Prevention and health promotion in primary care: baseline results on physicians from the INSURE Project on Lifecycle Preventive Health Services

The INSURE Project on Lifecycle Preventive Health Services is a 3-year feasibility study to develop and test a clinical model of preventive health services, including patient education, in primary medical care as an insurance benefit. Seventy-four primary care physicians in group practices were surveyed regarding their baseline attitudes toward, and practice of, preventive services. Physicians report that they tend to be conscientious in educating their patients about their health risks, although they spend little time in patient education. Physicians are not sanguine about their success in getting their patients to follow their recommendations and tend to harbor doubts about their own efficacy in these areas. Specialty differences exist in these parameters. Physicians evidence contradictory attitudes about prevention. They believe doctors should spend more time providing preventive services but also believe that the lack of insurance reimbursement is an obstacle to providing these services. The concept of structural or sociological ambivalence is advanced to explain this pattern.     

The independent contributions of socioeconomic status and health practices to health status

The objective of this study was to determine whether the much-repeated finding of a relationship between socioeconomic status and health status is explained by individuals' health practices. The investigation was carried out using data tapes from the 1977 Health Interview Survey in which a one-third subsample of adults was asked a series of questions related to the seven nonmedical health practices identified in the Alameda County Study. The group selected for analysis comprised 15,892 white, responding adults. With age controlled statistically, perceived health status was found to be associated with socioeconomic status, whether the indicator was educational level, family income, or occupation, and to number of positive health practices. When number of health practices, in addition to age and other socioeconomic indicators was controlled for, the association was still positive and significant. The finding of an independent contribution by socioeconomic status to health status emphasizes that individual health habits are not the only influence on health status.     

Mental health professionals' knowledge in the field of caring for chronic mental disorders

A national sample of 246 Canadian mental health professionals was given a knowledge test concerning principles of care for chronic mental patients. Results showed that: (1) mental health professionals were moderately knowledgeable on this topic (mean score 66%), (2) errors made were more commonly in the direction of over-enthusiastic support for the community approach and (3) there were no differences in knowledge scores by a demographic or professional status variables included in this study.     

A national survey of health promotion activities in health systems agencies

This paper reports the results of a national survey of the involvement of health systems agencies (HSAs) in health promotion. Responses were received from 72% of the 203 agencies surveyed, representing all DHEW regions. Survey data include information on resource allocations within the agencies for staff activities related to remedial health care services and facilities, prevention, and health promotion. More than 90% of the responding agencies reported planning activities for health promotion, and more than one-half of these agencies were actively working to develop health promotion programs in their areas. An index of involvement of health promotion was used in this assessment. The results reveal substantial involvement in health promotion on the part of HSAs. It is suggested that HSAs may be attempting to address at the local level a major deficiency in our health care system which has not received adequate attention, namely the provision of services and programs to enhance health.     

Physical health and depression: An epidemiologic survey

Levels of mental depression, physical health, and medical care utilization for physical health conditions were measured in Los Angeles County during 1979 in a multiethnic probability sample of 1,003 adults (66% participation). A strong association was observed between the rate of depression, based on the 20-item Center for Epidemiologic Studies-Depression (CES-D) scale, and measures of physical health status. Depressed persons reported more physical illnesses than the nondepressed (1.32 versus 0.89 per person), and they were more likely to contact a health professional for these conditions (1.49 versus 0.97 consultations per physical illness). Similar patterns were observed among the depressed and nondepressed for bed-disability days, hospital admissions, and hospital bed-days. While depression was more common in women than men, a parallel association with physical health status was observed in both sexes.     

Nicotine yields of cigarettes,plasma nicotine in smokers,and public health

Previous research by M. A. H. Russell, M. Jarvis, R. Iyer, and C. Feyerabend (Brit. Med. J.280, 972–976 (1980)) concluded (a) that standard nicotine yields of cigarettes are very poor indicators of plasma nicotine concentrations in smokers, and therefore, (b) that the presumed health advantage of lower-yield cigarettes was likely not due to reduced “tar” intake by smokers of these cigarettes. The laboratory data, however, were not analyzed in a way that permits direct generalization to the epidemiological findings. A reanalysis of the data shows that the odds of deriving high yields increases substantially as the standard nicotine yield increases: lower risks associated with lower-yield cigarettes may be attributable to reduced nicotine (tar) yields to smokers. Implications for public health and the special risks of ventilated-filter cigarettes are discussed.     

