Survey of psychological health in women with infertility.

The aims of this study were to assess mental well-being in women undergoing investigation and initial management of infertility and to determine any specific factors, such as the duration or type of infertility, that might be associated with an increased risk of psychological morbidity. A postal survey was sent to 1080 women with infertility attending gynecology outpatient departments in 12 Scottish centres. The survey included the Twelve-Item General Health Questionnaire (GHQ-12) and three multi-item scales from the Short Form Health Survey Questionnaire (SF-36). The response rate was 47.4% (512/1080) of which 507 completed the GHQ-12. Of the 507 GHQ-12 responders, 32.5% had a GHQ-12 score of > or = 8/12 suggesting they were at risk of clinically significant psychological disturbance. There were no significant associations between GHQ-12 scores and duration of infertility, the presence of existing children, or the cause of infertility. GHQ-12 scores significantly increased with the number of clinic attendances and decreased as the patient's age increased. Responders scored significantly lower on all aspects of the selected SF-36 questions as compared to published population data, suggesting poorer mental health. These standardized psychological instruments suggest that approximately 32% of women in the early stages of infertility management may be at risk of developing clinically relevant mental health problems. Psychological aspects of infertility should be addressed as part of a more holistic approach to management of these patients.

Chronic pain in primary care.

Chronic pain is a very common cause of suffering, disability and economic adversity in the community. It is a complex problem that needs to be understood in a multi-dimensional way for effective management. Most research to date has been based in specialist clinics rather than in primary care, with consequently limited findings. Chronic pain differs from acute pain in that management follows a rehabilitative rather than a treatment model, though these are not mutually exclusive. Full assessment of the patient, preferably multi-disciplinary, will improve his or her outlook. Management should be holistic, rigorous in the application of conventional therapies (including analgesics and physical therapy) and ready to admit an improved understanding of psychological and social techniques. There may be a role for complementary therapies. As a large proportion of chronic pain presents only in the community, there may be a role for greater primary care input to management.

Patient satisfaction with the management of infertility.

The objective of this study was to assess patient satisfaction with the investigation and initial management of infertility. A postal questionnaire survey was carried out of 1366 women attending outpatient clinics for the investigation and initial management of infertility at 12 hospitals throughout Scotland. The response rate to the questionnaire was 59% (806/1366). Overall, 87% of responders were satisfied or very satisfied with their care but a number of deficiencies were identified. Thirty-nine per cent had never been asked to bring their partner to the clinic and 86% felt they had not been given enough help with the emotional aspects of infertility. Forty-seven per cent felt they were not given a clear plan for the future and 23% of those who had been given drug treatments reported receiving little or no information about the treatment or possible side-effects. Overall, only a third had been given any written information and 78% expressed a wish for more written information. Women ranked 'the information and explanation given' and the 'attitude of the doctor at the clinic' highly in comparison to other aspects of their care, including 'help with the emotional aspects of infertility'. In general women were satisfied with their care but improvements may be made by giving more explanation and written information and by adopting a more couple-centred approach. Where resources allow, clinics should take steps to address the emotional aspects of infertility.

Housing conditions and mental health in a disadvantaged area in Scotland.

OBJECTIVE: To examine the mental health impact of different aspects of poor housing. DESIGN: This was a post hoc analysis of data from a household interview survey. SETTING: A public sector housing estate on the outskirts of Glasgow. SUBJECTS: These comprised 114 men and 333 women aged between 17 and 65 from 451 households. MEASURES: Dependent variable: scoring > or = 5 on the 30 item general health questionnaire (GHQ30). INDEPENDENT VARIABLES: self reported data on household composition, whether ill health was a factor in the move to the current dwelling, length of time at address, household income, whether the respondent was employed, chronic illness, and 6 problems with the dwelling. RESULTS: Reporting a problem with dampness was significantly and independently associated with scores of > or = 5 on the GHQ30 after controlling for possible confounding variables. CONCLUSION: Initiatives to tackle housing dampness may be important in developing a strategy to improve mental health for the study area. More research on the mental health impact of different aspects of poor housing is required.

Measuring psychological well-being. The adapted General Well-Being Index in a primary care setting: a test of validity.

The measurement of health outcomes is central to the development of health services. Many acute and chronic illnesses and health interventions have implications for mental health. This study tests the validity of a 22 item measure of psychological well-being, the adapted general well-being index (AGWBI). A postal health survey, including the AGWBI, was sent to a 10% random sample of patients aged 16 or over drawn from the computerized list of one general practice. Two hundred and sixty-six respondents returned questionnaires (a response rate of 76%). The AGWBI was fully completed by 94% (249) of the respondents who returned their questionnaires. Only respondents who fully completed the AGWBI are included in the analysis. The AGWBI significantly discriminated people with a limiting long term illness, those reporting suffering from anxiety, depression or bad nerves, users of general practitioner services over the previous two weeks and respondents reporting taking anti-depressants, tranquillizers or sleeping tablets. It was also able to discriminate respondents with psychosocial difficulties in a small sub-sample who reported that they were in excellent health and did not have a limiting long term health problem or psychological illness. The results are broadly supportive of the validity of the AGWBI and suggest it may be appropriate for use in the evaluation of several developing areas of primary care. Further research is needed to test concurrent validity, responsiveness and to establish population norms.

