Age at menarche: secular trends and association with adult anthropometric measures.

BACKGROUND: Age at menarche has been used as a marker of environmental conditions during childhood. Previous work has shown trends of decreasing age at menarche throughout the 19th century, but reported trends in the 20th century have been less consistent. The nature of the relationship between age at menarche and adult life anthropometric measures may be important in understanding the importance of this measure on disease in later life. AIM: To establish whether mean age at menarche changed during the first half of the 20th century, and to determine the nature of associations between age at menarche and anthropometric measures in young adulthood. SUBJECTS AND METHODS: 3433 female students, who were born between 1919 and 1952 and who attended health checks at the student health service of the University of Glasgow between 1948 and 1968. RESULTS: Mean age at menarche decreased from 13.2 years in the earliest born to 12.5 years in the latest born students. These results were not explained by changes in socio-demographic factors. Menarcheal age was positively associated with height and negatively associated with weight and BMI, results independent of socio-demographic and behavioural factors. CONCLUSIONS: The falling age at menarche described here may be related to nutritional influences in the first half of the 20th century. The influence of menarche on BMI in early adulthood may have important health consequences.

Needs assessment in primary care: general practitioners' perceptions and implications for the future.

BACKGROUND: Health needs assessment can guide the appropriate shift to primary care by identifying the most effective and efficient resource allocation to meet the needs of populations. Assessing health care needs will be a continuing challenge for primary care trusts in Scotland (or equivalent groups in other parts of the United Kingdom); however, lessons must be learned from the experience of needs assessment that followed the 'internal market' reforms of the 1990s. AIM: To examine general practitioners' (GPs') awareness and experience of needs assessment, to identify barriers to needs assessment in primary care, and to ascertain how better progress might be made in the future. METHOD: A postal questionnaire survey of 1777 Scottish GPs (a one-in-two sample) was combined with a semistructured interview survey of 'lead' GPs from a random sample of 64 mainland Scottish practices between May and August 1996. RESULTS: Sixty-five per cent (1154) of GPs responded to the questionnaire, of which 54% (965) were completed. Over 73% (47) of interviews were completed. Most GPs were unfamiliar with the concept of needs assessment and there was no evidence that needs assessment had influenced commissioning decisions. Most GPs argued that it was not a 'core' activity and that they lacked training in the relevant skills. While the attitude of the majority was indifferent, cynical, and sometimes hostile, a minority, comprising mostly younger fundholders, was more enthusiastic about needs assessment. CONCLUSION: The motivation and attitude of the majority of GPs present a barrier to needs assessment in primary care. GPs will require more resources and training if they are to undertake this responsibility. Most GPs believe than incentives (financial or organisational) will be necessary. Primary care trusts and equivalent structures should be aware of these attitudes as they seek to establish plans based on estimates of population needs in defined locations.

Organisation of services for acute stroke in Scotland--report of the Scottish stroke services audit.

An audit was undertaken of hospital service provision for acute strokes in Scotland, using as a template key recommendations in the four SIGN guidelines on management of stroke. A questionnaire and structured interview was undertaken of key personnel in the 43 Trusts and three directly managed units providing in-patient stroke care in Scotland, and the 15 Health Boards commissioning stroke care. All Trusts and Health Boards participated and a complete set of information for each was recorded on a data-base and analysed. This report gives an overview for 14 key components of an integrated stroke service with results presented in four bands according to Trust type determined by the number of strokes admitted. No Trust provided all key components and for a few components a lack of provision was widespread, e.g. fast-track assessment clinics for TIA and minor stroke, access to CT scanning within 48 hours. Variation occurred between Trusts of similar size, between Trusts of different sizes. Overall the Health Boards were at a preliminary stage in the development of stroke specific service specifications. The results of the audit are a view of stroke services around April 1998, and should enable commissioners and providers to consider how to progress implementation of the clinical guidelines on stroke care.

Randomised trial of personalised computer based information for cancer patients.

