A widening health gap in general practice? Socio-economic differences in morbidity between 1975 and 2000 in The Netherlands

BACKGROUND: During the past two decades, socio-economic inequalities in health have been a major research theme in Western Europe. Research has shown that there are persistent differences in health between people with a high socio-economic status (SES) compared with people with a low SES. There are also indications for a widening health gap. The present paper aimed to find out whether this widening health gap exists in The Netherlands using morbidity data from a general practice (GP) registry. METHODS: Incidence data from a GP registry were used, involving over 12,000 patients. Morbidity data from 1975 to 2000 were grouped into 25 disease categories. SES was based on household occupational status. Poisson regression was used to determine the relationship between morbidity and SES and its changes over time. Separate analyses were performed for men and women. RESULTS: In most disease categories, a clear SES gradient disadvantageous to the lowest-SES group was identified: 17 out of 22 morbidity categories for men and 17 out of 24 for women. For seven (men) and eight (women) morbidity categories out of 17, the SES gradient increased between 1975 and 2000. CONCLUSIONS: This study provides new evidence for a widening gap in health between higher and lower SES in The Netherlands, using GP-defined disease data and a wide range of morbidity categories.     

Racial differences in post‐neonatal mortality in Chicago: What risk factors explain the black infant's disadvantage?

Objectives. To investigate the extent to which the place of residence affects the black to white differential in post‐neonatal (28–365 days) mortality, we performed a univariate analysis and multivariate logistic regression of the 1982–1983 Illinois vital records, Chicago Police violent crime information and 1980 US Census income data.

Methods. Four environmental predictors of post‐neonatal death were examined: a median family income of < $10 000 per year, a poverty prevalence of > 50%, violent crime rates of > 11/1000 and limited community access to primary medical care based on physician supply ratios.

Results. The post‐neonatal mortality rate of black (n = 50 765) infants was three times that of white (n = 50 690) infants: 10/1000 versus 3/1000, respectively. Thirty‐six percent of the white infants had none of the environmental risk factors, whereas only 13% of the black infants had none of the risk factors. For black infants, the presence of any one factor was associated with a slightly increased risk of post‐neonatal mortality (9/1000 as compared to 7/1000 with no risk factors), whereas the presence of two or more risk factors was associated with a higher risk (11/1000). When the number of these environmental risk factors were taken into account, the OR for black infants declined from 3.0 (95% CI 2.5–3.6) to 1.7 (95% Cl 1.5–1.9). When the differences in maternal age, education, marital status and infant birth weight were also taken into account the odds ratio of post‐neonatal death for blacks was 1.5 (95% CI 1.3–1.7).

Conclusions. We conclude that a substantial proportion of the black to white difference in post‐neonatal mortality is associated with specific environmental conditions.     

Determinants of mammography adoption among iranian women: What are the differences in the cognitive factors by the stages of test adoption?

Our aim in this cross-sectional study was to investigate the predictors of the stages of change in mammography adoption (MA) based on Health Belief Model among Iranian women. Through multistage cluster sampling, we recruited and interviewed 1131 women older than 40. After statistical adjustment for other risk factors, perceived barriers (OR D 0.84, 95% CI D .81–.87) and benefits (OR D 1.17, 95% CI D 1.11–1.24) were significant predictors for MA. Majority of the women were in the pre-contemplation and contemplation stages of change for MA. Our findings are informative for the development of targeted interventions to foster MA among women.     

How to improve mental health competency in general practice training?: A SWOT analysis

It is quite evident there is room for improvement in the primary care management of common mental health problems. Patients respond positively when GPs adopt a more Practctive role in this respect. The Dutch general practice curriculum is currently being renewed. The topics discussed here include the Strengths, Weaknesses, Opportunities and Threats (SWOT) of present primary mental healthcare teaching. What works well and what needs improving? Integrated teaching packages are needed to help general practice trainees manage various presentations of psychological distress. Such packages comprise training videotapes, in which models such as problem-solving treatment (PST) are demonstrated, as well as role-playing material for new skills, self-report questionnaires for patients, and small-group video feedback of consultations. While GP trainees can effectively master such skills, it is important to query the level of proficiency required by registrars. Are these skills of use only to connoisseur GPs, or to all? More room for specialisation and differentiation among trainees may be the way forward. We have just developed a new curriculum for the obligatory three-month psychiatry housemanship. It is competency oriented, self-directed and assignment driven. This new curriculum will be evaluated in due course.     

