Helping people change--an ethical approach?

This paper is a normative analysis of an empowerment approachin health promotion. In particular it utilizes two increasinglyinfluential idioms of normative analysis (analytic health careethics and Foucauldian analysis) to evaluate the ethics of ‘helpingpeople change’. The HEA pack entitled ‘Helping PeopleChange’ (HPC) is used as an exemplary case study and asa starting point for analysis; but the implications are intendedto be more wide ranging and the purpose of the analysis is two-fold.First, ethical discussion is presented as an important dimensionof the substantive evaluation of HPC-type interventions (i.e.interventions which emphasize support for voluntary change).Second, it is presented as a means of comparing and contrastingthe role of the two normative idioms in such ethical evaluation.The aims and the underlying rationale of the HPC pack are setout. Analytic health care ethics is represented by the well-known‘four principles’ approach and the longest sectionof the paper applies each of these principles in turn (beneficence,non-maleficence, autonomy and justice) to the HPC pack. It isargued that for each principle there are ethical difficultiesattaching to HPC-type interventions. This is (albeit superficially)paradoxical given that such interventions are arguably exemplaryand are self-consciously ‘ethical’. It is here thata Foucauldian perspective presents a sharp contrast. Accordingto such a perspective, it is argued, the idea of helping peoplechange is ‘obviously’ questionable. This is becauseFoucauldian analysis centres around the intimate links betweenempowerment, control and ‘the creation of subjects’.Finally, some of the other contrasts between, and the potentialcomplementarity of, the two normative perspectives are brieflyreviewed.     

Who gets what: politics, evidence, and health promotion

Science journal, starting with its July 2005 issue, presentsits readers with 125 questions and problems yet to be resolvedby the scientific community. These range from the deceptivelysimple (‘what is the structure of water?’), theobvious (‘what triggers puberty?’ or ‘whatare the roots of human culture?’), to the amazingly esoteric(‘do mathematically interesting zero-value solutions ofthe Riemann zeta function all have the form of a+bi?’). More than half of these issues have     

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.     

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.     

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.     

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.     

ERRATUM

The title of the editorial in the Journal of the Society forOccupational Medicine, 25, p. 1 should have been ‘ A HopefulProspect ’. Page 34, line 6 in the paragraph ‘ ScientificMeetings ’ should have read ‘ The Provincial Meetingwas held in York ’.     

The role of health education versus safety regulations in generating skin cancer preventive behavior among outdoor workers in Israel: an exploratory photosurvey

The present photosurvey corroborated with our 1995–1997evaluation study of a multifaceted skin cancer control programamong outdoor workers of Mekorot—Israel National WaterCompany (Shani et al., 1998, Final Research Report presentedto the Committee for Research and Prevention in OccupationalSafety and Health). While the survey's primary purpose was toinvestigate the impact of health education versus sun-protectionregulations (issued when the project ended) on workers' skincancer preventive behavior (SCPB), it also experimented with‘objective’ tools of data collection. Visiting workingsites and mother-base, 118 workers were approached. Of these,51 former program-involved workers (‘education’group) and 50 former non-participants (technical barriers),and newly recruited ones (‘regulation’ group) whofilled out a one-page questionnaire, had their photographs takenand were measured (spectrophotometer) for melanin presence,were included in the present study. Findings indicated thatparticipants in the ‘regulation’ group had a significantlylower mean years of seniority and a higher number of workersin semi-skilled occupations. Both groups were identical in age,ethnic origin and reported skin type. Consistent and significantbetween-group differences were observed in the SCPB and melaninpresence mean scores, suggesting better SCPB habits among the‘education’ group employees in comparison to theircounterparts. The multiple regression analysis indicated thatformer program-involved participants and older workers weresignificantly more likely than others to comply with desiredSCPB practices. Combined, our previous and present findingssuggest that the educational approach was indispensable forgenerating and sustaining long-term skin cancer control practicesand was preferable to the use of regulations, per se. Thoughno final conclusions could be drawn regarding the validity ofthe spectrophotometer- and camera-related procedures, and bothare limited with regard to uncovering the motivational factorsof behavioral outcomes, it should be recognized that the camerais a low-cost and easily available tool for capturing ‘reality’while overcoming management's claims on workers' time. Resultsare also discussed in terms of practical implications.     

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.     

ERRATUM

In the article by A. L. Morgan ‘Cholinesterase Problemsarising in a Plant Manufacturing Tri-aryl Phosphates’(Journal of the Society of Occupational Medicine 31, 119–122)on p. 120, the first sentence of Case 1 should read ‘Thisindividual had three split blood samples examined.’     