OBJECTIVE: To compare the use and effect of a computer based information system for cancer patients that is personalised using each patient's medical record with a system providing only general information and with information provided in booklets. DESIGN: Randomised trial with three groups. Data collected at start of radiotherapy, one week later (when information provided), three weeks later, and three months later. PARTICIPANTS: 525 patients started radical radiotherapy; 438 completed follow up. INTERVENTIONS: Two groups were offered information via computer (personalised or general information, or both) with open access to computer thereafter; the third group was offered a selection of information booklets. OUTCOMES: Patients' views and preferences, use of computer and information, and psychological status; doctors' perceptions; cost of interventions. RESULTS: More patients offered the personalised information said that they had learnt something new, thought the information was relevant, used the computer again, and showed their computer printouts to others. There were no major differences in doctors' perceptions of patients. More of the general computer group were anxious at three months. With an electronic patient record system, in the long run the personalised information system would cost no more than the general system. Full access to booklets cost twice as much as the general system. CONCLUSIONS: Patients preferred computer systems that provided information from their medical records to systems that just provided general information. This has implications for the design and implementation of electronic patient record systems and reliance on general sources of patient information.

The accessibility of information systems for patients: use of touchscreen information systems by 345 patients with cancer in Scotland.

AIM: To examine cancer patients' use, and satisfaction with touchscreen information systems. By examining the experience of subgroups, to address issues of equality of access. PATIENTS: 345 patients starting radiotherapy at the Beatson Oncology Centre (BOC), Glasgow. METHODS: Patients were invited to use a touchscreen computer at the start of treatment. They were sent a printout of what they saw on screen. Patients had open access to the system. Data were collected at recruitment, intervention, 3 weeks and 3 months. Predictor variables included: patients' demographics, information preferences, technology use, and psychological state. Outcome variables included: use and views of the computer and printout. RESULTS: Younger, broadsheet readers with previous computer use were more likely to find the system easy to use. Older, tabloid readers were more likely to find the content new and relevant. DISCUSSION: We need to make systems adapt to users' different needs. More effort should be made to provide affordable information for older, generally less literate and technologically less literate groups in suitable locations.

Community-oriented medical education in Glasgow: developing a community diagnosis exercise.

OBJECTIVES: Recent NHS changes have included an increasing emphasis on primary care settings, and hence community needs assessment. This has led to suggestions that medical education should become more community-oriented if today's medical students are to become effective medical practitioners. Recent curriculum reforms in a number of medical schools frequently involve a more student-centred approach, which encourages students to learn by intellectual discovery and critical thinking. We describe one such exercise in community diagnosis that has been developed in Glasgow's new undergraduate medical curriculum. DESIGN: The exercise has been developed as three teaching sessions, each with specific learning objectives. The first session explores the strengths and weaknesses of routine statistics, and reveals the lack of information regarding individual's and community's health and health care needs. The second session is a community-based rapid participatory appraisal arranged by general practitioners. Students interview patients, carers, and local key informants and health care professionals about their perceptions of health and health needs. In the final campus-based session, students combine and present their findings. Development included two pilot exercises involving detailed evaluation. SETTING: University of Glasgow. SUBJECTS: Medical students. RESULTS: Students valued the contrasting perspectives and information provided by different sources. After completing the three sessions, most students and tutors considered it an interesting, enjoyable and educational experience. CONCLUSIONS: This innovative community-oriented teaching programme gave students some insight into how health, morbidity and mortality are measured, why these might vary between different communities, and how different community members' perspectives might differ regarding perceived health and social needs.

A study to determine how needs assessment is being used to improve health.

