Factor analysis as a tool in community diagnosis

For the family physician, community diagnosis can be likenedto individual diagnosis by the application of methods of informationacquisition and analysis. This paper describes the techniqueof factor analysis, applied to data from an urban inner-cityarea, for reducing a multitude of factors to a manageable numberwithout an appreciable loss of information. The variables wereselected from four broad categories which have been shown toinfluence both health states and health care needs: demography,socioeconomics, social disorganization and morbidity/mortality.A correlation matrix based on 40 of the most accessible indicesserved as input for a principal axes factor analysis. Six factors acounted for 74% of the total variance and wereinterpreted as: ‘Poverty and social disorgan ization’,‘Distribution and problems of the elderly’, ‘Ethniccomposition’, ‘Fertility’, ‘Infant mortality’and ‘Foetal mortality’. Representative indices fromeach factor were then mapped to identify and display censustract differences. Finally, the application of the factors toa specific community illustrated important differences withinthe community and identified areas of high risk and need.     

The impact of the COSHH regulations on workers with occupational asthma

In the UK, the COSHH Regulations give specific guidance thatemployers have duties to inform, instruct and train their employeesabout occupational risks and provide them with suitable healthsurveillance. The aim of the study was to evaluate the impactof the Regulations on employees with occupational asthma. Onehundred consecutive patients attending an occupational lungdisease clinic completed a questionnaire assessing the implementationof the COSHH Regulations in their workplace. Twenty-eight percent had a pre-employment inquiry about asthma, 31% had regularhealth surveillance by questionnaires and 19% had regular lungfunction assessment at work. Pre-employment spirometry was carriedout in 44% of the workers who were exposed to one of the originalseven prescribed agents, significantly more than those who wereexposed to other agents (19%) (p < 0.05). Moreover, figuresfor spirometry during employment were 31% and 8% respectively(p < 0.05). The patients who worked after ‘COSHH’but before ‘MS25’ had a tendency to be providedwith health surveillance more than those who worked after both‘COSHH’ and ‘MS25’. Ninety-one per centof the patients had never been informed about the risks of gettingasthma at work and 73% had never seen the safety data sheets.The workers who (1) worked after ‘COSHH’ introduction;(2) worked in larger firms and (3) were exposed to one of theoriginal seven prescribed agents, had a tendency to be informed,instructed and trained more than the rest. However, there wereonly significant statistical differences (p<0.05) in termsof the safety data sheet provision between the cases who workedbefore the time of the legislation and those employed afterwards.     

THE SWEDISH ALCOHOL USE INVENTORY (AVI), A SELF-REPORT INVENTORY FOR DIFFERENTIATED DIAGNOSIS IN ALCOHOLISM

AVI is a self-report inventory intended for standardized anddifferentiated assessment and diagnosis in alcoholism; it includes75 items adapted from Horn and Wanberg's Alcohol Use Inventory(AUI) and an assessment of the alcohol intake during a typicalweek of heavy drinking. The drinking profile is presented infive second-order factor scales: ‘alcohol abuse’,‘psychological benefits’, ‘interpersonal complications’,‘social drinking’ and ‘daily drinking’and in 17 first-order factor scales. The reliability and specificityof the scales are satisfactory. Preliminary norms based on asample of more than 600 alcoholic patients are available. Usingthe original American scoring and norms the results indicateimportant similarities in the alcoholism pattern between Swedenand the U.S.A.     

