Addressing the costs of quitting' smoking: a health promotion issue for adolescent girls in Canada

While intense efforts have been implemented to address the problemof cigarette smoking, the prevalence of tobacco use among adolescents,in particular young women, remains high. Older adolescent girlsare joining their younger counterparts in taking up the smokinghabit. The literature has examined the reasons for young peoplestarting to smoke; however, little is known about the smokingcessation process in adolescents. This paper reports findingsfrom an in-depth qualitative study of 25 girls ages 18 and 19which uncovered the struggles young women experience as theyattempt to quit smoking. These struggles and losses are referredto as the ‘costs’ of quitting smoking. The ‘costs’reflect not only their ‘real’ experiences when attemptingto quit smoking, but also reflect ‘anticipated’struggles and losses. The study addressed the ‘costs’in relation to the social, emotional and physiological domainsof the adolescent girl's life. Findings from this research projectprovide theoretical direction for the development of comprehensivehealth promotion interventions. If health care professionalsare to assist in reducing cigarette smoking among young women,the ‘costs’ which girls see to quitting smokingmust be considered.     

Images of contracting for the mental health service

Research into the development of contracts for mental healthservices with 12 localities in the Northern Regional HealthAuthority was conducted in 1990/91. Purchasers and providersin each locality negotiated a specific contract for the firstyear of the reforms introduced in ‘Working for Patients’.From this exercise three images of the contracting process weredeveloped to describe the variety of attitudes to the new systemamong local managers and professional staff. These images, ‘businessas usual’, ‘competitive bidding’ and ‘collaborativecommissioning’, are described and their relevance to theanalysis of policy implementation discussed.     

Uncertainty and lack of trust with Parkinson's disease

‘Uncertainty’ is frequently observed in researchon the chronically III. The present research confirms this finding.In 20 out of 23 life stories of men and women diagnosed as havingParkinson's disease for more than 3 years, indications of uncertaintycould be found. The research question is whether a specificexplanation for this uncertainty can be found in the life stories.One such explanation, a condition and a specification were detected.In 12 of the 20 life stories in which the informants speak ofuncertainty, a specific and differentiated context of the uncertaintywas found: ‘a problem of trust’, located in thecapacities of ‘the body’, in ‘themselves’and in ‘the world outside the home’. These relatedtrust problems are presented by the informants as explanationsfor their uncertainty. Two conditions for the trust problemwere presented by the informants: ‘declining naturalness’and ‘unpredictability’ of the functioning of thebody. The explanation could also be specified. The trust problemis located socially. The Interpretations of trust are primarilysituated in ‘the world outside the home’.     

Sticks or carrots: The challenge of implementing a management development strategy in the new NHS

The National Health Service (NHS) is involved in a process offundamental change, with a shift towards devolved responsibilitiesand the establishment of a form of internal market. The challengesof designing and implementing a national management developmentstrategy in such a situation are discussed. A brief examinationof the strategy Itself illustrates the move away from a ‘top-down’approach. In contrast to an earlier strategy, no major nationalprogrammes are proposed. The emphasis is on a ‘nationalframework’ supporting a ‘local relationship betweenindividual and manager’. A number of mechanisms for implementation,measurement and monitoring are analysed: the most promisingin the circumstances is considered to be some kind of accreditationsystem.     

A critical analysis of different leadership approaches to community health work in Kirseberg, Sweden

This paper examines some dilemmas of both professional and communityled approaches in health promotion with reference to an alcoholreduction programme implemented in Kirseberg, Sweden. A ‘traditional’health education programmed designed at changing life-stylehabits was combined with a community action design. The processby which the public health messages were sent to and receivedby the residents was explored in a qualitative study. The study focused on the possibly contradictory relationshipbetween the ‘professional’ concept of public healthand individuals' personal concepts of health. it is argued thatif the ‘top down’ and ‘bottom up’ approachesare combined without detailed consideration being given to thepossible connecting links the risk is that the result will bethe operation of two parallel strategies which do not interact. The process of making health a collective issue within a communityaction programme is illustrated with examples from the Kirsebergproject and discussed with reference to the chief aim of achievingequity in health provision.     