MISSED 'PSYCHIATRIC' CASES? THE EFFECTIVENESS OF A COURT DIVERSION SCHEME

Court Diversion Schemes have been evaluated in terms of clinicaloutcome or case disposal in studies focusing on individualswho are referred to the scheme. Little is known about the ‘psychiatriccaseness’ of court defendants not referred. The presentstudy was undertaken with the aims of identifying levels of‘missed caseness’ in an ‘in-custody’population at a busy London Magistrates court and to considerhow such populations might be more effectively screened. A randomsample of individuals in custody was selected and semi-structuredinterviews conducted (n = 100). Very high levels of alcoholabuse, illicit drug misuse and histories of deliberate self-harmwere found. Such individuals were very unlikely to be referredto the duty psychiatrist scheme. These findings highlight thedifficulties in screening for alcohol abuse, illicit drug misuseand histories of deliberate self-harm in an in-custody courtpopulation. The context in which screening takes place is discussed.Realistic and inexpensive improvements are suggested for identifyingthose at greatest risk.     

erratum

JOURNAL OF THE SOCIETY OF OCCUPATIONAL MEDICINE, 24, 87 and88. Table I and Table II were transposed. 81, the first sentenceunder Treatment with.Calcium Gel should have read: ‘Klauderet al. (1955) reported the successful treatment of a late hydrofluoricacid burn by topical 5 per cent calcium gluconate in wool fatcombined with calcium gluconate intravenously’. 84, column1, line 8, ‘articles’ should have read article.     

Laboratory-based Evaluation of the Protection Provided Against Cold Water by Two Helicopter Passenger Suits

The thermal protection provided by two helicopter passengerimmersion suits was evaluated. Suit A was a standard ‘dry’suit and suit B was a ‘dry’ suit with inherent insulationprovided by inflation of the outer shell of the suit. Duringfour hour immersions in water at 4°C with simulated rain,wind and waves, suit B provided significantly (p < 0.01)better protection against the long-term effects of immersionthan suit A. The skin and core temperature of subjects fellat slower rates over the immersion period when they wore SuitB, they shivered less, had lower heart rates and were more comfortablein this suit. The problems of testing and selecting appropriateimmersion suits are discussed and it is concluded that testsof immersion suits should be as realistic as possible and, whenthis is so, ‘dry’ suits with inherent insulationwhich is unaffected by leakage are likely to perform betterin cold water than those without such insulation. Requests for reprints should be addressed to: M. J. Tipton, Institute of Naval Medicine, Gosport, Hampshire, UK     

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     

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.     

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     

ERRATUM

The Journal of the Society of Occupational Medicine, 27, 53,second column, contains eight lines of text which should haveappeared on 70–71. 53, second column. The section Complaints in General shouldhave ended (second paragraph, lines 8–9) with the sentence:‘This pattern is present in the experiences of both "old"and "new" employees.’ The text should then continue withthe section Complaints about Slow Work, appearing on 55. 70–71. The final paragraph of the section Finance on 70(bottomof second column) should have been completed by matter appearingat the end of the section Complaints in General on 53 (secondparagraph, lines 9–12) so as to read: ‘Staff salariesare related to the appropriate scales recommended by the BritishMedical Association and the Royal College of Nursing. Despitethe distances involved, transport costs are not unduly high(total of 5.5 per cent)’. The Finance section should befollowed by the section The Future, the heading and first paragraphof which appear at the bottom of 53, second column; this sectioncontinues on 71, first column, paragraph beginning: Furtheremphasis is given by the actions of government and by decisionsin court and settlements out of it'.The headline on 71 shouldread: ‘East of Scotland OHS’. The publishers much regret these errors, which have been correctedon the reprints of the articles concerned.     

Doctors, their mental health and capacity for work

Background Information about doctors’ mental ill-healthis limited. This study looks at doctors’ careers followingmental illness and the strategies that helped them return towork. Aim To examine the effect of mental ill-health on doctors’careers. Methods Questionnaire survey of members of the Doctors SupportNetwork (DSN). The DSN is a peer support group for doctors whohave experienced, or are experiencing, mental ill-health. Results One hundred and sixteen doctors (35% response rate)returned completed questionnaires (n = 116, 63% female, 37%male). Prior to their ill-health, 80% worked full time, 15%part-time, 2% were not working and 3% were medical students.Following illness, 33% worked full time (P < 0.05), 36% part-time(P < 0.05) and 29% were not working (P < 0.01). Flexibleworking practices were the most helpful reported strategy forenabling a doctor to return to work. Conclusions Following mental ill-health, a doctor’s capacityto work full time is reduced. Most doctors return to full-timeor part-time work. With improved support, more doctors may beable to return to work.     

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.