Patient Requests in Family Practice: A Focal Point for Clinical Negotiations

A growing body of literature has stressed the importance ofeliciting the patient's views on the management of health andillness. In particular, it is recognized that patients frequentlyenter into clinical encounters with specific requests for services,that is ideas about how they hope to be helped. The presentinvestigation examined the following two questions: (1) whatkinds of requests do adult patients coming to a family practicecentre have prior to seeing the doctor; and (2) will factoranalysis of a 25-item patient request questionnaire provideevidence of the basic or most common dimensions of patient requestsin this population? Two newly-developed instruments were administeredto a sample of 144 adult patients before their visit to thedoctor. Factor analysis yielded five major request factors—‘medicalinformation’, ‘psycho-social assistance’,‘therapeutic listening’, ‘general health advice’,and ‘biomedical treatment’ —partially replicatingthe findings of an earlier pilot study. The clinical implicationsof eliciting patient requests in the light of current behaviouraland social science research into the doctor-patient relationshipare discussed. Future research directions are also outlined.     

The Impact of Discussion of Non-Medical Problems in the Physician's Office

Martin FJ, Bass MJ. The impact of discussion of non-medicalproblems in the physician's office. Family Practice 1989; 6:254–258. To determine the impact of discussion of non-medical problemswith the physician, patients with at least one chronic illnesswho were taking medication were interviewed in their familydoctor's office. Of 149 patients interviewed, 90.6% reportedat least one non-medical problem. Half (51%) of those patientswith a problem had discussed it with their doctor. More thanhalf (55%) of those patients discussing a problem reported thatthe discussion was helpful. Patient compliance and satisfactionwere positively associated with ‘helpful’ discussion,but not with discussion per Se. In particular, the two aspectsof doctor-patient communication which were significantly associatedwith feeling helped were: ‘Doctor tells me all I wantto know about my illness’ and ‘Doctor gives me achance to say what is really on my mind’. Both factorsreflect care which is oriented to patient concerns. The studyresults provide support for a patient-centred approach to care.     

Ambulatory or Self Blood Pressure Measurement? Improving the Diagnosis of Hypertension

There are major problems with blood pressure (BP) measurementthat must be addressed in the diagnosis and treatment of hypertension.Errors in taking BP are widespread and failure to allow forregression to the norm often leads to premature treatment. ‘Whitecoat hypertension’, a condition in which raised BP levelsin the presence of a doctor or nurse do not regress towardsthe norm on repeated measurement, may be responsible for between10–20% of our patients being given medication unnecessarily.Ambulatory measurement is becoming an accepted method of attemptingto deal with these problems whereas self measurement at homeis little used. Used properly, both methods prevent most observererror and bias, eliminate regression to the norm, and allowthe diagnosis of ‘white coat hypertension’. Bothcurtail the period necessary to establish patients' ‘true’BP. Ambulatory measurement has established scientific advantagesbut is expensive in time, equipment and staffing. Home measurementat the moment is less reliable but is easier and cheaper. Problemswith the accuracy of instruments for home measurement can besolved and, even in their present form, enable the diagnosisof white coat hypertension and help in the diagnosis of manyhypertensive patients. Ambulatory monitoring is already undergoingtrials in primary care. It is suggested that home measurementshould also be more widely used where most patients with hypertensionare exclusively managed.     

Screening, Detection and Management of Depression in Elderly Primary Care Attenders. II: II: Detection and Fitness for Treatment: a Case Record Study

Case note data were obtained for 186 elderly primary care attenderswho also completed the 15 item Geriatric Depression Scale (GDS15).The presence or absence in the case notes of a current or pastdiagnosis of depression, of current treatment of depression,and of a number of clinical features of depression were noted.Case notes were also rated for the presence or absence of contraindicationsto the use of tricyclic antidepressants (TCAs) and to serotonin-specificreuptake inhibitors (SSRIs). Whereas 65 (35%) patients wererated as ‘cases’ of depression on the GDS15, only28 (15%) had a current case note diagnosis of depression and37 (20%) had one or more current symptoms of depression recordedin the case notes. Patients rated by their GP as having oneor more current symptoms of depression scored higher on theGDS15 (P < 0.05) and were more likely to be categorized asa GDS case (P = 0.05). There was no significant relationshipbetween GDS caseness and a current case note diagnosis of depression.Seventy-three patients (39%) had a past history of depressionand 53 (28.5%) patients had previously been treated with antidepressants.The former was significantly associated with GDS caseness (P< 0.05). Twenty-four patients (13%) were currently on antidepressants,19 of them receiving adequate doses (equivalent to at least75 mg of amitriptyline). Current antidepressant treatment wasnot associated with GDS ‘caseness’. A significantlyhigher proportion of patients (both in the sample as a wholeand in the subgroup of GDS15 depression ‘cases’)had a medical condition or were taking a drug that mitigatedagainst the use of TCAs than was the case for SSRIs.     

