistemic beliefs about medicine is to develop an instrument to survey such beliefs. However, no such medicine-specific instrument exists. To date, research on laypeople’s views on knowledge about medicine has only considered laypeople’s subjective theories of illnesses [33]. Therefore, the objective of the study described in the following is to develop an instrument to survey laypeople’s epistemic beliefs about medicine. More specifically, we aimed for an instrument that assesses different aspects of laypeople’s epistemic beliefs about medicine and that explicitly focuses on the appearance of medical knowledge in everyday life. Items should especially consider that laypeople must rely on others to justify their beliefs and particularly take into account the trustworthiness of different sources.

Methods

Sample

In this study, 284 people (125 male, 158 female) completed the questionnaire. Participants’ average age was 20.79 years (SD = 3.83). Among the participants, 161 were in the final classes of German higher school education, while the other 123 were students of various subjects, predominately belonging to the subject areas of humanities and social sciences (30.1%), natural sciences (13.8%), and economics (12.2%). Because none of the participants’ studies focused on medical knowledge (e.g., medicine, pharmacy), they were assumed to be laypeople in this domain.

IRB approval for psychological survey studies is not (yet) common practice in Germany. In consequence, we did not apply for IRB approval. We did not collect data with identifying information and participation was voluntary.

Materials: construction of the instrument

The EBAM was intended to extend and refine earlier work on discipline-specific measurement of epistemic beliefs to reach a medicine-specific instrument. We aimed for a questionnaire that explicitly focuses on the appearance of medical knowledge in everyday life. That is, it should consider such aspects of epistemic beliefs that are crucial for laypeople’s search and evaluation of competing sources of medical knowledge. In the first step, we scanned existing discipline-specific questionnaires and surveyed their dimensions. As a result, we selected several dimensions that should also be included in the first item sample of the EBAM from the instrument “Epistemological Beliefs Assessment for Physical Science” (EBAPS) [34]. These were the structure of scientific knowledge (whether knowledge is a coherent whole or a bunch of weakly connected pieces), real-life applicability (whether knowledge is applicable to real life or only applicable to restricted spheres) and evolving knowledge (whether knowledge is only mere opinion or set in stone). We left out the EBAPS dimensions “nature of knowing and learning” and “source of ability to learn”, as they focus on aspects of intelligence and learning and are therefore in our view [35] and the view of many other researchers [18,36] outside the construct of epistemic beliefs. We furthermore wished to consider the dimension certainty of knowledge, which is arguably the most agreed on dimension in conceptualizations of epistemic beliefs [37-39]. The Global Certainty Scale [40], which focuses on the fallibility of scientific knowledge, seemed to be a promising source of inspiration. This scale consists of seven items measuring in how far knowledge and theories in the soft and hard sciences are perceived as certain and unchangeable respectively as changing and fallible (a sample item for this scale is “Scientific theories can be proven false at any time” (reverse scored)).

In addition, the EBAM should specifically take into account the situation that a layperson has to manage a medical problem. Therefore, we included items on the credibility of different sources in which a layperson might search for medical information, namely the credibility of information on the Internet and the credibility of information in textbooks. We also added items to address a specific aspect of laypeople’s justification of medical knowledge: How should one decide on a medical treatment? Should one rely on current scientific research results or on the experiences of an affected patient or those of a general practitioner? These aspects are especially important with regard to laypeople’s epistemic beliefs: Because laypeople do not have substantial knowledge or experiences themselves, they have to rely on others to justify their beliefs. Furthermore, we added several items focusing on theory versus facts as well as on the connectedness, respectively isolatedness of medicine-specific knowledge to assess the structure or simplicity of medical knowledge.

All items collected were then rewritten, shortened, or modified so that they clearly focused on the discipline of medicine and laypeople’s understanding of it and could be answered on a Likert scale. The resulting preliminary version of the survey was carried out with a small number of individuals (six students) who were interviewed after answering each question to ensure that items were interpreted in a similar and intended way. After these interviews, minor revisions of the items were made. The final item pool for the EBAM consisted of 43 items that could be answered on a five-point Likert scale, ranging from “I totally disagree” to “I totally agree”. We administered additional items that surveyed several demographical variables (age, sex, subject, and length of study when applicable).