Patients' perceptions of need for primary health care services: useful for priority setting?

OBJECTIVES: To assess the feasibility of using patients' perceptions of need for primary health care services to develop priorities. DESIGN: A postal survey of a random sample of 3478 patients registered with five general practices. SETTING: Lothian, Scotland. MAIN OUTCOME MEASURES: Comparison of rankings of 36 different kinds of help or advice according to (a) popularity in the sample size as a whole and in healthy and unhealthy subgroups and (b) health status (severity of need) of potential service users. RESULTS: Popularity rankings differed between the healthy and unhealthy subgroups and the whole sample. Popularity rankings were almost the inverse of rankings based on health status. The analysis identified two areas of substantial need both in terms of popularity and severity: pain management and advice about welfare benefits. CONCLUSIONS: Methodological efforts to ensure equal participation in the processes of assessing health needs and of priority setting do not in themselves promote equity. To promote equity some opinions may need to be given greater weight.

Need and demand for primary health care: a comparative survey approach.

OBJECTIVE: To develop general practice profiles of needs and demand for primary health care. DESIGN: Postal survey of a stratified random sample of 3478 people registered with five general practices. Data from a single practice were compared with data from the remaining four to identify areas of comparative need. SETTING: Five general practices in Lothian. MAIN OUTCOME MEASURES: Differences between the single practice and the comparison practices in terms of social and economic circumstances, limiting long term illness, specific ongoing conditions, minor illness or symptoms, psychosocial problems, discussion of lifestyle, associated use of services. RESULTS: Respondents from the single practice reported higher rates than those in the four comparison practices of ongoing mental health and respiratory problems and use of antidepressants, tranquillisers, or sleeping tablets. Although rates of limiting long term illness and other specific ongoing conditions were comparable, the rates of minor illness or symptoms and psychosocial difficulties were higher in the single practice. Respondents from the single practice were more likely to consult frequently, to have contacted the practice out of normal working hours, and to have discussed psychosocial difficulties with a general practitioner. For any specific ongoing condition or "minor" illness, respondents from the single practice were no more likely to consult. CONCLUSIONS: A comparative survey approach is a useful method of developing an understanding of patterns of need and demand among general practice populations. It has the potential to inform planning within individual general practices and the process of commissioning among general practices within a given area.

The need for another look at the patient in general practice satisfaction surveys.

Although patient satisfaction research has looked at the aspects of care which patients are satisfied with and at which patients are satisfied with their care, few studies have looked at which patients are satisfied with which aspects of care. A retrospective analysis of data collected from 1599 patients attending 43 GPs was undertaken to examine the way that different patient characteristics influenced responses to a 31 item survey completed at the surgery after a consultation. Information on perceived distress [as measured by the Nottingham Health Profile (NHP)] was collected from patients prior to the consultation and further information about the patient and the consultation was recorded by the doctor after the consultation. Levels of satisfaction were high, with only seven of 31 items producing more than 5% of negative responses. These seven items covered whether the waiting time was too long, whether the doctor was relaxed, whether the doctor was in a hurry, whether there was anything else the patient would have liked to talk about had there been more time, whether the doctor had said or done anything to reduce the patient's worries, whether the doctor gave the feeling that the patient's opinions were important and whether there was anything about the consultation which disappointed the patient. Age, waiting time prior to the consultation, consultation length and positive scores on the six NHP dimensions of distress were all significantly associated with responses to one or more of these seven items. Patients experiencing pain and those with emotional distress were dissatisfied with different aspects of the consultation.(ABSTRACT TRUNCATED AT 250 WORDS)

The chief scientist reports ... The Scottish general practice shadow fund-holding project--outline of an evaluation.

After the agreement in January 1989 between the Minister of Health at the Scottish Office, Mr Michael Forsyth, and six groups of General Practitioners (GPs) in the Grampian and Tayside Regions of Scotland to embark on a 'shadow fund-holding' project, the Government agreed to promote an independent evaluation of the scheme. As a result, the Department of General Practice at Edinburgh University was invited to present plans to evaluate the working of and results of the scheme. Consultations with the Minister and Health Department officials, the general practices concerned, and staff of the two Health Boards involved took place during the first three months of 1990, and an outline protocol for the evaluation was approved and funded through the Chief Scientist Organisation for a three-year period from April 1990. It was agreed by all involved that piecemeal publications of results during the period of the research would be inappropriate, but with other attempts to evaluate fund-holding now being reported elsewhere in the UK, it has been agreed that an outline of issues being explored and the methods being used would be in the general interest. This paper first outlines the principal areas in which the evaluation is being focused, then describes the general methods being used, and finally comments on some of the problems encountered with the evaluation. The project should be seen as a descriptive beginning to what may well be a period of around a decade needed to appreciate the full implications of any major change in the organisation of health service provision.