Drug prescribing in hospital as experienced by general practitioners: East versus West Germany

BACKGROUND AND OBJECTIVES: Drugs prescribed by the general practitioner (GP) are oftenchanged during hospitalization. This study set out to test thehypothesis that the extent of drug change and the informationprovided by the hospital determines the GPs' assessment of hospitalco-operation. The perception of drug change and hospital co-operationmay also be influenced by the degree of institutional separationof primary and secondary care. Therefore we compared GPs' respectiveattitudes in ‘East’ and ‘West’ Germany. METHOD: In 1993, a representative sample of ‘eastern’ and‘western’ German doctors received a structured questionnaire;554 doctors (63%) participated. RESULTS: Fifty-seven per cent of the western and 39% of the eastern GPsbelieved that their medication was changed in hospital in morethan 60% of their patients. Only a minority of eastern (10%)and western (15%) doctors described the information providedby the hospitals as more or less satisfactory. More westernthan eastern doctors (56% versus 32%) expressed dissatisfactionwith hospital co-operation. Respondents in eastern Germany whofelt sufficiently informed about hospital drug change were morelikely to express satisfaction with the hospital doctors' co-operation.In the former area of West Germany the judgement of co-operationwas significantly better if the extent of drug change and thefrequency of generic drug replacement by original brand-namedrugs were lower. CONCLUSIONS: The study showed that hospital-initiated drug change is a matterof concern, especially for GPs who are working in an area witha tradition of strictly separated primary and secondary care. Keywords. Drug prescribing, family practice, interprofessional relations, health system.     

Anxiety and depression in general practitioners: associations with type of parctice, fundholding, gender and other personal characteristics

BACKGROUND: There is evidence both that a doctor's own well-being is closelyassociated with efficiency and positive attitude to patients,and that levels of stress, anxiety and depression in doctorsare rising. OBJECTIVES: This postal survey aimed to measure anxiety and depression levelsin general practitioners in 1994 and identify any associationswith personal and practice characteristics. METHODS: All general practitioners with patients in Staffordshire wereinvited to complete the Hospital Anxiety and Depression (HAD)scale. RESULTS: Six hundred and twenty of 896 general practitioners replied(response rate 69%). No gender differences were found in ratesof anxiety and depression; overall, 19% of respondents were‘cases’ of anxiety and 22% others had borderlineanxiety scores; 10% were ‘cases’ of depression and16% others had borderline depression scores. Anxiety ‘caseness’was associated with living alone, amount of on-call duties undertaken,and being fourth/fifth wave fundholders. Depression ‘caseness’was associated with having little free time from practice work,amount of on-call, being single handed, and working in a non-trainingpractice. CONCLUSIONS: The authors concluded that the level of mental ill-health ingeneral practitioners is a matter of concern and is associatedwith workload. Keywords. Anxiety, depression, general practitioners, personal characteristics, practice characteristics.     