OBJECTIVE: To determine how needs assessment is being used in Health Authorities and General Practice. DESIGN: A postal survey of a one in two sample of Scottish GPs, semistructured interviews with selected health authority executives and a random sample of GPs. SUBJECTS: Nine hundred and sixty-five GPs (54% of those sent the postal questionnaire), 47 randomly selected GP practices and 36 selected health authority (called health boards in Scotland) executives. RESULTS: In health authorities, a view of commissioning/planning emerged with three components: (1) planning (including needs assessment); (2) leadership; and (3) strong relationships with stakeholders. Health authority executives believed that GP involvement is one of several vital components but doubted the commitment of all but a few GPs to the planning process. GPs welcomed enhanced influence but feared increases in workload and admitted to a lack of training in the skills required for needs assessment. Health authority executives aspired to place needs assessment at the centre of planning but admitted that, at present, cost and volume issues predominate. Most GPs were not involved in needs assessment and argued that it is not part of a GPs core activity. National needs assessment documents were well received by health authorities but made little or no impact on GPs. CONCLUSIONS: Needs assessment will have little involvement from primary care until there are changes in the attitudes and skills of the majority of GPs. Fundamental changes are required in health authority priorities and practice if their rhetoric about needs assessment is to be turned into reality. The role of needs assessment could be enhanced but this will only happen if it can be shown to lead to improved health outcomes while addressing the financial pressures that currently dominate the agenda.

Tak Tent. Studies conducted in a cancer support group.

A descriptive study using two interviewer-administered questionnaires was conducted with the aim of getting to know more about cancer support groups and the people who are using these services. All 71 patients and relatives attending six cancer support groups in the West of Scotland at the time of the investigation were interviewed. They were asked about their satisfaction with care and support, past and current concerns, global health and quality of life, and needs. The majority of participants were married women, middle class, aged 50-65 years old, and were long-time survivors. Fifty-two per cent of cancer patients and 70% of relatives of cancer patients stated that they were very satisfied with support were receiving. Nearly 90% of patients reported that they did not receive any counselling either during their pretreatment from their cancer specialists or latter from a professional counsellor. The "general perceived health" and "global quality of life" among patients and relatives were found to be moderately good or good. Concerns of patients and relatives were studied. Patients reported optimistic changes, while relatives were more negative. Needs assessment indicated that 52% of patients require symptom relief and family support, whereas 53% of relatives need counselling from a professional counsellor and informational support. One-third of patients reported that they had no problems at present, and the rest identified difficulties with home duties, shopping and transportation, and financial problems. The study suggests that there is value in encouraging cancer patients and their relatives to take part in existing cancer support groups. This may help to reduce the burden of disease and the care-burden imposed on families.

Use of the Nottingham Health Profile to test the validity of census variables to proxy the need for health care.

BACKGROUND: Data on health or health service use are invariably used to test the validity of proxy measures of need, for use in resource allocation formulae. Perceived health state is a good measure to use in this respect, as it is closely linked to perceived need and the decision to consult health services. This being the case, a large community based study was undertaken which collected data on perceived health, using the Nottingham Health Profile (NHP), with the aim of testing the validity of a variety of Census based measures as proxy measures of the need for health care. METHOD: A postal questionnaire survey of 9565 people living in the former South East Thames Regional Health Authority was conducted and the relationship between their perceived health state and the socio-economic characteristics of their electoral ward of residence analysed. RESULTS: A relatively low response rate (59 per cent) weakened any conclusions to be drawn from the results. However, significant correlations between perceived health and a variety of the Census based indicators were found. The highly skewed distribution of responses to the NHP statements made the results difficult to analyse and interpret. CONCLUSIONS: Although the study gave an indication of those variables that might be incorporated into resource allocation formulae, the NHP is not a particularly efficient instrument to use in a community setting. It is argued that the appropriateness of an approach to determining appropriate needs weights in allocation formulae, which attempts to find one indicator of all health care needs at the District Health Authority level, must be questioned.

Measuring quality of life in oncology: is it worthwhile? II. Experiences from the treatment of cancer.

This is the second part of the paper on quality of life in cancer patients which appeared in this journal (Montazeri et al., 1996a). In this part experiences from the treatment of cancer are given and relevant literature is reviewed. Several topics have been covered, including new directions and methods in assessing quality of life. It is argued that in a chronic condition, adding life to years instead of years to life is an important task. Adding years to life may prolong survival, but whether this is to the benefit of patients is debatable. Considering patients' views, their values and preferences may improve the quality of care and at the same time, reduce the psychological distress and physical discomfort in patients with cancer. It is concluded that quality of life measures have considerable potential in this challenging issue.

Costs and remuneration for cervical screening in general practice in the west of Scotland.

