Compliance after 17 years of breast cancer screening: Factors associated with reattendance for periodic breast screening

The motives and reasons for regular attendance, irregular attendanceand drop-out were studied in women who were enrolled in a biennialbreast screening programme in 1975 and who were invited to eachsubsequent screening round until 1992. Three compliance groupswere compared: ‘attended all rounds’ (group A, n=79),‘missed 1 or 2 rounds’ (group B, n=73) and ‘missedmore than 2 rounds’ (group C, n=64). The groups did notdiffer with respect to background variables such as sociodemographiccharacteristics, actual health problems or preventive healthorientations, but significant differences were found in generalattitudes to breast screening and to the organizational aspectsof screening procedures. The results suggest that during thecourse of a screening programme, for a substantial group ofnot strongly motivated women, the recurring negative aspectsof mammography (pain and anxiety) are increasingly becominga burden. ‘Circumstantial factors’ like waitingfor one's turn, the distance to the screening centre and incidentaldissatisfaction with handling by screening staff, appear totrigger the decision to skip screening rounds or to drop outof the programme. From the perspective of maintaining a regularattendance throughout the programme this is an important group.Special efforts must be made to encourage these women to stayin the programme.     

Information disclosure, smoking and health protection: A critique of the European directive on the labelling of tobacco products

European Directive 89/622, which came into operation in January1992, made it obligatory to display health warnings on the packetsof cigarettes marketed in the European Union and to displaytar and nicotine yields, in numerical form, on such packets.The directive can be seen as involving a two-pronged healthprotection strategy: the health warnings were designed to encouragesmokers to stop, while the tar and nicotine yields were partof a policy to induce those who could not give up to switchto ‘low tar’ brands. This article critically analysesthe approach to health protection taken in the Directive. Itargues that, as research evidence indicates that smokers frequentlymisperceive yield data as indicating maximum intake levels,two dangers stem from the directive: brands with ‘low’tar numbers may be seen as ‘safe’, thus negatingthe health warning and smokers who ‘switch down’are likely to have an exaggerated view of their likely reductionin tar intake as they are not alerted to the significance ofsmoking patterns for intake levels.     

Health under fire: The WHO in the former Yugoslavia

In July 1992, in former Yugoslavia the World Health Organization(WHO) launched a humanitarian assistance programme. The programmewas aimed at maintaining public health in the war-affected areaswith 4 million refugees and displaced persons, over 200,000dead, at least twice as many wounded, over 60,000 patients inneed of rehabilitation and at least 1 million persons with deeppsychological scars. The programme had 4 objectives: publichealth Interventions (Induding health and nutrition monitoring),physical and psychosodal rehabilitation, distribution of medicalsupplies and health care reform. A key feature was a systematicassessment of the needs of the affected population by meansof health and nutrition monitoring which helped to target theassistance. For some areas the WHO'S medical supplies were theonly source of much needed drugs. With the health authoritiesWHO initiated a health care reform, to enable the qualitativelyreasonably good but top-heavy and expensive health care systemsInherited from the socialist era to recuperate and survive.The WHO programme has helped avert major epidemics, preventedscurvy and rickets and helped people to survive the cold ofthe winter.     

Evaluation techniques for the Healthy School project in Yugoslavia

In preparation for the implementation of the Healthy Schoolproject in Yugoslavia, great attention was paid to evaluationprocedures and instruments. One of them was the ‘Drawand Write Investigation Technique’ suitable for monitoringchanges in pupils' knowledge during first four grades of elementaryschooL The pupils (n=473) in first four grades were tested inthree cities: Belgrade, Novi Sad and Zajecar. The results werecompared and tested by age, sex, residence, and type of health-promotingmeasures mentioned. The results proved that the technique issensitive enough to reveal expected differences in knowledgeacquired in school. The technique was accepted by teachers,health workers, and pupils as very attractive and interesting.With some adaptations and modifications ‘Draw and WriteInvesti gation Technique’ will be used as a knowledge-changeevaluation instrument in the Healthy School project in Yugoslavia     

WHO and the effects of extrabudgetary funds: is the Organization donor driven?

