The preventive medicine physician: a national study

Following the 1980 Graduate Medical Education National Advisory Committee report, postal questionnaires were sent to a random sample of physicians self-designated as preventive medicine specialists primarily in an effort to verify the committee's assumption that preventive medicine is not a clinical specialty. The questionnaires represented each of the preventive medicine subspecialties: general preventive medicine, public health, occupational medicine, and aerospace medicine. After three reminders, 419 out of 942 (44%) responded. Seventy percent of the physicians who responded engage in clinical activities for at least part of their workweek. Preventive medicine is practiced in a wide variety of settings. For the majority of preventive medicine physicians, prevention plays an important role in their practice. They perceive that they practice medicine differently from their colleagues who are not preventive medicine specialists because of their prevention focus. Many of these physicians have made career changes, and some have made many such changes, as board certification in one of the subspecialties does not preclude practice in another subspecialty. The specialty appears to allow considerable flexibility. The preventive medicine physician is prepared to incorporate prevention into clinical practice and seems well equipped to integrate community and individual clinical approaches.     

The health belief model and preventive health behaviour in Singapore

Every theoretical model in the social sciences confronts a common challenge: to maintain its explanatory power in different cultural contexts. This is, of course, only one of many challenges faced in theory building. But, this discussion shall focus only on the possibility of a cultural bias. More specifically, the aim of this paper is to discuss some of the findings from a test of the Health Belief Model (HBM) in a multi-ethnic society, Singapore. The HBM is a theoretical framework frequently used in the analysis of health-related behaviour. The discussion will be divided into four sections. The first section will present briefly the components of the HBM. The second section will summarize the procedure used to conduct the empirical test of the HBM. And the third and final sections shall deal with the comparison of preventive health behaviour among three ethnic subpopulations in Singapore, highlighting the main findings of the test of the HBM.     

Implementing preventive health measures: a pilot study

OBJECTIVE: Implementation of preventive services guidelines is performed inconsistently. In an attempt to reduce variation in guideline implementation, we developed a patient questionnaire based on the US Preventive Services Task Force Guide and the Health Plan Employer Data and Information Set 3.0 performance measures of the National Committee on Quality Assurance. SUBJECTS: 100 hospitalized patients of five primary-care physicians. METHODS: In a pilot study, 100 hospitalized patients of five primary-care physicians were questioned about their compliance with evidence-based, preventive healthcare recommendations. Information was requested on blood pressure measurement, cholesterol screening, fecal occult blood testing, smoking-cessation counseling, Pap testing, mammography, postmenopausal hormonal replacement therapy counseling, prostate examination and prostate-specific antigen (PSA) testing, use of aspirin and beta-blockers following an acute myocardial infarction, testing of diabetics for hemoglobin A1c and retinal eye examinations, questioning of the elderly for auditory and visual problems, and receipt of influenza and pneumococcal vaccines. Information on variations from the recommended preventive service was fed back to their physicians. Six months after the initial survey, the patients were requestioned to determine if compliance had improved with the recommendations. RESULTS: We found significant improvement in fecal occult blood testing, smoking cessation, Pap smear testing, mammography use, prostate examinations and PSA testing, hemoglobin A1c testing, seeing or hearing loss follow-up, and the administration of influenza and pneumococcal vaccines. CONCLUSIONS: Improving implementation of preventive services recommendations is a challenge. This pilot study suggests that involving the patient more in the process and informing the physician of the results may improve the process.     

Natural mentoring relationships and adolescent health: evidence from a national study

OBJECTIVES: We used nationally representative data to examine the impact of natural (or informal) mentoring relationships on health-related outcomes among older adolescents and young adults. METHODS: We examined outcomes from Wave III of the National Longitudinal Study of Adolescent Health as a function of whether or not respondents reported a mentoring relationship. Logistic regression was used with control for demographic variables, previous level of functioning, and individual and environmental risk. RESULTS: Respondents who reported a mentoring relationship were more likely to exhibit favorable outcomes relating to education/work (completing high school, college attendance, working >/= 10 hours a week), reduced problem behavior (gang membership, hurting others in physical fights, risk taking), psychological well-being (heightened self-esteem, life satisfaction), and health (physical activity level, birth control use). However, effects of exposure to individual and environmental risk factors generally were larger in magnitude than protective effects associated with mentoring. CONCLUSIONS: These findings suggest a broad and multifaceted impact of mentoring relationships on adolescent health. However, mentoring relationships alone are not enough to meet the needs of at-risk youths and therefore should be incorporated into more comprehensive interventions.     