Synergism between radiation and other risk factors for breast cancer

The question of whether the risk of radiation-induced breast cancer is additive or multiplicative (synergistic) with other risk factors for breast cancer has important implications for determining optimal guidelines for mammographic screening. Data from a follow-up study of 571 women given X-ray therapy for acute postpartum mastitis in Rochester, New York, and 993 control women were analyzed to examine this question. No synergism was found between breast irradiation and family history of breast cancer, late parity, oral contraceptive use, menopausal hormone use, or a composite of ovarian-related factors. Results indicated that women with a history of breast irradiation who develop benign breast disease, particularly cystic disease, are at high risk for breast cancer and should be carefully monitored. Women who were irradiated at the time of their first childbirth are also at especially high risk for breast cancer.     

Spirometric "lung age" estimation for motivating smoking cessation

Motivation for smoking cessation benefits from physician counseling. To further improve this educational process, spirometry can demonstrate ventilatory impairment to the smoker. In addition to comparing a person's spirometric results with predicted reference values for normal subjects, estimation of "lung age" can be used to demonstrate the effects of cigarette smoking. Equations were developed from reference linear regression equations permitting lung age estimation in terms of ventilatory function. This age can then be compared with the individual's chronological lung age. Normal and abnormal groups determined by a respiratory health questionnaire and pulmonary function testing were used to compare the value of single and combination spirometric tests. The forced expiratory volume at 1 sec proved superior to any other single test or combination for best separation of the two groups and had the lowest standard error for estimated lung age. Both spirometry and estimated lung age calculation may be useful for motivating cessation of cigarette smoking.     

Experimental analysis of adherence counseling: implications for hypertension management

A time series "reversal" design demonstrated that behavioral counseling increased medication adherence from about 60 to 100% for a black, hypertensive patient. However, inadequate pharmacological treatment yielded no clinically important blood pressure decrease. The combination of improved compliance and minimal blood pressure reduction led the patient's physician to explore higher doses and alternate medications to achieve blood pressure control. The physician's aggressive medical treatment was initiated only after the patient's compliance had been improved. Thus, this study suggests that paraprofessional counseling can increase compliance and illustrates the need for both behavioral and physiological data in clinical management to avoid blaming patients for poorly controlled blood pressure.     

The stress concept as a problem for a ‘theoretical pathology’

Theoretical pathology' is defined as the conceptual foundation of medicine. Research in this area is concerned with the analysis of explicit and implicit patterns of thought dominating research and practice. Using the example of the stress concept, it is suggested that it is a 'key word' with denotative and connotative meanings accessible to professional and laymen, contributing to explore the 'gray zone' between 'health' and 'disease' by linking psychological, social and biological determinants of 'well-being' and 'discomfort'. Examples of current research illustrate possible expansions of medical theorization.     

Screening for hypertension: results of the Munich Blood Pressure Program

The Munich Blood Pressure Program (MBP) is a community hypertension control program for the metropolitan area of Munich. It tries to improve "incidental screening" in doctors' offices in the city through continuing education programs for physicians and auxiliary personnel and, in addition, emphasizes worksite screening to bring high-risk hard-to-reach groups under treatment and control. Blood pressure (BP) is measured at the worksite under standardized conditions. Those with values greater than or equal to 140 mm Hg systolic BP and/or greater than or equal to 90 mm Hg diastolic BP at the first visit have BPs measured again within 1-5 days. If their BP values are still elevated, they are referred to their family physicians for further assessment. At the same time, they are given a postage-paid card on which their doctors are asked to note the BP value measured in their offices. This postcard is returned to the MBP for evaluation. A computer-based reminder system informs all MBP participants at certain time intervals to have their BP checked. The text of the letters and the time interval between them depend on the most recent BP and treatment status data available to the MBP. In 1983, screenings were performed in seven firms. Participation rates of up to 57% were achieved for this entirely voluntary examination (3,948 participants). Age- and sex-specific prevalence rates (for the pooled data of the seven firms) were similar to those of a random sample of the Munich population (Munich Blood Pressure Study I). Seventy-four percent of those with elevated BP at first visit participated in the remeasurement at a second visit. Only 58% of these showed elevated BP values the second time. More than half (n = 101) of those second-visit hypertensives (greater than or equal to 160/95 mm Hg; n = 183) returned at least one completed postcard. The examining physician confirmed the hypertensive BP values in 60 of those cases. Of the 101, 57 were under treatment, 19 controlled and 38 uncontrolled. The follow-up period considered here lasted until May 1984 and varied from 5 to 15 months according to the date of screening in the respective firm. Only the first returned card has been evaluated thus far.     