'If I let a goal in, I'll get beat up': contradictions in masculinity, sport and health

This paper presents a critical exploration of the relationshipbetween masculinity, sport and health by reporting findingsfrom a wider qualitative study on lay men’s and healthprofessionals’ beliefs about masculinity and preventativehealth care. Recent years have seen a surge of interest in relationto ‘men’s health’. In particular, the Departmentof Health has highlighted how men’s connection to sport,fitness and competitiveness can be used in health promotioninitiatives to introduce facets of health. In contrast, workin the sociological and feminist literature has raised issuesof concern about the relationship between men, masculinity andsport, particularly the links to aggression, misogyny and homophobia.It would appear then that a straightforward ‘men + sport= health’ relationship cannot be assumed. Focus groupsand interviews with health professionals and men, includinggay and disabled men, were undertaken to facilitate examinationof the socially integrative meanings of sport and masculinity,and their relationship to health. Socializing, ‘macho’culture and the body emerged as three main themes, and the implicationsof these empirical findings for health promotion are discussed.     

Value of the Diagnostic Sodium Calcium Edetate Mobilization Test as a Criterion of Lead Absorption

Among the laboratory tests available for the follow-up of lead-exposedworkers, the EDTA mobilization test is presently underestimatedin the diagnosis of lead intoxication. The authors present theresults of regression comparison between the urinary lead excretion3 h (PbU 3) or 6 h (PbU 6) after EDTA injection and blood lead(PbB), urinary aminolaevulinic acid (ALAU) and urinary lead(PbU). The results were collected from 133 medical examinationsof workers exposed to lead, who put in a claim for compensationto the ‘Fund of Occupational Diseases’ in Belgium.On the basis of the regression curves, PbU 3 and PbU 6 limitvalues are calculated for different cut-off values of PbB inexcessive lead absorption and lead intoxication. For each ofthese values the ‘sensitivity’, ‘specificity’and ‘validity’ are calculated. As a result the authorsstill consider the EDTA mobilization test as a valuable parameterin the diagnosis of lead absorption. Requests for reprints should be addressed to: Dr D. Lahaye, Fund of Occupational Diseases, Sterrenkundelaan 1, 1030, Brussels, Belgium     

Can One be a Good Doctor and have a Sexual Relationship with One's Patient?

This paper presents a qualitative exploration of social andsexual contact between general practitioners and their patients.Social contacts have been implicated in the development of sexualrelationships between members of the mental health professionsand their patients. However, there has been little examinationof the implications for general practitioners. Six focus groupswere conducted by teleconference with New Zealand general practitioners.Participant anonymity was maintained. Questions focused on issuesof social and sexual contact in general practice. Major themeswere extracted from the data. A range of definitions of ‘patient’,‘sexual contact’ and ‘social contact’were offered by the participants which demonstrated that ‘greyareas’ existed for them in relation to social and sexualrelationships with patients. Mandatory reporting of colleaguesfor alleged sexual misconduct was not supported, informal mechanismsbeing preferred. General practitioners need to be aware of potentialboundary violations in their practice. These issues are alsoimportant to address in the teaching of medical students, continuingmedical education, and in the development of appropriate guidelinesfor general practice.     

ISRAELI ARAB AND JEWISH YOUTH KNOWLEDGE AND OPINION ABOUT ALCOHOL WARNING LABELS: PRE-INTERVENTION DATA

This article presents baseline data on the opinion toward alcoholbeverage warning labels and on levels of knowledge of the risksdiscussed in the contents of the labels prior to the labels'introduction, and on levels of knowledge of additional alcohol-relatedhazards not included in the proposed warning labels, among asample of 3065 adolescents of four religions living in the northernregion of Israel. About 2220 Arab participants (Moslems, Christiansand Druze) and 845 Jewish respondents answered in the winterof 1996 a Hebrew version of an American questionnaire, whichhad been used to measure levels of knowledge of the label inthe United States. More respondents were in favour of warninglabels on alcohol containers than on advertisements. Arabs asa group were more in favour of warning labels on alcohol containersthan Jews. The initial knowledge levels among the participantswere not very high, especially concerning the item ‘Drinkingimpairs ability to operate machinery’ (74.4%) which isincluded on the proposed warning label, and concerning two hazardswhich are not included: ‘Drinking increases risk of cancer’(54.6%) and ‘Drinking increases risk of high blood pressure’(60.4%). Abstainers knew more than drinkers that ‘Pregnantwomen should not drink’, ‘Drinking increases riskof cancer’ and ‘Alcohol in combination with otherdrugs is hazardous’. Implications for public health arediscussed and alternative warning messages that might be usedto inform the Israeli public of several less well-known hazardsare suggested.     