Patterns in preventive behaviour: a study of women in middle age

There has been little comparative research to discover if the same people take part in different preventive health programmes. The study described here examines if the same women carry out seven different types of preventive health behaviour and attempts to identify ways of characterising participants or non-participants in the various forms of behaviour. The results show that the probability of women who carry out one type of preventive health behaviour carrying out another was low. However, the one factor that distinguished between participation and non-participation in various forms of preventive health behaviour was social class. The need to develop a model of health behaviour which accommodates both general structural factors and specific beliefs and circumstances is recommended.     

Functional health literacy and health-promoting behaviour in a national sample of British adults

OBJECTIVES: To measure the prevalence of limited functional health literacy in the UK, and examine associations with health behaviours and self-rated health. DESIGN: Psychometric testing using a British version of the Test of Functional Health Literacy in Adults (TOFHLA) in a population sample of adults. SETTING: UK-wide interview survey (excluding Northern Ireland and the Scottish Isles). PARTICIPANTS: 759 adults (439 women, 320 men) aged 18-90 years (mean age _ 47.6 years) selected using random location sampling. MAIN OUTCOME MEASURES: Functional health literacy, self-rated health, fruit and vegetable consumption, physical exercise and smoking. RESULTS: We found that 11.4% of participants had either marginal or inadequate health literacy. Multivariable logistic regression analysis indicated that the risk of having limitations in health literacy increased with age (adjusted odds ratio 1.04; 95% confidence interval 1.02 to 1.06), being male (odds ratio _ 2.04; 95% confidence interval 1.16 to 3.55), low educational attainment (odds ratio _ 7.46; 95% confidence interval 3.35 to 16.58) and low income (odds ratio _ 5.94; 95% confidence interval 1.87 to 18.89). In a second multivariable logistic regression analysis, every point higher on the health literacy scale increased the likelihood of eating at least five portions of fruit and vegetables a day (odds ratio _ 1.02; 95% confidence interval 1.003 to 1.03), being a non-smoker (odds ratio _ 1.02; 95% confidence interval 1.0003 to 1.03) and having good self-rated health (odds ratio _ 1.02; 95% confidence interval 1.01 to 1.04), independently of age, education, gender, ethnicity and income. CONCLUSIONS: The results encourage efforts to monitor health literacy in the British population and examine associations with engagement with preventative health behaviours.     

Mental health literacy as a function of remoteness of residence: an Australian national study

Background

Although there have been many population studies of mental health literacy, little is known about the mental health literacy of people who reside in rural areas. This study sought to determine the impact of remoteness on public knowledge of depression and schizophrenia.

Methods

The mental health literacy of residents of major cities, inner regional, and outer-remote (including outer regional, remote, and very remote) regions were compared using data from a 2003–04 Australian national survey of the mental health literacy of 3998 adults. Measures included the perceived helpfulness of a range of professionals, non-professionals and interventions, and the causes, prognosis, and outcomes after treatment for four case vignettes describing depression, depression with suicidal ideation, early schizophrenia and chronic schizophrenia. Participant awareness of Australia's national depression initiative and depression in the media, their symptoms of depression and exposure to the conditions depicted in the vignettes were also compared.

Results

Mental health literacy was similar across remoteness categories. However, inner regional residents showed superior identification of the disorders depicted in the suicidal ideation and chronic schizophrenia vignettes. They were also more likely to report having heard of Australia's national depression health promotion campaign. Conversely, they were less likely than major city residents to rate the evidence-based treatment of psychotherapy helpful for depression. Both inner regional and outer-remote residents were less likely to rate psychologists as helpful for depression alone. The rural groups were more likely to rate the non-evidence based interventions of drinking and painkillers as helpful for a depression vignette. In addition, outer-remote residents were more likely to identify the evidence based treatment of antipsychotics as harmful for early schizophrenia and less likely to endorse psychiatrists, psychologists, social workers and general practitioners as helpful for the condition.