Procedure

The survey software “EFS Survey” by Globalpark® was used to build a web-based survey. Participants were asked to participate in two different ways. Members of a German social networking website for students were invited to participate and students in their final year of school were asked to participate during an open day at the psychology department. Participation was voluntary.This procedure was chosen because it was economic and it ensured diversity and a heterogeneous sample. In both data collections, the introduction of the survey emphasized that all questions of the survey focus on a personal view of medical knowledge and medical information, and that there are no right or wrong answers. Participants could take as much time as they needed to answer all questions, that is, there was no time limit.

Results

Appropriateness of the data

Before conducting a factor analysis, some parameters were checked to ensure that the data were appropriate for factor analysis: A Kolmogorov-Smirnov-test revealed that data are normally distributed. Bartlett’s test of sphericity was statistically significant at p < .05, indicating that items were not coincidentally correlated. The measure of sampling adequacy was .72 for the initial sample, which can be interpreted as “middling” [41]. In sum, data were appropriate for factor analysis.

Decisions on model-fitting method, rotation method and number of factors retained

An Exploratory Factor Analysis (EFA) was determined as the most appropriate form of analysis to uncover the underlying structure of the set of variables. Maximum Likelihood (ML) was chosen as the model-fitting method [42,43] and we decided for an oblique rotation method (direct oblimin rotation), because the statistical independence of epistemic dimensions in the sense of uncorrelated factors is questionable.

According to the scree plot, a five-factor solution was compared with a six-factor solution [43]. A comparison of the item loadings showed that the five-factor solution had the cleanest factor structure, which will therefore be reported in the following results.

Factor solution

The five-factor solution was obtained by successively omitting items with no substantial factor loadings. Following the rule of thumb for a minimum loading of .32 for an item [44], a total of 17 items were removed. As a result, the final factor solution consisted of 24 items. ML factor analysis generates a chi-square goodness-of-fit test for the sample. Results underscored the goodness of fit (χ2 = 217.01; df = 166, p <. 01).

The first factor focused on the solvability of medical questions and the certainty or stability of medical knowledge. Therefore, it was called Certainty of Medical Knowledge. The factor consisted of seven items and yielded an acceptable Cronbach's α-value (α = .69). The dimension ranged from beliefs that there are or will be clear answers to medical problems to beliefs that there is no strong supporting evidence for medical knowledge. An exemplar item of this factor is: “Research in medicine has shown that there is one clear answer to most problems.”

The second factor consisted of four items which focused on the credibility of textbooks as a source of medical knowledge. The factor had a satisfactory α coefficient value (α = .73). This dimension ranged from the assumption that medical textbooks always provide credible information to the perception that the credibility of medical textbooks is always questionable and should therefore be critically scrutinized. An example item from this factor is: “Medical textbooks almost always contain reliable statements with regard to medical research.”

The third factor consisted of four items focusing on the credibility of the Internet as a source of knowledge. Cronbach's α was .74. Comparable to factor 2, this dimension ranged from the assumption that medical information on the Internet is always credible to the perception that the credibility of medical information on the Internet is always questionable and should therefore be critically scrutinized. An item example is: “One can almost always receive verified medical information on the Internet.”

The fourth factor consisted of four items. The α coefficient reached a satisfactory .61. Items belonging to this dimension took into account whether only people who have a specific disease or physicians who are experienced in treating a specific disease have true medical knowledge. The factor also assessed the applicability of medical research results. One of the items loading on this factor is: “People who suffer from a disease usually know better what to do than physicians.”

The fifth factor consisted of five items, focusing on the preliminarity, respectively Stability of Medical Knowledge. It yielded an acceptable Cronbach's α-value (α = .60). An item representing this factor is “Scientific theories in medicine, that I currently assume to be right, can be confuted in the future.”

Table 1 displays the pattern matrix for the reported five-factor solution.