Management of symptomatic patients with suspected mild-moderate COVID-19 in general practice. What was published within the first year of the pandemic? A scoping review

BackgroundMost COVID-19 patients experience a mild course of the disease and can be managed in general practice. However, in the early pandemic, most research was conducted in secondary care.ObjectivesThis scoping review aimed to identify original research published within the first year of the pandemic relevant to general practice regarding symptomatic, non-hospitalised patients with mild to moderate COVID-19 disease to provide an overview of published research.MethodsPubMed was searched for studies written in English, Swedish, Danish, or Norwegian published before 1 April 2021. Two authors screened all titles and abstracts and identified full texts.ResultsWe screened 1303 titles and abstracts and retrieved 128 full texts. An additional 44 full-texts were obtained from references. After full-text reading, 79 articles were included, six of which were conducted in general practice, 20 in the community, 42 in hospitals, and 11 in other settings. Therapy and harm were investigated in randomised controlled trials in 11 out of 17 studies; the diagnosis was investigated using a diagnostic accuracy design in four out of 26 studies and prognosis in prospective studies in 10 out of 21 studies. The remaining 15 studies had other research questions.ConclusionAlthough general practitioners in most countries must have been involved in managing patients with COVID-19, little research has been published from general practice during the first year of the pandemic. General practice research environments must be able to respond quickly in case of future pandemics.     

Does smoking explain sex differences in the global tuberculosis epidemic?

To date there has been no satisfactory explanation of the worldwide excess of tuberculosis (TB) notifications among adult males. We investigated the epidemiological basis for sex differences in TB notifications in high-burden countries using available group-level data. Multiple linear regression analysis was used to explore the ecological relationship between smoking and sex differences in TB notifications among high-burden countries. Cigarette consumption was a significant predictor of the sex ratio of TB notifications, and explained 33% of the variance in the sex ratio of TB notifications. Our findings suggest that smoking is an important modifiable factor which has a significant impact on the global epidemiology of TB, and emphasize the importance of tobacco control in countries with a high incidence of TB. This analysis provides support for the interpretation of sex differences in worldwide TB notification rates as indicative of true differences in the epidemiology of TB between males and females.     

What indicates competency in systems based practice? An analysis of perspective consistency among healthcare team members

In many parts of the world the practice of medicine and medical education increasingly focus on providing patient care within context of the larger healthcare system. Our purpose is to solicit perceptions of all professional stakeholders (e.g. nurses) of the system regarding the U.S. ACGME competency Systems Based Practice to uncover the extent to which there is agreement or discrepancy among key system stakeholders. Eighty-eight multidisciplinary personnel (n = 88) from two academic medical centers were invited to participate in one of 14 nominal group process sessions. Participants generated and prioritized resident characteristics that they believed were important for effective System Based Practices. Through content analysis the prioritized attribute statements were coded to identify embedded themes of resident roles and behavior. From the themes, three major resident roles emerged: resident as Self-Manager, Team Collaborator, and Patient Advocate. No one professional group (e.g., nurses, attending physicians, social workers) emphasized all of these roles. Some concepts that are emphasized in the ACGME definition like using cost–benefit analysis were conspicuously absent from the healthcare team generated list. We showed that there are gaps between the key stakeholders prioritizations about the ACGME definition of SBP and, more generally, the behaviors and roles identified by healthcare team stakeholders beyond the U.S. This suggests that within the process of developing a comprehensive working understanding of the Systems Based Practice competency (or other similar competencies, such as in CanMEDS), it is necessary to use multiple stakeholders in the system (perhaps including patients) to more accurately identify key resident roles and observable behaviors.

Can social factors explain sex differences in insomnia? Findings from a national survey in Taiwan

STUDY OBJECTIVE: To examine sociological explanations for the higher level of insomnia in women, including social roles and socioeconomic status (SES). DESIGN: Cross sectional survey research SETTING: Taiwanese 2001 "social trend survey" PARTICIPANTS: A nationally representative sample of 39,588 citizens aged 15 years or older living in Taiwan. MAIN RESULTS: On average, women scored 1.25 points higher than men on the insomnia inventory (p<0.001) but after controlling for social roles, the sex discrepancy in insomnia decreased slightly. SES did not, however, explain women's higher levels of insomnia. Subscale analysis showed an association between the role of homemaker and increased night time sleep disturbance and decreased daytime sequelae of poor sleep while higher educational attainment was related only to more severe daytime sequelae. CONCLUSION: The sex discrepancy in insomnia narrowed slightly after taking social role factors into consideration but was not explained by SES. The persistent sex gap in insomnia warrants further investigation.     

Which factors determine the use of diagnostic imaging technologies for gastrointestinal complaints in general medical practice?

