The Ubiquity of Chronic Illness.

This is a review of five different books dealing with some aspect of what might be termed a "chronic illness" - Alzheimer's disease, lupus, addiction, erectile dysfunction, and leprosy. The array of different subjects examined in these books points to the negotiable limits of this hugely open category. What exactly constitutes an "illness"? Why not use a less biomedical term instead: "disturbance", "problem", or simply "condition"? And how are we to understand "chronic" - simply as the flipside of "acute" or "curable"?

Assessing clinical significance of treatment outcomes using the DASS-21.

Standard clinical significance classifications are based on movement between the "dysfunctional" and "functional" distributions; however, this dichotomy ignores heterogeneity within the "dysfunctional" population. Based on the methodology described by Tingey, Lambert, Burlingame, and Hansen (1996), the present study sought to present a 3-distribution clinical significance model for the 21-item version of the Depression Anxiety Stress Scales (DASS-21; P. F. Lovibond & Lovibond, 1995) using data from a normative sample (n = 2,914), an outpatient sample (n = 1,000), and an inpatient sample (n = 3,964). DASS-21 scores were collected at pre- and post-treatment for both clinical samples, and patients were classified into 1 of 5 categories based on whether they had made a reliable change and whether they had moved into a different functional range. Evidence supported the validity of the 3-distribution model for the DASS-21, since inpatients who were classified as making a clinically significant change showed lower symptom severity, higher perceived quality of life, and higher clinician-rated functioning than those who did not make a clinically significant change. Importantly, results suggest that the new category of recovering is an intermediate point between recovered and making no clinically significant change. Inpatients and outpatients have different treatment goals and therefore use of the concept of clinical significance needs to acknowledge differences in what constitutes a meaningful change.

Programas de prevención de ocio alternativo / Prevention programs on alternative activities

Los programas de ocio alternativo han cobrado un gran interés en España, durante los últimos seis años, como consecuencia de la rápida expansión de los nuevos patrones de uso recreativo de las drogas entre importantes sectores de la población juvenil. Aunque bajo ese epígrafe se reúnen muy diversos tipos de intervenciones, puede afirmarse que se trata de un tipo de programas de base comunitaria que se ejecuta en horarios y espacios de ocio y que tienen como objetivo primordial el desarrollo de actividades incompatibles a la vez que alternativas al uso de drogas. Sin embargo, existe poca evidencia en investigaciones rigurosas que nos indiquen exactamente qué tipo de programas, qué tipo de actividades dentro de ellos o con qué poblaciones específicas son más efectivos. En Estados Unidos, donde estos programas se vienen aplicando durante las dos últimas décadas, autores como Hansen y Tobler han llevado a cabo revisiones sistemáticas y aplicaciones de metaanálisis que sí nos permiten acceder a una evaluación de resultados e identificar algunas claves para garantizar su buen funcionamiento. De igual modo, en España existe una evaluación de resultados de dos conocidos programas -Abierto hasta el Amanecer (Gijón) y La noche más Joven (Ayuntamiento de Madrid)- así como diversas fuentes de información que recogen programas de este tipo–Idea Prevención y OED-. De su revisión se extrae la necesidad de mejorar la fundamentación científica de estos programas así como su adecuación a una definición de necesidades más precisas y unas expectativas más realistas respecto a los resultados de su aplicación (AU)

Alternative leisure programmes have aroused widespread interest in Spain in the last six years as a consequence of the rapid expansion of the new recreational drug use patterns in significant sectors of the juvenile population. Although this heading can cover many kinds of different interventions, it can be said that it includes a type of programme with a community basis that is carried out in leisure hours and spaces. Their overall priority objective is to organise activities which are both incompatible with drug use and as an alternative to it. Nonetheless, there is little evidence of any rigorous research that would indicate exactly which kind of programme, which of their activities or on which of their specific populations these are the most effective. In the United States, where these programmes have been operating for the last twenty years, authors such as Hansen and Tobbler have carried out systematic reviews and used metaanalysis, enabling us to make an assessment of the results and identify certain keys to guarantee their good operation. Similarly, in Spain, there is an evaluation of the results of two well-known programmes Abierto hasta el Amanecer (Gijón) and La Noche más Joven (Madrid City Council) as well as a database- - Idea Prevención, which has accumulated and analysed a total of 73 programmes. One result of the investigation is the need to improve the scientific foundation of these programmes in addition to adjusting them to a definition of more precise needs and to more realistic expectations from the results of their application (AU)

Seven ways to increase power without increasing N.