Table 1. Pattern matrix for the five-factor solution obtained through exploratory factor analysis

Estimated stability of the factor solution

For an estimation of the stability of the factor structure, the FS parameter was calculated, which takes into account that the interpretation of factor loadings is dependent on sample size [45]. For the EBAM, FS was .91, indicating a good accord between the found factor structure and the “real” factor structure.

Recoding of the items for further analyses

For the calculation of sum scores for the five factors, several items need to be recoded after administering the questionnaire. For factor 2 and factor 3, the forth item needs to be recoded. Furthermore, all items of factor 5 should be recoded. As a result, for factor 1 higher scores indicate a deeper belief in the certainty of medical knowledge and in the solvability of medical questions. For factor 2 and factor 3, higher scores indicate a deeper belief in the trustworthiness of medical textbooks respectively in the trustworthiness of medical information on the Internet. For factor 4, higher values mean that participants believe more that medical knowledge is better justified by (daily) experience than by medical research. For factor 5, higher values point to a stronger belief in the stability of medical knowledge.

Discussion

For the purpose of this study, the most important result is that a meaningful five-factor solution was found for the EBAM. Cronbachs’s α was suitable for all factors. Results not only indicated that measuring laypeople’s epistemic beliefs about medicine is possible with a questionnaire, they also showed that laypeople have meaningful beliefs about the nature of medical knowledge and the trustworthiness of different sources.

The dimensions found are similar to those found in most popular epistemic questionnaires, because the EBAM takes into account aspects of the certainty and stability of knowledge, the justification for knowing, and the source of knowledge. The dimension Certainty of Medical Knowledge focuses on the extent that medical knowledge is fixed. The dimension Justification of Medical Knowledge taps how laypeople justify knowledge, e.g. by making use of authority and expertise (similar to Hofer’s dimension “justification for knowing” [37]). However, the EBAM thereby also considers that people also make use of patients who have a specific disease (as specialized “experts”) to justify knowledge. The two EBAM factors on sources of knowledge, factor 2 and factor 3, both explicitly focus on the credibility of sources. In contrast to other instruments on epistemic beliefs, the EBAM does not explicitly consider the self as a knowing person. In the context of the EBAM where a layperson deals with medical information, it is rather unrealistic that the layperson becomes a knower herself or himself in the sense of an active maker of meaning. Instead, a layperson will probably use different and more or less reliable sources to come to know. Therefore, the factor solution for the EBAM underlines the importance of considering the role of sources in laypeople’s understanding of medicine: due to the fact that laypeople only have limited medical knowledge on their own, they have to rely on others. For example they may gain information from medical textbooks (Credibility of Medical Textbooks) or the Internet (Credibility of Medical Information on the Internet). The factor Stability of Medical Knowledge focuses on how stable or variable medical knowledge is perceived to be.

This first study on the EBAM was successful at reducing the number of items of the EBAM. One of our aims was to minimize the number of items for further analyses. Results suggested that 17 items of the initial sample should be excluded in further analyses. The EBAM is a promising new measure of laypeople’s epistemic beliefs about medicine. In future research, the instrument could be improved in by adding new items to enhance the number of items per factor and the item to factor loadings, because some factors (factor 2, factor 3 and factor 4) could be represented by more items, and for these factors item to factor loadings could be higher (however, the measurement of epistemic beliefs is always a challenge and instruments usually do not show excellent psychometric values [46]). Furthermore, subsequent studies should aim for a replication of the factor structure across other, more heterogeneous samples, as the sample in this first study is rather homogenous with regard to age and education. In addition, it will be interesting to investigate whether the EBAM is able to differentiate between specific subgroups, e.g. between persons with low and substantial prior medical knowledge. A further topic for future research is how people’s medicine-specific epistemic beliefs guide their decision making when facing a health problem.

