Evaluating the progress of the health promoting hospitals initiative? A WHO perspective. Commentary on: Whitehead, D. (2004) The European Health Promoting Hospitals (HPH) project: how far on? Health Promotion International, 19, 259-267

We have read with interest the contribution of Dean Whiteheadon ‘The European Health Promoting Hospitals (HPH) project:how far on?’ in a recent issue of Health Promotion International(Whitehead, 2004). He points out some of the issues the HPHmovement has faced over the years that are linked to the inherentdifficulties in changing the behaviour of organizations. However,we would like to clarify a number of points. Dean Whitehead's article aims ‘to investigate the natureand progress of the European HPH movement’ and he concludesthat ‘the majority of the available literature demonstratesa more limited impact than perhaps the World Health Organization(WHO) might have     

Lessons from community participation in health programmes

Although primary health care emphasizes community participationand many health care programmes attempt to develop participation,good analysis of these developments is still rare. This paper,based on a review of about 200 case studies, examines some ofthe lessons for planners which are emerging from experiencesof the last decade. These lessons focus on the problems of definingthe term ‘community participation’, of gaining andsustaining broad-based community participation, of failing torecognize the political implications of the concept and of attemptingto develop a management model of community participation forhealth. Based on these lessons, a planning framework is suggestedthat seeks individual programme answers to three questions:‘Why participation?’, ‘Who participates?’,‘How do they participate?’. The answers to thesequestions will help to define a programme's objectives and tomonitor and evaluate its development.     

Testing a conceptual model related to weight perceptions, physical activity and smoking in adolescents

The purpose of this study was to test a conceptual model basedon theoretical and empirically supported relationships relatedto the influences of weight perceptions, weight concerns, desiresto change weight, friends, age and location in relation to physicalactivity (PA) and smoking in adolescents. A total of 1242 malesand 1446 females (mean age = 15.6 ± 1.3) were recruitedfrom rural and urban Canadian schools. Study respondents providedself-reports of PA, ‘smoking’, ‘perceivedbody weight’, ‘desire to change weight’, ‘concernabout weight gain’ and ‘friends' smoking and PAbehaviors’. Results revealed an acceptable fitting model² (40) = 155.63, P < 0.05, root mean square error of approximation= 0.047 and comparative fit index = 0.98. Large effect sizesfor both genders were observed between friends' and adolescents'smoking behavior, and between perceived body weight and desireto change weight. Further, significant differences were identifiedbetween the male and female models [² difference (24) = 65.28,P < 0.05]. Several findings of this study point to the needto design programs to motivate adolescent females to adopt healthyweight-control practices and to target young peoples' socialnetworks to promote health behaviors, especially with regardto smoking. Received on December 22, 2005; accepted on June 15, 2006     

Predictors of cardiovascular health knowledge among suburban cable TV subscribers and non-subscribers

This study focused on how social-psychological and demographicfactors combined to predict information-holding about cardiovasculardisease prevention among subscribers and non-subscribers toa suburban Midwest cable television system. Data come from oneof three education communities of the Minnesota Heart HealthProgram, a research and demonstration project to reduce communitylevels of heart attack and stroke. A principal component factoranalysis of the total sample (N = 635) extracted two factorsfrom variables operationalizing involvement, self-efficacy andsalience: ‘orientation to health behavior change’,and ‘orientation to disease consequences’. Separatefactor analyses for non-subscribers (N = 228) and subscribers(N = 407) showed a similar factor structure for the former,but the addition of a ‘transitional orientation’factor for the latter characterized by less orientation to healthbehavior change, but greater awareness of increasing informationabout heart disease prevention. These factors together withvariables of gender, age, education, occupation, family compositionand television use were entered into multiple regression analysesfor the total sample (P 0.001), and separately for subscribers(P 0.01) and non-subscribers (P 0.01). In general, gender,education and age emerged as significant predictors with healthorientation and television exposure marginally predictive amongcable-subscribers only.     