Social indicators of health needs for general practice: a simpler approach.

The ability of different measures of socioeconomic position to predict distress in a sample of general practice attenders has been examined. Perceived distress was measured using the Nottingham health profile. The measures of socioeconomic position included: social class, Jarman scores of patients' areas of residence, whether or not patients owned their own home, whether or not patients owned a car, whether or not they had been unemployed during the previous year and whether or not they had had further education. Social class data were only available for 84% of the 1075 respondents completing the Nottingham health profile. Those respondents for whom social class data were not available were significantly more likely to score positively on the social isolation, sleep and physical mobility dimensions of the Nottingham health profile. Not owning one's own home emerged as the measure of socioeconomic status that best predicted distress. The other measures of socioeconomic status that were significantly predictive of distress were not having had further education and having been unemployed during the last year. Different measures of socioeconomic position significantly predicted positive scores on different dimension of the Nottingham health profile. Although the Jarman score significantly predicted a positive score on the sleep dimension, it did not predict distress well when compared with the direct measures of disadvantage. There are simple, more direct measures of socioeconomic position than social class that could be collected routinely by practices which would form a better basis for the evaluation of services required to target those needs created by persisting social inequalities in health.(ABSTRACT TRUNCATED AT 250 WORDS)

Attitudes to medical care, the organization of work, and stress among general practitioners.

Eighty five volunteer general practitioners in Lothian region recorded clinical and contextual information on 21,000 consultations during 1987-88. During their recording sessions they reported their perceived levels of stress using a previously validated scale. Subsequently, 80 of the doctors completed a previously validated multi-dimensional scale about their attitudes to patient care. Three attitude subscales (psychological orientation, appropriateness of consultations and responsibility for decisions) correlated with processes of care previously identified as indicators of good care. The 20 doctors who scored most highly on these patient-centred scales recorded self-perceived stress in 27% of their consultations compared with 11% of the consultations of the 33 doctors who scored lowest on these scales. Among the 20 most patient-centred doctors those booking patients at eight patients per hour or more reported stress at twice as many consultations as those with a longer booking interval; doctors whose preferred working styles conflicted with their booking patterns reported stress in up to 62% of consultations. Doctors with a higher patient-centred orientation find their work more stressful. Longer booking intervals remove much of that stress, particularly when doctors' preferred style of consulting requires them to spend more time at individual consultations. Previously described work stressors offer a theoretical explanation for a problem which is important for both doctors and patients.

A measure of perceived health in evaluating general practice: the Nottingham Health Profile.

The paper describes two ways in which the Nottingham Health Profile (NHP) may be useful in evaluating general practice: it can provide useful and relevant information about the needs of patients, and can also be used to evaluate outcome by examining the relationship between changes in perceived health status before and 4 weeks after a consultation in relation to care received during that consultation. Findings are based on a sample of 1979 consulters who completed the Nottingham Health Profile prior to consultation and 732 consulters aged 16 years who also completed a Nottingham Health Profile 4 weeks after consultation. Comparisons are made according to the age, sex and illness status of the consulters, length of consultation and psychosocial care received. As a measure of need, significant differences were found in the health profile according to age, sex and illness status, length of consultation and doctors perception of the presence of relevant psychosocial issues. The only variable which was significantly related to short-term outcome was reported presence of a long term illness relevant to the consultation. The NHP is shown to have shortcomings as a measure of outcome for a cross-section of general practice consulters; it is, however, useful in demonstrating how processes of care relate to need in general practice.

Long to short consultation ratio: a proxy measure of quality of care for general practice.

Eighty five general practitioners in the Lothian region recorded information on all surgery consultations on one day in every 15 for a year. On the basis of their mean consultation times with patients the working styles of the general practitioners were described as 'faster' (n = 24), 'intermediate' (n = 40) or 'slower' (n = 21). The 21,707 consultations which they carried out over this period were defined as 'short' (five minutes or less), 'medium' (six to nine minutes) or 'long' (10 minutes or more). Independent of doctor style, 'long' consultations as against 'short' consultations were associated with the doctor: (1) dealing with more of the psychosocial problems which had been recognized and were relevant to the patient's care; (2) dealing with more of the long term health problems which had been recognized as relevant; and (3) carrying out more health promotion in the consultation. Patients also reported greater satisfaction with longer consultations. The ratio of long:short consultations was found to be 0.28:1 for 'faster' doctors as against 2.3:1 for 'slower' doctors. When doctors in either group had more heavily booked surgeries or were running late, the long:short consultation ratio fell, in some cases by over 50%. This paper suggests that the ratio of long to short consultation length for a general practitioner might become the basis of a simply proxy measure of quality of care; and that its use might help monitor the effect of recent and proposed changes in the way in which general practice care is delivered.