Conclusions

The EBAM exemplarily refers to everyday aspects of living in a knowledge society, in which people must assess and make judgments on knowledge for which they are not an expert. Our results suggest that laypeople’s epistemic beliefs about medicine include more “classic” aspects of epistemic beliefs but especially aspects of the nature of knowing like the credibility of sources and how knowledge can be justified. In solving medical problems, laypeople not only have to rely on experts' explanations and advice, but they also have to cope with the fact that they are not able to acquire the knowledge and skills which would be necessary to assess the experts’ knowledge claims. A real understanding of most medical topics requires conceptual knowledge about medical, biological and chemical structures and processes and goes far beyond a non-expert’s understanding of medicine, biology and chemistry. That means that the question which source is credible and relevant becomes even more important [9]. The factors found for the EBAM exemplify this importance.

We hope that the EBAM will in the long run enhance an understanding of what laypeople think about the nature of medical knowledge and knowing, and how this influences their processing of medical information and medical decision making. Which views about the nature of medical knowledge and knowing are typically held by which people? Which views can doctors expect from their patients? How do people who hold advanced views and people who hold less advanced views differ in dealing with medical information? Considering a patient’s epistemic beliefs would be helpful for the doctor-patient-relationship. Patients holding different epistemic beliefs about medicine may deal with medical information differently and they also may be differently persuaded to initiate a certain therapy. The introduction in this article to laypeople’s epistemic beliefs about medicine and why they are important will hopefully call attention to the construct.

Competing interests

The authors have no potential conflict of interest related to the subject of the paper.

Authors' contributions

DK and RB contributed equally to the conception of the study and the acquisition of data. DK analyzed the data and drafted a first version of the manuscript. RB reviewed and edited this version and DK and RB worked on subsequent revisions of the manuscript and approved the final draft. Both authors have read and approved the final version of the manuscript.

Acknowledgements

The authors wish to thank everybody who took the time to participate in this study.The research and writing of this article is associated to the Priority Program 1409 “Science and the General Public: Understanding Fragile and Conflicting Scientific Evidence” of the DFG (German Research Foundation).

References

  1. Burton D, Blundell N, Jones M, Fraser A, Elwyn G: Shared decision-making in cardiology: Do patients want it and do doctors provide it?

    Patient Educ Couns 2010, 80:173-179. PubMed Abstract | Publisher Full Text OpenURL

  2. Phillips L, Leventhal H, Leventhal E: Physicians' communication of the common‒sense self‒regulation model results in greater reported adherence than physicians' use of interpersonal skills.

    Br J Heal Psychol 2012, 17:244-257. Publisher Full Text OpenURL

  3. Eysenbach G: The impact of the internet on cancer outcomes.

    CA Cancer J Clin 2003, 53:356-71. PubMed Abstract | Publisher Full Text OpenURL

  4. Dale KM, Coleman CI, Henyan NN, Kluger J, White CM: Statins and cancer risk: A meta-analysis.

    JAMA 2006, 295:74-80. PubMed Abstract | Publisher Full Text OpenURL

  5. Galesic M, Garcia-Retamero R: Do low-numeracy people avoid shared decision making?

    Health Psychol 2011, 30:336-341. PubMed Abstract | Publisher Full Text OpenURL

  6. Ford S, Schofield T, Hope T: Observing decision-making in the general practice consultation: Who makes which decisions?

    Health Expect 2006, 9:130-137. PubMed Abstract | Publisher Full Text OpenURL

  7. Hall MA, Dugan E, Zheng B, Mishra AK: Trust in physicians and medical institutions: what is it, can it be measured, and does it matter?

    The Milbank Q 2001, 79:613-639. Publisher Full Text OpenURL

  8. Hofer BK: Epistemological understanding as a metacognitive process: thinking aloud during online searching.

    Educ Psychol 2004, 39:43-55. Publisher Full Text OpenURL

  9. Bromme R, Kienhues D, Porsch T: Who knows what and who can we believe? Epistemological bliefs are beliefs about knowledge (mostly) to be attained from others. In Personal epistemology in the classroom. Edited by Bendixen LD, Feucht FC. Cambridge University Press, Cambridge; 2010:163-93. OpenURL

  10. Bromme R, Pieschl S, Stahl E: Epistemological beliefs are standards for adaptive learning: a functional theroy about epistemological beliefs and metacognition.

