How common is repetitive strain injury?

OBJECTIVE: Statistics from Labour Force Surveys are widely quoted as evidence for the scale of occupational illness in Europe. However, occupational attribution depends on whether participants believe their health problem is caused or aggravated by work, and personal beliefs may be unreliable. The authors assessed the potential for error for work-associated arm pain. METHODS: A questionnaire was mailed [corrected] to working-aged adults, randomly chosen from five British general practices. They were asked about: occupational activities; mental health; self-rated health; arm pain; and beliefs about its causation. Those in work (n = 1769) were asked about activities likely to cause arm pain, from which the authors derived a variable for exposure to any "arm-straining" occupational activity. The authors estimated the relative risk (RR) from arm-straining activity, using a modified Cox model, and derived the population attributable fraction (PAF). They compared the proportion of arm pain cases reporting their symptom as caused or made worse by work with the calculated PAF, overall and for subsets defined by demographic and other characteristics. RESULTS: Arm pain in the past year was more common in the 1143 subjects who reported exposure to arm-straining occupational activity (RR 1.2, 95% CI 1.1 to 1.5). In the study sample as a whole, 53.9% of 817 cases reported their arm pain as work-associated, whereas the PAF for arm-straining occupational activity was only 13.9%. The ratio of cases reported as work-related to the calculated attributable number was substantially higher below 50 years (5.4) than at older ages (3.0) and higher in those with worse self-rated and mental health. CONCLUSIONS: Counting people with arm pain which they believe to be work-related can overestimate the number of cases attributable to work substantially. This casts doubt on the validity of a major source of information used by European governments to evaluate their occupational health strategies.

High completion rates of isoniazid preventive therapy among persons living with HIV in Swaziland.

SETTING: Five human immunodeficiency virus (HIV) care facilities in Swaziland. OBJECTIVE: To assess adherence and treatment completion of a 6-month course of isoniazid preventive therapy (IPT) provided to HIV-infected patients through a self-selected model of facility-based, community-based or peer-supported IPT delivery coordinated with antiretroviral refills. DESIGN: Prospective cohort study. RESULTS: Between February and August 2015, we enrolled 908 patients, with follow-up until February 2016. Most were female (66.2%), with a median age of 38 years (interquartile range 31-45). Most (n = 797, 87.8%) chose facility-based delivery, 111 (12.2%) selected community-based delivery, and none selected peer-supported delivery. Adherence was high in both cohorts; among those with available data, 794 (94.8%) reported taking at least 80% of their IPT (P > 0.05). Twenty-two patients screened positive for tuberculosis (TB) at any visit; all had TB excluded and most continued IPT. In total, 812 (89.4%) patients completed treatment: 711 (89.2%) were on facility-based and 111 (91.0%) on community-based IPT (P > 0.05). No confirmed treatment failures occurred. Few patients discontinued IPT (6.3%) or were lost to follow-up (4.1%). CONCLUSION: Self-selected IPT delivery aligned with HIV care achieved high rates of adherence and treatment completion. This model may improve outcomes by simplifying clinic visits and conferring agency to the patient, and may be readily implemented in similar high TB-HIV burden settings.

Declining tuberculosis notification trend associated with strengthened TB and expanded HIV care in Swaziland.

This retrospective observational review documents the efforts of the Swaziland National Tuberculosis (TB) Control Programme between 2004 and 2014. The objective is to describe the disparity between actual declines in case notification and increases in estimated incidence. The review of policies and practices shows the most influential factors associated with the decrease in TB case notification to be an increase in access to antiretroviral therapy for co-infected TB patients, the general success of TB and human immunodeficiency virus service integration in the country and improvements in implementation of all components of directly observed treatment, active case finding, and rapid diagnosis using new technologies.

Cette étude d'observation rétrospective documente les efforts du programme de lutte contre la tuberculose (TB) du Swaziland entre 2004 et 2014. L'objectif est de décrire la disparité entre un réel déclin dans la déclaration des cas et une augmentation de l'incidence estimée. La revue des politiques et des pratiques montre que les facteurs les plus influents associés au déclin de la déclaration des cas de TB sont liés à une augmentation de l'accès aux antirétroviraux pour les patients tuberculeux co-infectés, au succès d'ensemble de l'intégration des services pour la TB et ceux pour le virus de l'immunodéficience humaine dans le pays et aux améliorations dans la mise en œuvre de tous les composants du traitement sous observation directe, de la recherche active des cas et d'un diagnostic rapide grâce aux techniques nouvelles.