Conclusion

Mental health awareness campaigns in rural and remote regions may be most appropriately focused on communicating which interventions are effective for depression and schizophrenia and which mental health and other professionals are trained in the best-practice delivery and management of these. There is also a need to communicate to rural residents that alcohol and pain relievers are not an effective solution for depression.     

Evaluating quality and health system performance from an international perspective

The Commonwealth Fund's International Working Group on Quality Indicators has brought together representatives from Australia, Canada, New Zealand, the United States, and the United Kingdom to look at which indicators could help benchmark and compare health system performance.     

建设项目预防性卫生审核质量评价指标量化研究

目的确立建设项目预防性卫生审核质量评价指标体系中三级指标的评分细则。方法系统采用专家咨询、焦点组访谈和实证研究等方法。结果确立了18个三级指标的指标说明和评分细则。结论指标说明和评分细则具有全面性、可操作性,为建设项目预防性卫生审核质量评价提供依据。     

建设项目预防性卫生审核文书质量评价指标体系研究

目的建立建设项目预防性卫生审核文书质量评价指标体系;方法在课题组积累资料的基础上,运用德尔菲法,小组讨论法确定并完善指标体系并确立指标权重;结果建立了包含4个一级指标、7个二级指标和18个三级指标以及对应的三级指标说明的较为完善的文书质量评价指标体系;结论通过回收率、变异系数、专家权威度等指标值可知德尔菲法的实施效果较好,证明指标体系的建立科学合理。     

Evaluating the importance of information sources for preventive health care in rural Australia

Abstract: Health promotion and prevention are critical elements of public health programs designed to improve health status and extend life chances. The pattern of mortality and morbidity in rural Australia suggests a particularly important role for health promotion and preventive measures in country areas. However, the importance of preventive health measures and how people access health-related information is not well understood. This study examines which sources of health-related information are most valued by rural residents and whether the importance attributed to different sources varies according to age, sex and geographic location. The results demonstrate the overwhelming importance of the general practitioner and pharmacist in provision of preventive health information for all rural people. There is a need to ensure that the work carried out by all those involved with health promotion is closely integrated with that of rural general practitioners.     

Risk of school failure as an early indicator of other health risk behaviour in American high school students

The present study assesses the value of educational risk factors as indicators of other risk behaviour in the adolescent age group. The authors analyzed anonymous questionnaire data from 6224 school-based adolescents collected in a Midwest state in the US in 1989. Seven behaviours were labeled 'educational risks' impacting on students' classroom behaviour and/or performance (that is skipping school, alcohol or marijuana use during school hours, purchasing alcohol or drugs on campus). The statistical analyses examined the relationship between educational risks and health risks such as delinquency and sexual activity. The findings suggest that health risk exposure increases with increased educational risk. In addition, educational risk behaviours are a significant predictor of experience of other health risk behaviours when grade level, gender, ethnicity, and average grades are held constant. An important 'window of opportunity' may exist in the school setting facilitating early identification and intervention with at risk youth.     

Long-term health correlates of timing of sexual debut: results from a national US study