    Metacognition & Learning 2010, 5:7-26. PubMed Abstract | Publisher Full Text OpenURL

  11. Coulson RL, Feltovich PJ, Spiro RJ: Cognitive flexibility in medicine: an application to the recognition and understanding of hypertension.

    Adv Health Sci Educ 1997, 2:141-61. Publisher Full Text OpenURL

  12. Patel VL, Kaufman DR: On poultry expertise, precocious kids, and diagnostic reasoning.

    Acad Med 1994, 69:971-72. PubMed Abstract | Publisher Full Text OpenURL

  13. King PM, Kitchener KS: The reflective judgment model: twenty years of research on epistemic cognition. In Personal epistemology: The psychology of beliefs about knowledge and knowing. Edited by Hofer BK, Pintrich PR. Erlbaum, Mahwah, NJ; 2002:37-61. OpenURL

  14. Bendixen LD, Feucht FC: Personal epistemology in the classroom: Theory, research, and implications for practice. Cambridge University Press, Cambridge; 2010. OpenURL

  15. Hofer BK, Pintrich PR (Eds): Personal Epistemology: The Psychology of Beliefs About Knowledge and Knowing. Erlbaum, Mahwah, NJ; 2002. OpenURL

  16. Khine MS (Ed): Knowing, Knowledge and Beliefs - Epistemological Studies across Diverse Cultures. Springer, New York; 2008. OpenURL

  17. Buehl MM, Alexander PA: Beliefs about academic knowledge.

    Educ Psychol Rev 2001, 3:385-418. OpenURL

  18. Hofer BK, Pintrich PR: The development of epistemological theories: beliefs about knowledge and knowing and their relation to learning.

    Rev Educ Res 1997, 67:88-140. OpenURL

  19. Chandler M, Boyes M, Ball L: Relativism and stations of epistemic doubt.

    J Exp Child Psychol 1990, 50:370-95. PubMed Abstract | Publisher Full Text OpenURL

  20. Kuhn D, Weinstock M: What matters in epistemological thinking and why does it matter? In Personal epistemology: The psychology of beliefs about knowledge and knowing. Edited by Hofer BK, Pintrich PR. Erlbaum, Mahwah, NJ; 2002:121-44. OpenURL

  21. Bromme R, Kienhues D, Stahl E: Knowledge and epistemological beliefs: An intimate but complicate relationship. In Knowing, knowledge and beliefs: Epistemological studies across diverse cultures. Edited by Khine M. Springer Science + Business Media, New York, NY; 2008:423-41. OpenURL

  22. Buehl MM, Alexander PA, Murphy PK: Beliefs about schooled knowledge: domain general or domain specific?

    Contemp Educ Psychol 2002, 27:415-43. Publisher Full Text OpenURL

  23. Muis KR, Bendixen LD, Haerle FC: Domain-generality and domain-specificity in personal epistemology research: philosophical and empirical reflections in the development of a theoretical framework.

    Educ Psychol Rev 2006, 18:3-5. Publisher Full Text OpenURL

  24. Schraw G: Current themes and future directions in epistemological research: a commentary.

    Educ Psychol Rev 2001, 13:451-64. Publisher Full Text OpenURL

  25. Mason L: Role of anormalous data and epistemological beliefs in middle students' theory change on two controversial topics.

    Eur J Psychol Educ 2000, 15:329-46. Publisher Full Text OpenURL

  26. Mason L, Boscolo P: Role of epistemological understanding and interest in interpreting a controversy an in topic-specific belief change.

    Contemp Educ Psychol 2004, 29:103-28. Publisher Full Text OpenURL

  27. Qian G, Alvermann D: Role of epistemological beliefs and learned helplessness in secondary school students' learning science concepts from text.

    J Educ Psychol 1995, 87:282-92. OpenURL

  28. Roex A, Degryse J: Introducing the concept of epistemological beliefs into medical education: The hot-air-ballon metaphor.