The Denominator for Audit in General Practice

Fleming D M (Birmingham Research Unit of the RCGP, LordswoodHouse, 54 Lordswood Road, Harborne, Birmingham B17 9DB). Thedenominator for audit in general practice. Family Practice 1985;2: 76–81. Different denominators for morbidity studies were compared fromtwo large studies in Britain. From the second national morbiditysurvey, data from 24 single-handed doctors showed a close correlationbetween the denominators ‘persons consulting’ and‘list size’ (r > 0.9) in both years of the survey,but a weaker correlation between ‘consultations’and ‘list size’ (r=0.6). However, when examiningrank order statistics for visiting and out-patient referralrates, it was immaterial for most doctors which denominatorwas chosen. Only for recorders with a consultation rate at theextremes of the range was the choice of denominator criticalto the interpretation of the data. In the practice activity analysis study, based on 47 doctorsand a mean of 284 consultations in two weeks, the correlationbetween ‘persons consulting’ and ‘total consultations’was 0.99. Thus the number consultations provided a satisfactoryproxy for persons consulting in a two-week study. These results justify the use of ‘consultations’over two weeks as a denominator in general practice audit incircumstances where rank order is appropriate for the interpretationof data.     

UROKINASE-LIKE PLASMINOGEN ACTIVATOR INCREASED IN PLASMA AFTER ALCOHOL DRINKING

After taking the local Japanese spirit ‘Shochu’,‘Sake’ and beer, increased plasma fibrinolysis wasconfirmed in normal persons at about 1 hr after for both thepyro-Glu-Gly-Arg-pNA amidolytic and Glu-plasminogen activatingactivities in eluates from [N-(-aminocaproyl)-DL-homoargiinehexlester;)]-Sepharose affinity column. The activity was highestin the Shochu group, followed by the Sake and beer groups withan approximately 2.1-, 1.7- and 1.5- fold increase in fibrinolyticactivity, respectively, compared to the control. The enzymecould be further purified using urokinase-IgG-Sepharose immunoadsorbentcolumn from the Shochu group and it reacted with and was inhibitedby urokinase specific antibody. The main molecular weight ofthe active enzyme was about 30,000, and those of minor componentswere about 50,000 and 100,000, as determined by zymography.These findings suggest that some of the enzymes appearing inthe plasma after drinking are related to ‘urokinase-likeplasminogen activator’, being endogenously produced.     

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.     

Patients' perceptions of their clinical interactions: development of the multidimensional desire for control scales

Interventions oriented toward enhancing patient-provider communicationwill benefit from having a satisfactory measure of patients’desires for control in clinical interactions. Findings fromtwo studies are reported describing the development and validationof the Multidimensional Desire for Control (MDC) Scales. A totalof 160 patients with non-insulin-dependent diabetes (NIDDM)participated in the first study, which was designed to developand validate a measure of patients‘ desires for control.Factor analysis yielded three subscales reflecting patients’desires for: (i) personal, (ii) clinician, and (ii) shared controlin the interaction. Alphas for the three subscales were high( 0.75–0.86). Correlations with other measures of controlwere suggestive of good construct validity. The second investigationinvolves a replication study verifying the factorial compositionand validity of the scales. An independent sample of 109 patientswith NIDDM participated in this study. Findings support thereliability of the subscales (0.75–0.81). Furthermore,patients‘ desires for control were significantly associatedwith patient satisfaction, with desire for personal controlnegatively related to patient satisfaction (r = –0.30,–0.41, affective and behavioural dimensions, respectively)and desire for clinician control positively related to satisfaction(r = 0.44, 0.28, 0.31, affective, behavioral, and cognitivedimensions, respectively).     