OBJECTIVES: To investigate associations between costs and remuneration for cervical screening in general practice in relation to skill mix, features of practice structure and deprivation levels in the local area; and, to identify efficient policies for organising cervical screening in general practice. METHOD: Questionnaire survey and interview study in 87 general practices in Greater Glasgow Health Board an area in the west of Scotland which covers a socio-economically varied population. The main outcome measures were remuneration to cost ratios (RCRs) for cervical screening and their natural logarithms (logRCRs). RESULTS: Both the costs of cervical screening and RCRs varied widely between the 87 practices taking part. RCRs ranged from 0.29 to 14.67 (mean 2.64, median 2.18, interquartile range 1.15-2.98). Twenty-one per cent (18) of practices earned less than they spent on the organisation of screening, whilst 9% (8) of practices had PCRs of more than 5:1. RCRs were significantly lower if medical staff were involved in either taking smears or dealing with results. RCRs did not vary by social deprivation score, despite uptake being lower in practices in more deprived areas. This was explained by nurses working in practices in deprived areas being more likely to take smears than nurses working in more affluent areas. Sensitivity analyses were undertaken, altering key time and cost assumptions. As a result, the absolute values of the RCRs changed, although the overall pattern of association did not, with the exception of doctor involvement in processing results which was no longer significant when average general practitioners' income was substituted for locum rates. CONCLUSIONS: Practices in deprived areas may be responding to greater pressure of work by making optimal use of skill mix within the primary health care team. A more graduated incentive payment scheme may more fairly reward practices in deprived areas which are less likely to achieve 80% uptake due to relatively intractable features of practice structure. Assuming that practice nurses provide an equivalent quality of service to that provided by general practitioners, results suggest that doctor-nurse substitution would be cost-effective for general practice based cervical screening. Resource savings (principally doctor's time) could be redeployed to other areas of primary health care.

Needs assessment: taking stock.

In 1994, the Scottish Needs Assessment Programme (SNAP) carried out a stocktaking review of all needs assessment reports in 14 topic areas produced in Scotland on the previous three years. National needs assessment documents from England in the relevant topic areas were also reviewed. The review identified two particular points for comment. First, in respect of content, the definition of need as "the ability to benefit'-while appropriate for NHS purchasing- must be balanced by a greater emphasis on the wider concerns for the public's health. At the same time, relevant economic and costing information should be incorporated. Secondly, the process of information collation for purchasing could be made more efficient. Closer links between clinical experts and public health specialists would ensure assessments based on timely opportunities for change. National reviews should provide generally applicable intelligence and comparative analyses; short local reports can then focus on local quantification and priority setting.

Uptake of cervical screening in general practice: effect of practice organisation, structure, and deprivation.

OBJECTIVES - To investigate associations between uptake for cervical screening in general practice and the organisation of screening, features of practice structure, and deprivation. SETTING - Greater Glasgow Health Board area in the west of Scotland, which covers a socioeconomically varied population. METHODS - General practice questionnaire survey and interview based study. The main outcome measure was the uptake rate for each participating practice over the five and a half years ending 31 December 1993. This was used to determine whether practices achieved 80% uptake to trigger maximum payment for cervical screening services. RESULTS - Forty seven percent (n = 92) of all practices in the Greater Glasgow Health Board area agreed to take part in the research, with complete data collected for 87 practices. Participation varied according to number of partners in the practice and the average deprivation score of the practice. Uptake rates ranged from 48-2% to 92-9% (median 77.5%, interquartile range 69.8% to 83.4%). Thirty seven practices (43%) achieved the 80% target. None of the recommended features of good organisation of cervical screening showed any statistically significant association with uptake rates. In stepwise multiple regression four variables were shown to have independent associations with uptake. These were the number of partners in the practice, the average deprivation of the practice, the presence of a female general practitioner, and using a practice's own lists for sending out letters of invitation. In stepwise logistic regression just two of these variables contributed to the prediction of achieving 80% uptake namely, average deprivation and number of partners. There were no significant interactions between deprivation and the organisation of screening in relation to uptake. CONCLUSIONS - Organising cervical screening in general practice according to accepted standards is less important in predicting uptake than more intractable features of the practice such as the size of the partnership, its average deprivation level, the presence of a female general practitioner, and using their own (presumed more accurate) register of addresses to call women. A flexible incentive scheme may more fairly reward the efforts of those general practitioners who achieve high uptake rates but who do not trigger remuneration at the 80% level.