Con el presente análisis observacional retrospectivo se documentan las iniciativas emprendidas por el Programa de Control de la Tuberculosis (TB) de Swazilandia del 2004 al 2014. El objetivo del estudio fue describir la discrepancia existente entre la disminución en la notificación de casos de TB y el aumento en las estimaciones de incidencia de la enfermedad. El análisis de las políticas y las prácticas puso de manifiesto que los factores que más influyen sobre la disminución de la notificación de casos de TB es un aumento en el acceso al tratamiento antirretrovírico por parte de los pacientes coinfectados por el virus de la inmunodeficiencia humana y la TB, el éxito general de la integración de los servicios que se ocupan de ambas enfermedades en el país y los progresos en la aplicación de todos los componentes del tratamiento directamente observado, la búsqueda activa de casos y el diagnóstico rápido mediante nuevas tecnologías.

CD4 deficit and tuberculosis risk persist with delayed antiretroviral therapy: 5-year data from CIPRA HT-001.

SETTING: Port-au-Prince, Haiti. OBJECTIVE: To determine long-term effects of early vs. delayed initiation of antiretroviral therapy (ART) on immune recovery and tuberculosis (TB) risk in human immunodeficiency virus (HIV) infected individuals. DESIGN: Open-label randomized controlled trial of immediate ART in HIV-infected adults with CD4 counts between 200 and 350 cells/mm(3) vs. deferring ART until the CD4 count was <200 cells/mm(3). The primary comparisons were CD4 counts over time and risk for incident TB, with 5 years of follow-up. RESULTS: A total of 816 participants were enrolled, with 408 in each treatment arm. The early treatment group started ART within 2 weeks, while the deferred treatment group started ART a median of 1.3 years after enrollment. After 5 years, the mean CD4 count in the early treatment group was significantly higher than in the deferred treatment group (496 cells/mm(3), 95% confidence interval [CI] 477-515 vs. 373 cells/mm(3), 95%CI 357-389; P < 0.0001). TB risk was higher in the deferred treatment group (unadjusted HR 2.41, 95%CI 1.56-3.74; P < 0.0001) and strongly correlated with lower CD4 counts in time-dependent multivariate analysis. CONCLUSION: Delays in ART initiation for HIV-infected adults with CD4 counts of 200-350 cells/mm(3) can result in long-term immune dysfunction and persistent increased risk for TB.

Tonsillectomy and circumcision: comparisons of two cohorts.

Changes in the prevalence of tonsillectomy and circumcision in eleven year olds are described in two birth cohorts spaced 12 years apart. Both types of operation were less prevalent in the later (1958) cohort; tonsillectomy fell by a fifth and circumcision by more than half. These falls were confined to tonsillectomy before the age of six and circumcision under one year. Social class differences in tonsillectomy were found in both cohort studies but the strong social class gradient in circumcision reported in the 1946 cohort had vanished in the 1958. Regional and birth rank differences are found for both types of operation; these show substantial changes over time. These results are discussed in the context of changing professional opinions about the worth of these operations.

Public trust in health care: the system or the doctor?

OBJECTIVES: To examine how the public assess trust in health care in England and Wales. DESIGN: Postal structured questionnaire in cross sectional survey. SETTING: Random sample of people on the electoral register in England and Wales. SUBJECTS: People aged 18 and over. MAIN OUTCOME MEASURES: General levels of trust and confidence in health care. RESULTS: The response rate was 48% (n = 1187). The mean level of confidence (trust) in the healthcare system was 6.0 out of a score of 10. Levels of distrust appeared relatively high with at least 356 (30%) respondents reporting little or very little trust for 28 of 32 specific aspects of health care. The highest levels of distrust were found in relation to how the health service was run and financed, particularly waiting times and the implication of cost cutting for patients. Statistical analysis by univariable linear regression of the specific determinants of generic assessments of public trust (confidence) suggested that the key aspects were patient centred care and levels of professional expertise. Being covered by private health insurance was also a key determinant of levels of public trust. CONCLUSION: Public assessment of trust tends to address the views of care at the micro level. Policy makers concerned with the erosion of public trust need to target aspects associated with patient centred care and professional expertise.

Compliance with a class teaching breast self examination.

As part of the evaluation of a class teaching breast self examination (BSE), a sample of women were interviewed shortly before they were invited to attend the class and again one year later. A comparable sample in a different "control" district were interviewed twice in the same way. The interviewers inquired about the practice of breast self examination (BSE) and about beliefs about breast cancer. The findings enable changes in behaviour and beliefs among those who attended and did not attend the class and among women in the control district during the same year to be compared. Women who attended the class showed a more pronounced improvement in BSE practice compared with non-attenders and with the control group. The improvement was in BSE technique rather than the frequency with which it was carried out.