Many readers of this monograph may wonder why a chapter on statistical power was included. After all, by now the issue of statistical power is in many respects mundane. Everyone knows that statistical power is a central research consideration, and certainly most National Institute on Drug Abuse grantees or prospective grantees understand the importance of including a power analysis in research proposals. However, there is ample evidence that, in practice, prevention researchers are not paying sufficient attention to statistical power. If they were, the findings observed by Hansen (1992) in a recent review of the prevention literature would not have emerged. Hansen (1992) examined statistical power based on 46 cohorts followed longitudinally, using nonparametric assumptions given the subjects' age at posttest and the numbers of subjects. Results of this analysis indicated that, in order for a study to attain 80-percent power for detecting differences between treatment and control groups, the difference between groups at posttest would need to be at least 8 percent (in the best studies) and as much as 16 percent (in the weakest studies). In order for a study to attain 80-percent power for detecting group differences in pre-post change, 22 of the 46 cohorts would have needed relative pre-post reductions of greater than 100 percent. Thirty-three of the 46 cohorts had less than 50-percent power to detect a 50-percent relative reduction in substance use. These results are consistent with other review findings (e.g., Lipsey 1990) that have shown a similar lack of power in a broad range of research topics. Thus, it seems that, although researchers are aware of the importance of statistical power (particularly of the necessity for calculating it when proposing research), they somehow are failing to end up with adequate power in their completed studies. This chapter argues that the failure of many prevention studies to maintain adequate statistical power is due to an overemphasis on sample size (N) as the only, or even the best, way to increase statistical power. It is easy to see how this overemphasis has come about. Sample size is easy to manipulate, has the advantage of being related to power in a straight-forward way, and usually is under the direct control of the researcher, except for limitations imposed by finances or subject availability. Another option for increasing power is to increase the alpha used for hypothesis-testing but, as very few researchers seriously consider significance levels much larger than the traditional .05, this strategy seldom is used. Of course, sample size is important, and the authors of this chapter are not recommending that researchers cease choosing sample sizes carefully. Rather, they argue that researchers should not confine themselves to increasing N to enhance power. It is important to take additional measures to maintain and improve power over and above making sure the initial sample size is sufficient. The authors recommend two general strategies. One strategy involves attempting to maintain the effective initial sample size so that power is not lost needlessly. The other strategy is to take measures to maximize the third factor that determines statistical power: effect size.

Quarantine and the problem of AIDS.

Through history, quarantine has been a response not only to the mode of disease transmission, but also to popular demands for a boundary between the kind of people so diseased and the respectable people who hope to remain healthy. Efforts to control epidemics--leprosy, cholera, tuberculosis, drug addiction--through quarantine of large numbers of people have never been successful. AIDS patients share characteristics often invoked in defense of quarantine; they do have reason to fear anachronistic and unenlightened outrage.

Where health is patriotism. Visit of New Zealand medical delegation to China: 20 August-9 September 1974.

PIP: At the invitation of the Chinese government a New Zealand delegation visited the People's Republic of China to observe medical administration and public health. The use of "barefoot doctors" and the integration of western and traditional medicine has led to a revision of the organization of medical care. Acupuncture has been implemented for anesthesia, diagnosis, treatment and drug addiction. Herbal medicine, treatment of fractures and burns and cupping and mixibustion are additional methods of treatment employed with success by the Chinese. The emphasis on preventive medicine has led to education of the people and "barefoot doctors" and to the elimination of various pests such as flies, mosquitoes, rats, bedbugs the semination of a wide range of endemic bacterial and viral diseases such as plague, cholera and leprosy and the elimination of diseases such as malaria, hookworm and venereal diseases. Population control is emphasized in schools (premarital sex is strongly disapproved of) and through the revolutionary philosophy that women can only gain equality when they are freed from endless childbearing. Birth rates have been reduced to 6.5 per 1000 in urban Shanghai. Medical training has been shortened to 3 1/2 years and is taught with the philosophy that it will be used to serve the people.^ieng