Needs assessment in Scotland: collaboration in public health.

The National Health Service reforms revitalized the national emphasis on the public's health and health needs assessment. In Scotland, in contrast with England, there was no central investment in the development of methods and programmes for needs assessment in the context of the new NHS. To achieve a concerted effort, therefore, a self-help network--the Scottish Needs Assessment Programme (SNAP)--was created by the Scottish Forum for Public Health Medicine. This paper describes its evolution to the point where it is now supported as part of a national network of information for purchasing.

Employee perceptions of workplace health and safety issues. Can a questionnaire contribute to health needs assessment?

A questionnaire survey was conducted to determine attitudes and perceptions of employees of a Scottish local authority of the role of occupational health services. Questions were included covering the following areas: influences on health, the effect of the workplace on health, satisfaction with work and working conditions, the role of occupational health services, and personal health experience. Most of the survey respondents believed that the prime function of an occupational health service is to ensure a safe working environment. However, it was indicated that management has responsibility for employee welfare at work and that an appropriate management structure to address safety issues should be accessible. In addition, employees would like the occupational health service to provide some health promotional activities, particularly stress management courses and the opportunity for exercise.

A survey of medical directors of life insurance companies concerning use of genetic information.

Rapid advances in our ability to test persons presymptomatically for genetic diseases have generated increasing concern that genetic information will be abused by insurance companies. Reasoning that the insurance companies may have the strongest interest in using genetic data and that the medical directors of those companies with responsibility for rating applicants would be a good source of information on the use of such data, we conducted a large survey of medical directors of North American life insurance companies. We received responses from 27 medical directors. Our results suggest that (1) few insurers perform genetic tests on applicants, but most are interested in accessing genetic test information about applicants that already exists; (2) the degree of insurers' interest in using genetic test results may depend on the face amount of the policy applied for and on the specificity and sensitivity of the test; (3) many companies employ underwriting guidelines with respect to certain genetic conditions but may not always have specific actuarial data in house to support their rating decisions; (4) a considerable degree of subjectivity is involved in most insurers' rating decisions; and (5) some of the medical directors who responded to our survey are not fully informed about certain basic principles of medical genetics.

A survey of state insurance commissioners concerning genetic testing and life insurance.

Rapid advances in genetic testing have stimulated growing concern about the potential for misuse of genetic data by insurance companies, employers, and other third parties. Thus far, reports of genetically based discrimination in life insurance have been anecdotal. Reasoning that state insurance commissioners were likely to be aware of (1) the extent of current use of and interest in genetic tests by life insurers and (2) consumer complaints about insurance being denied because of genetic condition or because of genetic test results, we conducted a survey of that group. We received responses from 42 of the 51 jurisdictions. Our results suggest (1) that those who regulate the life insurance industry do not yet perceive genetic testing to pose a significant problem in how insurers rate applicants, (2) that life insurers have much legal latitude to require genetic tests, and (3) that so far few consumers have formally complained to commissioners about the use of genetic data by life insurers.

State legislative efforts to regulate use and potential misuse of genetic information.

The purpose of this study was to review existing and proposed legislation specifically intended to regulate the collection, use, and potential misuse of genetic data. The study encompasses laws relating to confidentiality, informed consent, discrimination, and related issues. It excludes from consideration legislation relating to medical records generally that may bear indirectly on genetic information. It also excludes both legislation relating to the regulation of DNA data collection for law enforcement purposes and state laws relating to the confidentiality of data collected by newborn-screening programs. While relatively few laws that explicitly regulate the treatment of genetic information have been enacted to date, a considerable amount of activity is currently underway in the nation's legislatures. Although most of the bills under consideration are not comprehensive in scope, they reflect a growing societal awareness that the uncontrolled dissemination and use of genetic data entails significant risks.