OUT-PATIENT ALCOHOL DETOXIFICATION--OUTCOME AFTER 2 MONTHS

We assessed the outcome after 2 months of 28 alcohol-dependentsubjects following out-patient detoxification using an uncontrolledfollow-up study with data collected at the time of detoxification(T1) and after 2 months (T2). We also determined the cost ofout-patient versus in patient detoxification. The setting wasa psychiatric emergency clinic at a South West London UniversityHospital. Self-reported alcohol consumption in the week beforeT1 and T2, score on the ‘Alcohol Problems Inventory’measuring alcohol-related relational, occupation, legal andmedical problems in the 2 months prior to T1 and T2, mean corpuscularvolume and gamma-glutamyl transferase at T1 and T2 were usedas outcome measures. Eight subjects had a ‘good’outcome (seven were abstinent and one only drank four unitson one day). Nine subjects were ‘improved’ by eitherhalving their alcohol consumption, or halving their ‘AlcoholProblems Inventory’ score at T2. ‘Good’ and‘improved’ outcome were confirmed by mean corpuscularvolume and gamma-glutamyl transference results. Eleven subjectswere ‘not improved’. Engagement following detoxificationwith voluntary alcohol agencies was associated with a betteroutcome. In-patient detoxification is calculated to be six timesmore expensive than out-patient detoxification. Out-patientdetoxification is a cost-effective step in the treatment ofalcohol-dependent patients.     

The Psychosocial Impact of Mass Screening for Cardiovascular Risk Factors

In Leek, a small town in the north of the Netherlands, 428 menaged between 30–33 years were invited to take part ina screening test for cardiovascular risk factors. Questionnaireswere sent to the 267 men who had participated in the screeningtest as well as to the 161 non-participants, in order to gainan insight into the participatory behaviour and the experienceof those involved. The non-participants gave a diversity ofmotives for not taking part but did not admit to anxiety aboutfinding abnormal results. More than half of the participantswho replied (51%, n = 107) were found to have an ‘abnormality’—;thatis they scored on one or more of cigarette smoking, overweight,hypertension, hyperlipoproteinaemia, albuminuna or glucosuria.The supplementary information provided on nutrition and smokingcaused a large proportion of them to claim they had changedto a more healthy life-style after the screening test. Thosewho were under the impression that they had led healthy livesbut were still found to have an ‘abnormality’ wereoften very astonished and sometimes worried about the result.The men without ‘abnormalities’ did not lead significantlyhealthier lives than the rest in terms of exercise, smoking,diet and so on; for them the result might have a ‘certificateof health’ effect justifying their not always healthybehaviour.     

ALCOHOLISM: A LONG-TERM FOLLOW-UP STUDY OF PARTICIPANTS IN AN ALCOHOL TREATMENT PROGRAMME

This paper reports the results of a long-term follow-up studyof 112 alcoholic patients admitted to an intensive 1-month residentialprogramme. Outcomes at the 6-month and 1-year stages were reportedin an earlier paper [G. K. Shaw et al. (1990) British Journalof Psychiatry 157, 190–196]. The length of the follow-upperiod in this study was an average of 9 years. Eighteen patientshad died before the long-term follow-up stage, and of the remaining94 a total of 60 patients were followed up. This study showsthat major improvements on social, psychological and drinkingbehaviour measures, made at 6 months and 1 year follow-up, were,on the whole, maintained and there was a progressive improvementon most variables at each follow-up stage. Major improvementswere achieved by those patients whose drinking was categorizedas ‘abstinent’, ‘controlled’ and ‘improved’.The proportion of patients categorized as ‘unchanged’dropped from 43% at 6 months to 33% at 1 year and to 15% at9 years. By the 1-year follow-up stage, the unchanged groupshowed deterioration on psychological variables such as neuroticism,self-esteem and satisfaction with life situations, continuedto make use of health service resources, and the high levelof alcohol-related physical and social complications remainedunchanged. This group had similar results at long-term follow-upwith the exception of neuroticism, which was significantly lowerin all drinking categories.     