Principles and strategies of effective community participation

A framework is offered for understanding the conceptual basisand the strategic implications of community participation, inachieving Health for All goals. Special focus is given to themeaning, settings and levels of participation in official decision-makingstructures and at the community level. Questions such ‘howis participation facilitated?’, ‘who participates?’and ‘what are the benefits and obstacles to participation?’are geared primarily towards the needs of individuals who functionat the city level and expect practical strategic advice andguidance. The structure of the 1989 WHO Healthy Cities Symposiumwhich was devoted to community action was based on the frameworkand conceptual approach of this paper.     

What do doctors mean by tenosynovitis and repetitive strain injury?

Confusion exists in both the scientific and the lay press onthe meaning of the terms tenosynovitis and repetitive straininjury. The courts are increasingly being asked to make judgementson individual cases but this gives little in the way of guidanceto doctors producing reports for the Department of Social Securityor solicitors. The aim of this study was to document what suchdoctors mean by these terms, what diagnostic criteria they use,and to make any necessary recommendations. The diagnostic criteriafor DSS industrial conditions A8 (tenosynovitis) and A4 (professionalcramp) varied greatly and what the experts understood by theterm ‘repetitive strain injury (RSI)’ was so variablethat the term is meaningless. Half of the doctors who respondedfelt that there was no genuine organic condition correspondingto their assessment of what the term means. As half of the doctorsproviding reports believe that ‘repetitive strain injury’is not a genuine disease entity and the other half do, courtcases will continue. The dilemma appears to be that completelydifferent meanings are ascribed to the same term. Therefore,the term ‘repetitive strain injury’ should no longerbe used.     

Effect of the application of the new diagnostic criteria of diabetes mellitus in the prevalence estimates and diagnostic level in the general population

Background: The objective was to study the effect of the applicationof the new diagnostic criteria for diabetes mellitus on itsprevalence in Galicia (northwest Spain). Methods: Analysis using‘old’ and ‘new’ criteria (diabetes undertreatment and/or fasting glycaemia 140 mg/dl or 126 mg/dl respectively)was performed in a cross-sectional study (1,275 participants)in the general population aged 40–69 years. Results: Prevalenceof diabetes rose from 7.5 (95% Cl: 6.1–9.1) to 10.4% (95%Cl: 8.8–12.2) with the new criteria. The proportion ofnon diagnosed diabetes rose from 22.2 to 37.8%. Conclusions:The new diagnostic criteria for diabetes mellitus make it necessaryto increase previous prevalence estimates by 30–35% Inmiddle age (40–69 years).     

Commentary: It's a difference of opinion that makes a horserace..

The authors of ‘Health behavior theory and cumulativeknowledge regarding health behaviors: are we moving in the rightdirection’ (Noar and Zimmerman, 2005) have taken a boldstep by advocating for change in the field of change. The authorsare correct when they note that our field should continuallyand critically reflect upon itself; however, it may be thatour systems of funding, publication, peer review and specializationhave made us too introspective, and discourage the types ofinnovation and risk-taking that could move our field to newesteem. Herein, we provide some additional points for considerationin an effort to continue the dialogue initiated by Noar andZimmerman (Noar     

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.     

Contamination incidents among doctors and midwives: reasons for non-reporting and knowledge of risks

A 6-month retrospective self-administered questionnaire studyof 482 doctors and 380 midwives in two NHS Trusts was undertaken.The response rate was 384 (80%) and 293 (77%) respectively.The study revealed that only nine per cent of doctors and 46%of midwives had reported the contamination incidents they hadreceived. The doctors' main reason for non-reporting was ‘tootime consuming’ and midwives' was ‘did not consideranything could be done’, although their awareness of theactive management of contamination incidents by occupationalhealth departments was good. Seventy-seven per cent of doctorsand 69% of midwives underestimated the risk of contracting hepatitisB virus from a needlestick injury, whilst 52% of doctors and36% of midwives underestimated the risks of acquiring infectionwith HIV (human immunodeficiency virus) infection followingsuch an injury. Strategies for improving the knowledge of thepotential risks of contamination incidents and methods for facilitatingease of reporting are discussed.     