'Well-being': health promotion's red herring

‘Well-being’ is frequently said to be the ultimategoal of health promotion. However, health promotion author itiesdo no: offer a clear definition of ‘well-being’.Instead health promoters either assume a causal relationshipbetween their activities and the increase of ‘well-being’or claim privileged knowledge of ‘well-being’ andits means of production, or both. These health promotion strategiesare questioned, and it is suggested that the use of ‘well-being’in health promotion acts to obscure the analysis of health promotionphilosophy and practice. It is concluded that either the term‘well-being’ should be given clear and substantialcontent, or it should be discarded by health promoters. Thelatter option is favoured.     

A quality management model for integrated care: results of a Delphi and Concept Mapping study

Objective. The objective of this study is to identify the elements andclusters of a quality management model for integrated care. Design. In order to develop the model a combination of three methodswere applied. A literature study was conducted to identify elementsof integrated care. In a Delphi study experts commented andprioritized 175 elements in three rounds. During a half-a-daysession with the expert panel, Concept Mapping was used to clusterthe elements, position them on a map and analyse their content.Multi-dimensional statistical analyses were applied to designthe model. Participants. Thirty-one experts, with an average of 8.9 years of experienceworking in research, managing improvement projects or runningintegrated care programmes. Results. The literature study resulted in 101 elements of integratedcare. Based on criteria for inclusion and exclusion, 89 uniqueelements were determined after the three Delphi rounds. By usingConcept Mapping the 89 elements were grouped into nine clusters.The clusters were labelled as: ‘Quality care’, ‘Performancemanagement’, ‘Interprofessional teamwork’,‘Delivery system’, ‘Roles and tasks’,‘Patient-centeredness’, ‘Commitment’,‘Transparent entrepreneurship’ and ‘Result-focusedlearning’. Conclusion. The identified elements and clusters provide a basis for a comprehensivequality management model for integrated care. This model differsfrom other quality management models with respect to its generalapproach to multiple patient categories, its broad definitionof integrated care and its specification into nine differentclusters. The model furthermore accentuates conditions for effectivecollaboration such as commitment, clear roles and tasks andentrepreneurship. The model could serve evaluation and improvementpurposes in integrated care practice. To improve external validity,replication of the study in other countries is recommended.     

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.     

Which way to sustainability? External support to health projects in developing countries

The purpose of this paper is to analyse the process by whichdonors decide whether or not to support specific primary healthcare projects. First of all, there has to be an ‘eligiblesituation’: an inability to start without external support,coupled with an ability to sustain the project (without suchsupport) once it has started. Secondly there must an ‘eligibleproject’, that is, a project that requires support ofa ‘one-time-only’ nature (for example, capital outlay);or recurrent support to temporary activities (such as salariesfor a temporary campaign), or temporary support to recurrentactivities (for the initial stages of innovative programmes).Proposals for really innovative programmes are seldom readilyavailable, and the most appropriate form of support may thenbe to support an institution charged with the development ofsuch innovative programmes.     

Capturing the meaning of 'community' in community intervention evaluation: some contributions from community psychology

Evaluations of community health promotion can underestimatethe gains that an intervention might make in a community ifthe outcomes reported are limited to aggregates of changes inhealth behaviour or attitude made at an individual level Thenotion of ‘community’ revealed by this type of evaluationis relatively unsophisticated compared to the ‘community’rhetoric which often accompanies program definition. Even thoseevaluations which report policy changes or evaluations of howcommunities became involved, often fail to capture the improvementsa community intervention can make on the problem-solving capacitiesof a community and its competence in tackling the issues whichface it. The essence of what some interventions (intentionallyor unintentionally) achieve is, therefore, missed. Empowerment is usually described as a process. But it can beconsidered as an outcome variable in community interventionsif capacity-building is a major activity of an intervention.To capture this in the evaluation design, evaluators shouldbe using active strategies to (i) articulate what empowermentactually means and (ii) challenge what intervention successreally means in interactive dialogues with program workers andthe community. Active and interactive strategies must be usedto clarify program values and intentions because evaluatorswill be misled or confused by words like ‘community involvement’,‘community development’ or ‘community participation’in program documents. These words mean different things to differentgroups. Similarly, ‘empowerment’ must be translatedinto aspects which are recognisable within the life of the programor period of interest. Community psychology is introduced in this paper as a fieldwhich may have much to offer in this analysis. Community psychologyis a field within psychology which should be distinguished fromthe more traditional approaches in community-based health promotionwhich are the legacy of behavioural health psychology.     