SCREENING FOR PSYCHIATRIC COMORBIDITY AMONG FEMALE ALCOHOLICS: THE USE OF A QUESTIONNAIRE (SCL-90) AMONG WOMEN EARLY IN THEIR TREATMENT PROGRAMME

The use of a questionnaire, Symptom Check List-90 (SCL-90),as a screening instrument for psychiatric disorders was studiedin 60 women attending their first treatment for alcohol abusein Stockholm, Sweden. A global SCL-90 index, the General SymptomaticIndex (GSI), measuring the total level of recent self-reportedpsychological distress, showed a high efficacy in distinguishing‘psychiatric cases’ from ‘non-cases’in the present sample. Psychiatric cases were defined as subjectssatisfying the criteria for any current DSM-III-R disorder otherthan substance abuse. The psychiatric diagnoses were obtainedindependently by use of the Structured Clinical Interview forDSM-III-R (SCID-I). Psychiatric disorders, especially depressionand anxiety disorders, frequently antecede or develop secondaryto alcohol abuse among women. The use of structured interviewsto diagnose these disorders is, however, time-consuming. Findingsfrom the present study indicate that SCL-90 can be used to detectpsychiatric comorbidity among female alcoholics, thus enablingclinicians to be aware of concomitant psychiatric disordersamong a subgroup of patients.     

Patient expectations: What do primary care patients want from the GP and how far does meeting expectations affect patient satisfaction?

There is growing recognition of the importance of patients'expectations in general practice. This study aimed to investigatethe types of expectations adult primary care patients have priorto consulting the GP, and how far meeting expectations is associatedwith increased satisfaction. Patients (n = 504) attending generalpractitioners (n = 25) at 10 London general practices were includedin the study. The Patients Intentions Questionnaire (PIQ) wasadministered prior to the consultation to investigate patients'expectations and the Expectations Met Questionnaire (EMQ) wasadministered after the consultation to find Out what the patientreportedly obtained. Satisfaction with the consultation wasalso measured using the Medical Interview Satisfaction Scale(MISS). The results of a principal components analysis of PIQitem scores indicated that the most wanted items were for ‘explanationof the problem’. There was less desire for ‘support’or ‘tests and diagnosis’. Many of the ‘support’items could potentially be provided to all patients, yet a proportionof patients reported not receiving these items from the GP.The results of one-way ANOVAs revealed that patients with greaternumbers of their expectations met reported significantly highersatisfaction with the consultation than those with lower numbersmet. The PIQ and EMQ could be potentially useful self-audittools for use by general practitioners and trainee GPs.     

Discourses and practices related to suntanning and solar protection among young Australians

For some decades there has been a strong cultural imperativeamong Australians of European descent to acquire a tanned skinin the summer months. This article reports the findings of aqualitative study that sought to identify some of the discoursesand practices around solar protection, skin cancer and tanningamong Australian young people, with a particular focus on genderdifferences. The participants' responses to a government-sponsoredsolar protection campaign, the ‘Me No Fry’ campaign,were also elicited. Twelve focus group discussions were conductedwith a total of 98 students in secondary schools in the stateof New South Wales. The findings revealed that the majorityof young people remained positive about acquiring a light ormedium tan, with negative attitudes expressed both about paleskin and sunburn. The deliberate acquisition of a tan was representedas feminine, while becoming tanned ‘unintentionally’while playing sport was viewed as masculine. These findingsare discussed in the light of the objectives of the ‘MeNo Fry’ campaign and in the context of Australian youthculture.