OBJECTIVE: Even though gastrointestinal complaints are among the most frequent reasons to contact general medical practitioners, little is known about the actual care of these patients, especially the use of diagnostic imaging technologies. METHODS: In a network of 57 family practitioners and 29 general internists in Lower Saxony, Germany, 1,217 contacts with patients with gastrointestinal diseases (16%, gastritis; 12%, gastroenteritis; 6%, cholelithiasis; 5% each, ulcus ventriculi and duodeni, and 14%, no final diagnosis) were documented. The effects of patient and physician/practice side factors on the use of ultrasonography and radiography were modeled using multivariate logistic regression. RESULTS: For ultrasonography, diagnosis and ownership of an ultrasound unit (odds ratio [OR] = 3.33) were highly significant predictors (p < .0001), followed by unknown diagnosis at beginning of contact (OR = 1.92; p = .0019), physician specialty (OR for internists = 1.89; p = .0025), and severity (p = .0085). For radiography, ownership of an ultrasound unit was the most significant factor (OR = 0.34; p < .0001), followed by severity (p < .0009), ownership of x-ray apparatus (OR = 2.56; p = .0025), physician specialty (OR for internists = 1.98; p = .0358), and unknown diagnosis at beginning of contact (OR = 1.79; p = .0451). Not significant were age and sex of patient and diagnosis for radiography. CONCLUSIONS: Physicians use diagnostic imaging technologies for patients with gastrointestinal complaints according to severity and knowledge about the diagnosis, but ownership of technology is the most predictive factor.     

Ten-year changes in smoking among young adults: are racial differences explained by socioeconomic factors in the CARDIA study?

OBJECTIVES: This study investigated whether socioeconomic factors explain racial/ethnic differences in regular smoking initiation and cessation. METHODS: Data were derived from the CARDIA study, a cohort of 5115 healthy adults aged 18 to 30 years at baseline (1985-1986) and recruited from the populations of 4 US cities. Respondents were followed over 10 years. RESULTS: Among 3950 respondents reexamined in 1995-1996, 20% of Whites and 33% of African Americans were smokers, as compared with 25% and 32%, respectively, in 1985-1986. On average, African Americans were of lower socioeconomic status. Ten-year regular smoking initiation rates for African American women, White women, African American men, and White men were 7.1%, 3.5%, 13.2%, and 5.1%, respectively, and the corresponding cessation rates were 25%, 35.1%, 19.2%, and 31.3%. After adjustment for socioeconomic factors, most 95% confidence intervals of the odds ratios for regular smoking initiation and cessation in African Americans vs Whites included 1. CONCLUSIONS: Less beneficial 10-year changes in smoking were observed in African Americans, but socioeconomic factors explained most of the racial disparity.     

What are the main motivating factors for young general practitioner trainees to work in rural areas in the Czech Republic?

PurposeThe global health workforce suffers long-term understaffing in remote and underserved areas. To attract young doctors for rural work, it is necessary to identify the main motivating factors.Materials and methodsThe pilot survey with 201 general practitioner trainees in the Czech Republic was conducted using a structured questionnaire. The response rate was 67%.ResultsNot only financial support motivates general practitioner trainees for rural work. A combination of incentives from sources other than medical would greatly increase the chance for general practitioner trainees to work in rural regions.ConclusionsTo what extent can the survey outcomes relate with other European regions needs to be investigated further.     

Diagnostic uncertainty in general practice. A unique opportunity for research?

General practice encounters often involve vague symptoms, potentially representing illness in its early stage. Managing such undifferentiated symptoms is difficult, but one of the key tasks of the general practitioner is to discover serious disease at an appropriate stage whilst also minimising over-investigation. Although the diagnostic process and methods of coping with uncertainty in general practice have been described, the early course of disease, especially undifferentiated presentations, is poorly understood. There is still much to learn about diagnosis in general practice, and important contributions could be made by researchers in any primary care setting.     

Choosing to practice in rural dietetics: What factors influence that decision?

OBJECTIVE: The present study aimed to identify those factors that influence the decision of a dietitian to consider working in a rural area. DESIGN: A qualitative design using focus groups was chosen for this study to allow for in-depth data to be obtained. SETTING: University of Newcastle, Callaghan Campus. SUBJECTS: Twenty-three students/new graduates from the Bachelor of Health Science (Nutrition and Dietetics) degree at the University of Newcastle. MAIN OUTCOME MEASURES: Not applicable, this project was an exploratory study. RESULTS: A number of factors that influence the decision of dietetic students and newly graduated dietitians to consider working in a rural area were identified. These fell into the following main thematic areas: job prospects; rural lifestyle; comfort zones; support networks; promotion opportunities/professional development; type of work/work role; rural needs; and time frame. CONCLUSIONS: The present study found that choosing a location to work (whether it be a rural one or not) is a complex process and involves a number of interacting factors. Also those factors that may influence one dietitian to choose a career in a rural area may also be the factors that influence another dietitian not to choose a career in a rural area.