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 ’.     

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.     

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.     

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.     

'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.     

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.     

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.     

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’.     

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.     

PREVENTION OF ALCOHOL ABUSE-RELATED BIRTH EFFECTS -- I. PUBLIC EDUCATION EFFORTS

Maternal alcohol abuse during pregnancy can result in a patternof anomalies in children called ‘fetal alcohol syndrome’(FAS) and more recently, ‘fetal alcohol abuse syndrome(FAAS)’. FAAS as well as individual alcohol-related anomalies,called ‘alcohol abuse-related birth effects’ (AARBEs),are widely considered to be totally preventable, because theystem from a behaviour that is presumably modifiable. However,current strategies to reduce their occurrence are more palliativethan preventive, because their underlying premise, viz, thatraising public awareness of the potential dangers of commonlyused substances such as alcohol is enough to reduce their use,lacks empirical support. Moreover, in some cases they are alsocounter-productive. After considenng the relevant literature,this review contends that ‘universal’ public educationefforts will only be effective in reducing FAAS and AARBEs ifthey focus on the cause of these disorders, which is alcoholabuse rather than the currently open-ended message that anyamount of alcohol consumption during pregnancy constitutes adanger to an unborn child. This argument lays the ground workfor an alternative and more pragmatic strategy set forth inthe following paper for preventing FAAS and AARBEs.     

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.     

Promoting school health education: examining the role of a statewide conference for school and community leaders

Improving the delivery of school health education may well belinked to the inclusion of and commitment from high-rankingdecision makers from schools and youth organizations. This studyexamined the role of a statewide school health summit in promotinghealth education among representatives from state and communityorganizations. We conducted the study in two phases: (1) developmentand testing of a measuring instrument, and (2) role examinationvia conference assessment. Overall, the measurement instrumenthelped us investigate two areas: the inclination of an individualleader of a health organization to promote organizational changesto assist school health education and the background of a participantin school health education, which affects his/her likelihoodto take action. Three factors (‘Participant Awarenessand Compatibility’, ‘Draft Plan Development’and ‘Summit Experiences and Satisfaction’) werefound to be important predictors of leaders’ ‘FutureAction’ and ‘Advocate Impact’ (P < 0.01).Future interventions targeted to influence health, educationand social service professionals’ support and adoptionof school health education should be structured to reinforcethese three variables.     

Family violence in primary care.: Stephen Amiel, Iona Heath (eds). (440 pages, {pound}32.50.) Oxford University Press, 2003. ISBN 0-19-262828-3.

I write this review in the same week that I received the ‘Summaryand Recommendations of the Victoria Climbie Inquiry’.The accompanying letter informs me that the full report wouldcost £42 to issue. The ‘Summary’ is 49 pageslong and contains 108 recommendations.     

Health education research: the problem of linkages

The idea that reality may be separated into a dichotomy is ancient,but equally ancient is the idea of the continuum. Current trendsin health education research are leading to the creation offalse dichotomies which are contrary to the best ‘spirit’of research concerned with understanding reality. The researchproblem is that of ‘linkage’. If health educationresearch continues to define reality bimodally, then it mustbe concerned with how the two ‘pieces’ relate toeach other. This paper limits its discussion to six dichotomieswhich are crucial to research in health education: (i) qualitative—quantitative,(ii) theory—method, (iii) concepts—research, (iv)knowledge/attitudes—behaviour, (v) campaign—evaluation,and (vi) individual—societal. The picture presented illustrateswhy dichotomies have been a source of difficulty in health-relatedresearch.     

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     

Genetic Epidemiology and the Future of Disease Prevention and Public Health

"As he chats with the young mother, the doctor flicks a cottonswab into the mouth of her infant son, collecting a small sampleof mucus from inside his cheek. In the back room of his office,he inserts the sample into a machine, which extracts DNA fromthe mucus cells and compares it with the genetic material ona dime-size chip. Minutes later, a computer printer begins tospit out a list of the infant's genes. Fortunately, all buta few genes are labeled ‘normal.’ It is those fewthat the doctor discusses as he explains the results to themother. ‘Your son's genetic inheritance is generally good’,he says ‘but he is somewhat predisposed to skin lesions.So starting right away, he should be protected against excessiveexposure to the sun.’ And the doctor warns, ‘hemay well be susceptible to cardiovascular disease later in life.To lessen this nsk, after about age 2, he should begin a lifelonglow-fat high fiber diet’" (1, p. 24).     

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.     

Using native riparian barriers to reduce Giardia in agricultural runoff to freshwater ecosystems

Waterway degradation in agricultural settings is caused by direct and diffuse sources of pollution. Waterway fencing focuses on reducing direct faecal contamination, but the extent to which it reduces overland surface runoff of pathogens is unknown. This study evaluated the potential of four riparian treatments to reduce Giardia in saturation excess surface runoff entering the waterway. Treatment 1 comprised exotic pasture grass and weeds that regenerated from bare soil between the fence and the waterway in the absence of cattle grazing and was compared with three others comprising monocultural plantings of New Zealand native grassland plants. Runoff experiments involving Giardia were performed after planting, both prior to and following the summer growing season. Giardia was not detected from any plot prior to cyst addition. In spring the native ‘C. secta’, ‘A. lessoniana’ and ‘C. richardii’ treatments showed significantly greater reductions in Giardia in runoff than the ‘exotic grasses’ treatment, while in autumn the ‘C. richardii’ treatment reduced Giardia more than the ‘exotic grasses/weeds’. A reduction in public health risk should follow from riparian vegetation, whether exotic or native, but with an added benefit in the case of the native tussock grass C. richardii, due to the associated lower runoff rate.     

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.     

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.