The findings and conclusions of an international policy studyare presented on the effects of donors and their voluntary financialcontributions upon the World Health Organization. Such extrabudgetaryfunds now account for over a half of the total expenditure ofthe Organization and more than 80% of these funds come froma small group of 10 industrialized donor countries. This hasled to widespread concerns that the Organization is being ‘donordriven’ and that powerful countries are unduly influencingthe priorities of the Organization and the management of itsprogrammes. With reference to such extrabudgetary funds, the study concludedthat: a) they have given essential support to internationalhealth research; b) they have enabled WHO to be a more effectiveinternational health development agency; c) these funds arepoorly defined and there is a lack of standardized financialinformation; d) these funds are closely integrated with theregular budget particularly at global programme level; e) theyhave not unduly distorted the initial setting of WHO priorities;f) they have encouraged vertical management systems; g) theyhave increased the problems of programme coordination; and h)the WHO World Health Assembly and Executive Board do have sufficientformal authority over such funds and they could exercise morecontrol if they wished to do so. The overall conclusion was that, although there is some truthin the assertion that WHO is being ‘donor driven’,it is also clear that donor involvement has brought many advantagesto the Organization as a whole. Despite the general conclusionthat extrabudgetary funds do represent value-for-money, manydonor countries are reducing their voluntary contributions toWHO, while at the same time the regular budget has also beencurtailed by the Assembly. These two trends have clear and importantimplications for the future of WHO and for all internationalhealth activities.     

Communicating coverage data with non-literate communities: beans, sticks or pie charts?

A study was undertaken by staff of a health project in Malawito identify the optimum strategy for reporting information tobeneficiary communities regarding project coverage and effectiveness.Three candidate methods for presentation of coverage data tothis non-literate or semi-literate population were selected,based on preliminary qualitative research: (1) a two-colourrotating pie chart; (2) a set of sticks cut in varying lengthsrelative to a ‘full length’ (100%) standard stickand; (3) measures of beans, with ten measures representing afull (100%) measure of beans. Data were presented to 60 individual participants, using twoexamples for each of the three methods. Questions requiringinterpretation of the data were then asked of each of 60 individualparticipants, using two examples for each of the three methods.Questions requiring interpretation of the data were then askedof each of 60 participants and responses recorded as corrector incorrect. All three methods were more than 80% effectivein communicating concepts of proportion, as measured by thepercentage of correct responses. The 'pie chart' method appearedleast effective, and the ‘beans method’ most effectivein presentation of the information. The effectiveness of the‘beans method’ was significantly greater than thatof the ‘pie chart’ method (P=0.02). This study providesinformation which may be of use to programme managers in selectingstrategies for communication of health service data to the communitiesin which they work. It also demonstrates a simple methodologyfor identifying and assessing the relative effectiveness ofpresentation methods.     

What about healthy networks? An analysis of the national networks of healthy cities in Europe

The World Health Organization (WHO)/Euro Healthy Cities Projecthas received much attention since the first project cities wereselected in 1987 in fact many more cities than can participateshowed (and still show) their interest. Thus initiatives havebeen taken to establish activities similar to the Healthy CitiesProject, not only in Europe but all over the worl4 ‘nationalnetworks of Healthy Cities’ have developed The nationalnetworks in Europe call themselves ‘EURONET’, aEuropean network of national Healthy Cities networks. EURONETis not a formal association; how this initiative will developin the near future is under discussion. A national network is an example of a social network but becauseof its complexity and different leveLs of ‘networking’,is difficult to analyse. However analysis, and evaluation, isneeded to review the functioning and impact of the healthy citiesidea. To study and analyse the networks in Europe, which areas a whole rather large, a selection has been made to reducethe number of participants (n=14), number of resources (n=4)and (categories of) activities (n=9) which were examined Theanalysis provided information about the development of the network;among other things it looked at why they started who took theinitiative, what changes occurred during the period of development,who were the participants at a national level, what activitieswere undertaken, and the relationship between activities andparticipants. As expected the findings did not provide a uniformpicture of ‘what a national Healthy Cities network shouldlook like’ nor did they give the recipe of ‘howto become a Healthy Cities network’. However, the strengthof national networks is that they have the potential to continuethe Healthy Cities project aims and objectives, even if theWHO project ever ceases.     