Alcohol and hypertension: an old relationship revisited

The American comedian Henny Youngman (1906–1998) oncesaid, ‘When I read about the evils of drinking, I gaveup reading.’ Ironic, but interestingly as though witha sense of foresight, he did not speak of giving up drinking!It is despite the fact that alcohol is responsible for increasedillness, being causally related to more than 60 different medicalconditions (Rehm et al., 2003). Around 4% of the global diseaseburden is also thought to be alcohol related, which is comparablewith that attributed to the effects of tobacco (4.1%) and highblood pressure (4.4%) (Ezzati et al., 2002; WHO, 2002). For most diseases related to alcohol consumption, a dose–responserelationship exists with risk of the disease increasing withgreater amounts of alcohol intake, with cardiovascular     

Errata

In the Lucas Lecture 1981, ‘Professional Ethics—ForWhose Benefit’, by Paul Sieghart (32, 4–14) the following errors occurred. The author's position is Barrister not Barrister-at-Law. The following lines should read: p. 4, column 2, line 2: ‘troubled Dr Conor Cruise O'Brien(1980).’ p. 5, column 1, line 32: ‘regard it as the study of morality,that is, the’. p. 9, column 1, line 27: ‘conflicts? Of all the specialties,that of. p. 9, column 2, line 4: ‘order of a competent court ortribunal’. p. 12, column 2, line 16: ‘himself of that obligationbecause another’.     

A soccer championship and hepatitis A outbreak

Background: An outbreak of hepatitis A took place in the coastalvillage of Bueu, Galicia, Spain in the period 15 July–1November 1997 involving a total of 114 reported cases out ofa population of 12,480. Preliminary investigations pointed toa waterborne outbreak. Methods: A matched case-control studywas designed. Results: A statistical association was found withconsumption of water from two public water fountains (‘A’and ‘B’) and a history of bathing at a nearby beach.Conclusions: After controlling for potential confounders, theonly source of the outbreak was water drunk from fountain ‘A’(odds ratio = 55.0 and 95% confidence interval: 18.0–168.0).     

Alcohol consumption and heavy drinking: a survey in three Italian villages

Aims: We investigated drinking habits, and heavy and problemdrinking prevalence in a sample of individuals attending theconsulting rooms of local General Practitioners in three Italianvillages. Methods: The samples were selected to be representativeof the entire population of the three villages. Informationon alcohol-drinking patterns was collected using a questionnairethat included a masked form of the CAGE rating scale. Accordingto the frequency of alcohol intake, subjects were grouped inthree categories: abstainers, occasional drinkers, and dailydrinkers. In agreement with WHO guidelines, 40 g/day for malesand 20 g/day for females were taken as cut-off for ‘heavydrinking’ and consumptions of >80 g/day for males and40 g/day for females were used to define ‘problem drinking’.Results: A total of 2972 individuals were included in the survey(19% of the population). Of these, 44% were abstinent, 20% occasionaldrinkers, and 36% daily drinkers. Daily drinking was found tobe more common in males than in females but heavy drinking wassignificantly higher in females compared with males (P 0.0001).The problem drinkers were 12% of the entire population and theCAGE-positive subjects (2 positive answers) were 3.5%. Conclusions:Our data indicate that alcohol drinking is widely diffused inthe three communities. A large layer of the population drinksabove the WHO-established cut-off. The incidence of heavy andproblem drinking seems to have significant gender and regionaldifferences that are important to consider when planning effectiveprevention programmes.     

Response to Hayden: Comment on 'ethnic cleansing' and 'genocide'

Note: This paper refers to a Commentary by Robert Hayden thatappeared in issue 17(6) of this journal of pages 546–547. Dictionaries describe ‘ethnic cleansing’ as genocide.¹A comparison of the accepted UN definition of genocide witha suggested definition for ‘ethnic cleansing’ leadsus to ask: what are the real differences in the outcomes? (SeeTable 1.) Proof of genocide does not depend on the