    Acad Med 2007, 82:616-20. PubMed Abstract | Publisher Full Text OpenURL

  29. Knight LV, Mattick K: 'When I first came here, I thought medicine was black and white': making sense of medical students' ways of knowing.

    Soc Sci Med 2006, 63:1084-96. PubMed Abstract | Publisher Full Text OpenURL

  30. Upshur REG: Seven characteristics of medical evidence.

    J Eval Clin Pract 2000, 6:93-7. PubMed Abstract | Publisher Full Text OpenURL

  31. Keselman A, Kaufman DR, Kramer S, Patel V: Fostering conceptual change and critical reasoning about HIV and AIDS.

    J Res Sci Teach 2007, 44:844-63. Publisher Full Text OpenURL

  32. Roex A, Clarebout G, Dory V, Degryse J: Can ill-structured problems reveal beliefs about medical knoweldge and knowing? A focus-group approach.

    BMC Med Educ 2009, 9:62. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  33. Keselman A, Kaufman DR, Patel VL: "You can exercise your way out of HIV" and other stories: The role of biological knowledge in adolescents' evaluation of myths.

    Sci Educ 2004, 88:548-73. Publisher Full Text OpenURL

  34. Elby A, Frederiksen J, Schwarz C, White B:

    Epistemological beliefs assessment for physical science (EBAPS).

    http://www2.physics.umd.edu/~elby/EBAPS/home.htm webcite

    OpenURL

  35. Kienhues D, Bromme R: Beliefs about abilities and epistemic beliefs - Aspects of cognitive flexibility in information rich environments. In Links between beliefs and cognitive flexibility: lessons learned. Edited by Elen J, Stahl E, Bromme R, Clarebout G. Springer, New York; 2011:105-124. OpenURL

  36. Sandoval WA: In defense of clarity in the study of personal epistemology.

    J Learn Sci 2009, 18:150-161. Publisher Full Text OpenURL

  37. Hofer BK: Dimensionality and disciplinary differences in personal epistemology.

    Contemp Educ Psychol 2000, 25:378-405. PubMed Abstract | Publisher Full Text OpenURL

  38. King PM, Kitchener KS: Developing reflective judgment: Understanding and promoting intellectual growth and critical thinking in adolescents and adults. Jossey-Bass, San Francisco; 1994. OpenURL

  39. Schommer M: Effects of beliefs about the nature of knowledge on comprehension.

    J Educ Psychol 1990, 82:498-504. OpenURL

  40. Trautwein U, Lüdtke O: Epistemological beliefs, school achievement, and college major: A large-scale longitudinal study on the impact of certainty beliefs.

    Contemp Educ Psychol 2007, 32:348-66. Publisher Full Text OpenURL

  41. Kaiser HF, Rice J: Little Jiffy, Mark IV.

    Educ Psychol Meas 1974, 34:111-17. Publisher Full Text OpenURL

  42. Fabrigar LR, Wegener DT, MacCallum RC, Strahan EJ: Evaluating the use of exploratory factor analysis in psychological research.

    Psychol Methods 1999, 4:272-99. OpenURL

  43. Osborne JW, Costello AB: Best practices in exploratory factor analysis: Four recommendations for getting the most from your analysis.

    Practical assessment, research & evaluation 2005, 10:1-9. PubMed Abstract | Publisher Full Text OpenURL

  44. Tabachnick BG, Fidell LS: Using Multivariate Statistics. Allyn & Bacon, Needham Heights, MA; 2001. OpenURL

  45. Guadagnoli E, Velicer WF: Relation to sample size to the stability of component patterns.

    Psychol Bull 1988, 103:265-75. PubMed Abstract | Publisher Full Text OpenURL

  46. DeBacker TK, Crowson HM, Beesley AD, Thoma SJ, Hestevold NL: The challenge of measuring epistemic beliefs: An analysis of three self-report instruments.

    J Exp Educ 2008, 76:281-312. Publisher Full Text OpenURL

Pre-publication history

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http://www.biomedcentral.com/1471-2458/12/759/prepub