A critical analysis of different leadership approaches to community health work in Kirseberg, Sweden

This paper examines some dilemmas of both professional and communityled approaches in health promotion with reference to an alcoholreduction programme implemented in Kirseberg, Sweden. A ‘traditional’health education programmed designed at changing life-stylehabits was combined with a community action design. The processby which the public health messages were sent to and receivedby the residents was explored in a qualitative study. The study focused on the possibly contradictory relationshipbetween the ‘professional’ concept of public healthand individuals' personal concepts of health. it is argued thatif the ‘top down’ and ‘bottom up’ approachesare combined without detailed consideration being given to thepossible connecting links the risk is that the result will bethe operation of two parallel strategies which do not interact. The process of making health a collective issue within a communityaction programme is illustrated with examples from the Kirsebergproject and discussed with reference to the chief aim of achievingequity in health provision.     

Some factors associated with compliance in the treatment of alcoholism

The investigation set out to examine the extent of problemsof low compliance at an alcoholism clinic, to investigate somevariables that might differentiate referral failures and initialclinic attenders as well as categories of patients who attendfor treatment, and to generate hypotheses concerning these differencesas a means of developing a compliance-enhancement strategy. Information, including sociodemographic and personality variables,patient self-reports of drinking behaviour, self-perceptionsof their need for help and of drinking problem severity, andtherapist ratings of drinking problem severity, was gatheredon one hundred referrals to a clinic for new patients. Results showed that 46% of patients were referral failures andthat, in comparison with attenders, the former group had bothwaited longer for the initial appointment and were younger.Few variables differentiated the categories of attenders. Agreater proportion of those remaining in treatment contact forlonger than a month rated the change in their drinking problemover the previous year as ‘worse’ and more of themhad been arrested for public drunkenness. Those who made fiveor more clinic visits had waited a shorter time for their initialappointment, and a greater proportion rated the effects of theirdrinking on their work as ‘serious’ and the changein their social life as ‘worse’ than patients whohad made fewer visits. The findings suggest that variables related to personal perceptionsof drinking problems offer a better account of compliance behaviourthan the sociodemographic variables which have been the focusof previous research.     

Health promotion in the market place: constraints and opportunities

An emerging trend internationally is for health promo tion servicesto be privatised and organised through a division of ‘purchaser’and ‘provider’ functions. This paper examines theconstraints and opportunities for health promotion in the marketplace through a discus sion often ‘vital signs’drawing on British experience where appropriate. If the marketis not closely managed there are considerable concerns thathealth inequalities could increase, that ethical issues couldbe ignored, and that health promotion practice could be seriouslycom promised. Nevertheless, there are also potential benefitsfrom a market economy, but these will only be realised if thereis a shared understanding of the purchaser/provider roles, adequateskills and resources for the purchaser function, earmarked fundingfor health promotion investment, effective monitoring and refereeingby government as ‘regulator’, and training for thenew tasks and responsibilities. To improve pe, formance a distinctionshould be made between health promotion Design, Development,and Delivery-the three ‘Ds’ of health promotionpractice. Tasks for the three stages are described, togetherwith the potential roles of govern ment, public sector agencies,professional bodies, voluntary organisations and private sectorcompanies. Long-and medium-term time scales are essential foreffective implementation.