Objectives. We explored long-term health consequences of age at sexual initiation and of abstinence until marriage to evaluate empirical support for the claim that postponing sexual initiation has beneficial health effects.Methods. We analyzed data from the 1996 National Sexual Health Survey, a cross-sectional study of the US adult population. We compared sexual health outcomes among individuals who had initiated sexual activity at an early or late age versus a normative age. We also compared individuals whose first sexual intercourse had occurred before versus after marriage.Results. Early initiation of sexual intercourse was associated with various sexual risk factors, including increased numbers of sexual partners and recent sexual intercourse under the influence of alcohol, whereas late initiation was associated with fewer risk factors. However, both early and late initiation were associated with sexual problems such as problems with arousal and orgasm, primarily among men. Relationship solidity and sexual relationship satisfaction were not associated with early or late initiation.Conclusions. Early sexual debut is associated with certain long-term negative sexual health outcomes, including increased sexual risk behaviors and problems in sexual functioning. Late initiation was also associated with sexual problems, especially among men. Further research is needed to understand how sexual initiation patterns affect later health outcomes.Adolescent sexual activity has various adverse public health consequences1^–5 that disproportionately affect adolescents from racial/ehtnic minority groups.1^,6^,7 In the United States, adolescent pregnancy rates have declined in recent years,8 but adolescents still account for the highest age-specific proportion of unintended pregnancies,2 with higher rates among African Americans and Latinas than among White women.7Moreover, although rates of certain sexually transmitted infections (STIs) have fallen dramatically,9 age-specific risks for many STIs continue to be highest among adolescents.1 For example, almost half of the estimated 18.9 million STIs reported in 2000 in the United States affected adolescents and young adults.10 Race/ethnicity is a factor as well; rates of gonorrhea and chlamydia among African American and Latino youths are 2 to 7 times higher than are rates among White youths.1 The United States ranks highest among developed countries in terms of both sexual health risks (e.g., nonuse of contraception) and undesirable outcomes (e.g., adolescent pregnancy).11 In addition, Bramlett and Mosher12 showed that the high US divorce rate (in comparison with rates in other developed countries)13 is associated with premarital sexual activity (corrected for the fact that the United States also has the highest marriage rate).Driven by concerns regarding these serious health risks as well as by the conservative belief that expression of sexuality is acceptable only in marriage, promotion of sexual abstinence until marriage has become the cornerstone of US domestic and global policies.4 According to federal guidelines, abstinence-only education should provide adolescents with knowledge about the presumed social, psychological, and health gains to be realized by abstaining from sexual activity. Abstinence-only education has been criticized on multiple grounds, including the promotion of ideas that are not scientifically grounded.4 Beyond government policy, abstinence-only education is part of a broader social movement among conservative Christian groups.14Proponents of abstinence-only education suggest that delaying sexual initiation has beneficial effects in terms of future marital relationship quality and sexual health, whereas initiation of sexual intercourse during adolescence causes later physical and psychological problems, including depression and marriage-related difficulties.4^,15 As part of the DHSS campaign (see http://www.4parents.gov), adolescents are informed about the supposed positive outcomes of postponing sexual activity until marriage, including increased likelihood of “better sex” once married and of a more trusting marriage and decreased likelihood of divorce. Although indeed in theory abstinence is the only certain way to avoid STIs and unintended pregnancies, delaying initiation of sexual activity may also create health risks by impeding development of the emotional, cognitive, and interpersonal skills that are crucial to satisfactory sexual functioning and general well-being.16^,17Very little is actually known about the long-term risks and benefits of abstinence intentions, virginity pledges, or early or late initiation in the context of consensual sexual experiences; however, numerous studies have documented long-term adverse outcomes of sexual abuse, including sexual risk behaviors.18^–28 Some research seems to suggest that early initiation of sexual activity is associated with continuing risk of STIs, HIV, and unintended pregnancy.26^,29^–31 These associations are mediated by number of sexual partners, STI history, alcohol and drug use related to sexual behavior, and partners’ number of sexual partners.5^,32 However, the results of a longitudinal study in which biological STI testing33 was used suggest that initial STI risk related to early onset of sexual intercourse is not persistent.Very few studies have assessed long-term outcomes other than STIs. Examining data from the National Longitudinal Study of Youth, Finger et al.34 found that virginity at age 18 years was positively associated with financial net worth and negatively associated with health problems and use of welfare benefits among women. Both men and women who had been virgins at age 18 years had a higher average level of education and were less likely to have been divorced. Current level of happiness did not differ between those who had been virgins at age 18 years and those who had not. Hallfors et al.35 found that, among women, substance use, sexual experimentation, and history of multiple sexual partners predicted depression 1 year later.As demonstrated in a study conducted by Else-Quest et al.,36 the specific contexts in which initial sexual experiences occur seem to be an important factor in later health outcomes. Using data from the National Health and Social Life Survey,37^,38 a cross-sectional investigation involving 3432 men and women aged 18 to 59 years, these researchers showed that long-term outcomes are determined more by whether initial sexual intercourse occurred in a negative context (e.g., forced intercourse, peer pressure) than by the timing of the experience. Individuals whose first sexual intercourse had occurred in such negative contexts were more likely to have sexual problems and sexual guilt, to be in poor health, to have an STI, and to have reduced life satisfaction.Else-Quest et al. found that, when participants with coercive experiences were excluded, early sexual debut was associated with slightly poorer health, more STIs, slightly poorer life satisfaction, and lower levels of sexual guilt. Sexual problems, such as inability to experience orgasm and experience of pain during intercourse, were not associated with early sexual debut. Causal inferences cannot be made from this study because of the correlational nature of the data. Furthermore, several other factors (e.g., race/ethnicity, sexual socialization, and personality factors) that were not controlled may have biased the relationships observed.Our goal was to explore the adult correlates of early or late sexual initiation and, in so doing, contribute to establishing sexual health policies aimed at adolescents. We chose to conduct a secondary analysis of data from the National Sexual Health Survey because this data set contains information on respondents’ initial sexual experiences, their current sexual behavior and STI risk, and indicators of healthy sexual functioning. We hypothesized that early or late initiation of sexual activity relative to their peers sets young people apart and thus may result in long-term negative health outcomes. Because of the political emphasis on abstinence until marriage, we also compared individuals whose first sexual intercourse occurred after marriage with those whose first experience occurred before marriage.     