The economic costs of smoking and benefits of quitting for individual smokers

The results of a study that estimated the expected lifetime economic consequences of cigarette smoking for individual smokers are reported herein. The estimates were obtained by combining age- and sex-specific estimates of the incidence-based costs of three smoking-related diseases (lung cancer, coronary heart disease, and emphysema) with estimates of smokers' increased likelihood of developing these illnesses in each remaining year of life relative to nonsmokers. Estimates of the economic consequences of quitting based on these disease cost estimates and on estimates of exsmokers' probability of future disease relative to continuing smokers are also reported. Both the estimates of the economic costs of smoking and the benefits of quitting were calculated separately for men and women between the ages of 35 and 79 who were light, moderate, or heavy cigarette smokers. While the economic costs of smoking varied considerably by sex, age, and amount smoked, they were significant for all groups of smokers. Costs for a 40-year-old man, for example, ranged from $20,000 for a smoker of less than one pack of cigarettes per day to over $56,000 for a smoker of more than two packs of cigarettes per day. The economic benefits of quitting also were found to be sizable for all groups of smokers.     

Diet and hormone profiles in teenage girls in four countries at different risk for breast cancer

In an attempt to assess the effects of diet on estrogen and prolactin levels, dietary histories, anthropometric measurements, and age at menarche were obtained, and Day 11 plasma and urine hormone levels measured in teenage girls in the United States (U.S.), Chile, Japan, and Papua New Guinea (PNG). Highly significant differences in diet were found, with the consumption of meat, dairy products, and fat being highest in the U.S., followed by Chile, Japan, and PNG. No significant differences in plasma levels of prolactin, estradiol, or estrone were found, suggesting that the dietary intake of meat and fat does not have a major role in determining the levels of these hormones. Subjects in PNG excreted significantly more estriol and had a significantly higher urinary estriol ratio [estriol/(estrone + estradiol)] than those in the other three countries; the Japanese and U.S. estriol ratio results were very close, with the results from Chile being intermediate (and statistically significantly different from both PNG and the U.S.-Japan results). No correlation of this pattern with any dietary component could be identified.     

Convictions for drunkenness or drunken driving, sick absenteeism, and morbidity in middle-aged males with different levels of serum gamma-glutamyltransferase

In a continuous population study of middle-aged males in Malmö, serum γ-glutamyltransferase (GGT) has been utilized both as a biochemical indicator of alcohol consumption and as an aid in further investigation and treatment. The individuals in the top decentile of the GGT distribution were compared with individuals in other GGT brackets. The number of individuals with legal convictions for drunkenness or drunken driving was 2.8 times larger in the top decentile of GGT compared with those below the median. The corresponding ratio for drunken driving alone was 3.4. The number of sick days was analyzed for 1,290 individuals in a 21-year long-term study before screening and random subsamples with different GGT values were compared. Increasing GGT values were correlated with the disability rate over all years. There was a dramatic rise in the occurrence of sick days in the top decentile of GGT during the 6 years before screening. Conversely, 50% of the individuals (below the median on GGT) had less sick absenteeism than the mean for all Swedish males throughout the 21 years before screening. Morbidity was analyzed in a subsample of 285 individuals with >90 sick days during the final 3 years of the study. The ratios of disability between the individuals in the highest and lowest decentile of the GGT distribution were highest in the diagnostic group's injuries (5.5) and mental disorders (4.3). We concluded that an accumulation of alcohol-related disabilities is present in groups of individuals with high GGT values.     

Alcohol consumption and blood pressure: analysis of data from the Canada Health Survey

Recent epidemiologic studies report a significant association between alcohol consumption and elevations in both systolic (SBP) and diastolic (DBP) blood pressures. To test this hypothesis, we conducted a multivariate analysis of physical examination and other data on 721 men and 697 women aged 20 or more collected during the Canada Health Survey in 1978-1979. SBP and DBP were considered as separate dependent variables in multiple regression models with the following independent variables: age, alcohol consumption (measured as a 7-day recall history and as an average frequency of consumption), serum cholesterol, plasma glucose, physical activity, Quetelet index, parental history of hypertension, cigarette consumption, income, education, and exogenous hormonal use in women. In both weighted and unweighted multiple regression analyses, we could not demonstrate for either sex, a significant association between alcohol consumption (as recorded and following quadratic and logarithmic transformations) and either SBP or DBP. For both sexes, only age and Quetelet index were highly significantly (P less than 0.0001) and consistently associated with both SBP and DBP. No other independent variables were consistently associated, for either sex, with SBP and DBP. Further, the dose-response patterns noted by other investigators suggesting either a positive and linear relationship or a curvilinear relationship were not found in either our univariate or multivariate analyses. Rather, the alcohol-blood pressure curves showed no consistent patterns of any kind in either sex. These findings do not support recent claims that alcohol consumption is a determinant of elevations in either SBP or DBP.     