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’.     

PERCEPTIONS OF DRINKERS AND ABSTAINERS IN A SAMPLE OF SCOTTISH ADULTS

Following Davies and Stacey's investigation (1972, Teenagersand Alcohol, HMSO, London) into perceptions of drinking andabstaining among Scottish teenagers, this study extended theirgeneral method to an investigation of the perceptions of 239Scottish adults. Results showed that the stereotypes of theheavy drinker as ‘tough and rebellious’ and theabstainer as ‘weak and cissy’ persist into adulthood.Heavy drinkers were seen as low on ‘sociability’and ‘sexual attractiveness’ and abstainers wereseen as less ‘sociable’ than moderate drinkers.There was also some evidence of a ‘double standard’in perceptions of male and female drinking roles. Other findingsconcerning the effects on perceptions of subjects sex and drinkingbehaviour are compared to those reported in the earlier studyand implications for the treatment of alcohol problems are discussed.It is concluded that the dimensions described by Davies andStacey represent a relatively stable structure within futureresearch where fresh initiatives in alcohol education may belocated.     

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.     

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.     

Focus Groups: a Method for Developing Consensus Guidelines in General Practice

The measurement of quality in any clinical discipline depends,in part, on a comparison with an accepted standard. Currently,such standards do not exist for the management of many commonclinical situations in Australian general practice. As partof the General Practice Evaluation Programme, a group of Illawarrageneral practitioners (GPs) selected ‘GP management ofthe menopause and asthma’ for in-depth study, and wereable to arrive at a consensus on ‘principles of practice’and ‘minimal acceptable care’ for these conditionsthrough a series of focus (research) group meetings. However,the process by which these standards were derived was felt,of itself, to be a valuable means of: (i) reducing professionalisolation; (ii) promoting quality assurance; (iii) introducingpeer review; (iv) introducing clinical audit; and (v) providingmeaningful and targeted continuing medical education appropriateto Australian general practice. This paper describes the focusgroup methodology used in this process.     

Health education and the ideology of health promotion: a review of alternative approaches

This paper discusses various approaches to the definition of‘health promotion’ and examines the role of theWorld Health Organization in its popularization. Health promotionis conceptualized as any deliberate intervention which seeksto promote health and prevent disease and disability. It incorporates‘health education’ and gives prominence to the influenceof legal, fiscal, economic and environmental measures on communityhealth. Various ‘models’ of health education areexplored and their contribution to health promotion is discussed.It is argued that ‘selfempowerment’ should be themain focus for health education programmes.     

Strategies, guidelines, policies and standards: the search for direction in community health promotion

In this paper, the authors respond on behalf ofa panel representingthe American Public Health Association in the USA to criticismsfrom Canada (by Higgins and Green, two health education researchersfrom British Columbia) regarding the relevance and adequacyof a set of criteria developed in the USA for guiding the developmentof health promotion programs in other developed countries, suchas Canada. The US criteria included a specific focus on riskfactors of disease or untoword health conditions, the characteristicsof an intervention's target group(s), the appropriateness ofan interivention for a given target group or socio-culturalsituation, the optimum use of available resources, and the abilityto evaluate intervention effects. The Canadian criticisms were that these criteria do not allowforor give proper appreciation to the process through which communitiescoalesce around specific problems or issues of importance to‘health’, and there is strong exception taken tothe focus by US groups on ‘risk factor reduction’.There is a preference among Canadians for the tenn ‘riskcondition’, which is defined as ‘local conditionshaving an impact on the health of neighborhoods’. Through a series of case illustrations, the Canadian authorsattempt to show the narrowness of the US criteria, thereforearguing for a broader set of criteria which would allow fora programatic focus on community-based health problems whichare not ‘"carefully deflned measureable, modifiable" riskfac tors’. In response, the authors of this paper argue that their Canadiancritics have misinterpreted the purpose and utility of the APHAguidelines, therefore over-interpreting the implications ofthese criteria for the specific Canadian community health promotioninitiatives they hoped to evaluate. The conclusion reached isthat the APHA criteria continue to represent a useful approachto guiding the consideration of pos sible health promotion investmentson the part of communities or organizations.     

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.     

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.     

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.