Theoretical issues concerning the relationship between perceived control and preventive health behaviour

The relationship between perceptions of control and preventivehealth behaviour (PHB) has a longstanding tradition in healtheducation theory. However, few studies have found a strong empiricalrelationship between perceived control and PHB. Possible reasonsfor this are: (1) the use of generalized as opposed to specificmeasures of control and (2) the existence of other importantfactors which influence PHB. Furthermore, most of the modelswhich attempt to predict PHB fail to adequately account forthe social structural factors affecting health behaviours. Thispaper examines these issues and argues for more condition-specificmeasures of control and the need to identify other importantinfluences on health behaviour. The example of exercise levelsamong blue collar workers demonstrates how objective conditionscan affect both perception of control and PHB.     

Domestic gardens and self-reported health: a national population study

Background

There is a growing recognition of the health benefits of the natural environment. Whilst domestic gardens account for a significant proportion of greenspace in urban areas, few studies, and no population level studies, have investigated their potential health benefits. With gardens offering immediate interaction with nature on our doorsteps, we hypothesise that garden size will affect general health—with smaller domestic gardens associated with poorer health.

Methods

A small area ecological design was undertaken using two separate analyses based on data from the 2001 and 2011 UK census. The urban population of England was classified into ‘quintiles’ based on deprivation (Index of Multiple Deprivation) and average garden size (Generalised Land Use Database). Self-reported general health was obtained from the UK population census. We controlled for greenspace exposure, population density, air pollution, house prices, smoking, and geographic location. Models were stratified to explore the associations.

Results

Smaller domestic gardens were associated with a higher prevalence of self-reported poor health. The adjusted prevalence ratio of poor self-reported general health for the quintile with smallest average garden size was 1.13 (95% CI 1.12–1.14) relative to the quintile with the largest gardens. Additionally, the analysis suggested that income-related inequalities in health were greater in areas with smaller gardens. The adjusted prevalence ratio for poor self-reported general health for the most income deprived quintile compared against the least deprived was 1.72 (95% CI 1.64–1.79) in the areas with the smallest gardens, compared to 1.31 (95% CI 1.21–1.42) in areas with the largest gardens.

Conclusions

Residents of areas with small domestic gardens have the highest levels of poor health/health inequality related to income deprivation. Although causality needs to be confirmed, the implications for new housing are that adequate garden sizes may be an important means of reducing socioeconomic health inequalities. These findings suggest that the trend for continued urban densification and new housing with minimal gardens could have adverse impacts on health.