Asbestos-activated peritoneal macrophages release a factor(s) which inhibits lymphocyte mitogenesis

Intraperitoneal asbestos injection in mice has previously been reported to elicit an activated macrophage population. In the present study supernatants from such macrophages were tested for their effect on thymocyte mitogenesis in response to concanavalin A; control supernatants were obtained from saline- and latex-elicited macrophages. Supernatants from asbestos-elicited macrophages were significantly inhibitory to thymocyte mitogenesis while saline- and latex-elicited macrophages did not release significant amounts of such activity. Asbestos-activated macrophage supernatants were inhibitory in a dose-dependent way and the activity was not secreted by macrophages from mice which had received asbestos in the long term. The inhibitory activity was partially dialysable. Supernatants prepared by treating macrophages in vitro with a lethal dose of asbestos were not inhibitory suggesting that the inhibitory activity in the supernatants of asbestos-activated macrophages did not leak from dead or dying cells. The asbestos macrophage supernatant was also significantly inhibitory to mature T-cell-enriched spleen cells but had no effect on fibroblasts, suggesting that the inhibitory effect could be lymphoid cell specific.     

Preventing and treating periodontal disease with the keyes technique: A preliminary assessment

This article uses data from 190 patient records in 18 dental practices to conduct a shortterm assessment of the effectiveness and costs of the Keyes technique, a nonsurgical method for treating and preventing periodontal disease. The results of this study, based on nonexperimental data, suggest that controlled clinical trials are called for in assessing the long-term effectiveness of the Keyes technique. If clinical trials support the study's short-term results, then the Keyes technique would provide a cost-effective alternative to surgery for the prevention and treatment of periodontal disease.     

A new view of the etiology of nasopharyngeal carcinoma

The epidemiological finding of high geographical similarity seen in the distribution of Croton tiglium, the parental plant for croton oil, as well as other related members of Euphorbiaceae family, and the nasopharyngeal carcinoma (NPC) in southern regions of China, led to the compilation of these data plus our recent laboratory observations on in vitro induction of Epstein-Barr virus (EBV) in human lymphoblastoid cell lines. The EBV genome-carrying P3HR-1 and Raji cells exerted a dramatic increase in EBV antigens when given a combined treatment with n-butyrate and croton oil, in nanogram concentrations. The Fusobacterium and other common microbial inhabitants of the mouth and nasopharynx of man efficiently produce, in laboratory culture fluids, n-butyric acid with EBV-inducer activity. Furthermore, the seeds and plant per se of C. tiglium and other Euphorbiaceae are currently being used as herbal drug in the southern parts of China. We hypothesize that NPC is initiated by persisting EBV as an essential and basic factor plus the combined action of the bacterial fatty acid and traditional intake of promoter substance of plant origin as cofactors, and that the EBV, induced and activated by such mechanisms, initiates the chain of events which ultimately lead to the emergence of the malignant disease.     

Randomized controlled trial of a nonpharmacologic cholesterol reduction program at the worksite

Under experimental clinical conditions diet modification has been shown to reduce serum cholesterol levels. This paper reports such a positive response to a nonpharmacologic, behavioral education program at the worksite. Employees at the New York Telephone Company corporate headquarters were assigned randomly to treatment and control groups. Treatment consisted of an 8-week group cholesterol reduction program conducted during employee lunch hours. It comprised a multiple-treatment approach--food behavior change techniques combined with nutrition education, physical activity planning, and self-management skills. The treatment group showed substantial change compared with the control group at the program's completion. Those treated displayed a significant 6.4% reduction in total serum cholesterol (266 mg% average at baseline) as compared with control subjects with a corresponding decrease in high-density lipoprotein levels. A significant increase in nutrition knowledge and moderate weight loss were also documented for this group. The magnitudes of a participant's baseline serum cholesterol level and his/her reduction in percentage of ideal body weight were positively and independently correlated with percentage changes in serum cholesterol levels. Over the same period, decreases in high-density lipoprotein levels and no changes in serum cholesterol, weight, and nutrition knowledge were observed for the control group. Overall, participants in the treatment program successfully reduced the coronary heart disease risk factors of elevated cholesterol and weight. Directions for future study are suggested.