The health belief model and participation in programmes for the early detection of breast cancer: a comparative analysis.

Extravagant claims have been made about the power of the Health Belief Model (HBM) to explain both decisions to adopt patterns of health behaviour and to use preventive health services. However, studies where information on beliefs are collected before information on behaviour are not common. The analyses presented here are based on prospective studies examining how far the variables which make up the HBM predict attendance at (i) a class teaching breast self-examination and (ii) a clinic providing mammography. The results show that different dimensions of the HBM are amongst the best predictors of attendance at each of the different services although the overall variance explained by the HBM in both sets of analysis was small.

Women and medicalisation: an empirical examination of the extent of women's dependence on medical technology in the early detection of breast cancer.

Recent criticisms of the thesis of medicalisation focusing at the level of doctor-patient interaction have suggested that patient dependency on or addiction to modern scientific medicine and in particular medical scientific technology is overstated. However, empirical research to examine this is difficult to find. The study presented here throws some light on this issue as it looks at women's beliefs and feelings about breast screening and breast self-examination and the prospect of attending for breast screening or a class which teaches BSE. The results show that the generalised concept of patient dependence is limited although there was more support for women's dependence on medical technology than choosing to be directly responsible for identifying abnormalities themselves and managing them.

Patterns in preventive behaviour: a study of women in middle age.

There has been little comparative research to discover if the same people take part in different preventive health programmes. The study described here examines if the same women carry out seven different types of preventive health behaviour and attempts to identify ways of characterising participants or non-participants in the various forms of behaviour. The results show that the probability of women who carry out one type of preventive health behaviour carrying out another was low. However, the one factor that distinguished between participation and non-participation in various forms of preventive health behaviour was social class. The need to develop a model of health behaviour which accommodates both general structural factors and specific beliefs and circumstances is recommended.

Images of general practice: the perceptions of the doctor.

During the post second world war period there has been considerable discussion both within and outside the medical profession about what the role of the general practitioner should be. This study, drawing on data gathered from a national representative sample of general practitioners in England and Wales, explores general practitioners' own perceptions of their work role. The evidence shows that general practitioners might be divided into those who see a broad role for the general practitioner and place emphasis on the social aspects of care, and those who see a more traditional role for the general practitioner focusing specifically on organic illness. Those with a social orientation were also more likely to doubt the value of financial incentives, whereas the medical oriented doctors were more likely to say that their behaviour was influenced by financial incentives. The analysis also showed that the medically oriented were distinctly different to those with a social orientation in terms of personal characteristics and the setting in which they worked. The implications of these findings are discussed in full.

Towards a conceptual framework of lay evaluation of health care.

It is argued in this paper that much of the empirical research into the public's and patients' perceptions of the adequacy of health care has suffered from conceptual weaknesses. In addition, and maybe as a result of these weaknesses, a contradictory pattern of findings has emerged from this research. To overcome some of these problems it is suggested that an investigation of lay evaluation of health care should be carried out within a conceptual framework which incorporates the following elements. (i) The goals of those seeking health care in each specific instance. (ii) The level of experience of use of health care. (iii) The socio-political values upon which the particular health care system is based. (iv) The images of health held by the lay population. Each of these elements interrelates with the others and their influence will be mediated through socio-demographic characteristics of the service users.

Control over health and patterns of health-related behaviour.

This paper empirically examines the relationship between position in the social structure, beliefs about control over health and three different types of health-related behaviour. The data are drawn from two large scale community surveys (N = 4224) carried out in southern England. The results show that the relationship between the Multi-dimensional Health Locus of Control (MHLC) and exercise, cigarette smoking and use of alcohol was never more than modest even within different social and economic contexts. Doubts are cast upon the value of the MHLC for explaining variations in health-related behaviour and more fruitful areas for research are suggested.

Social networks and patterns of help-seeking behaviour.

Previous research has suggested that patterns of help-seeking behaviour are influenced by who the sufferer consults when deciding whether to seek medical care or not. This research has been extended to include episodes of illness and injury where more formal contacts are brought into the consultation process. The results show that the perceived urgency with which medical care is required is influenced by who the person has contact with. Some groups such as the police, bystanders and neighbours and friends may be more likely to suggest that the sufferer should seek medical attention than other consultants. This difference was explained in terms of the social, economic, moral and legal pressures associated with these people's positions.

The limits of medicine: women's perception of medical technology.

This paper develops an analysis of women's perceptions of medical technology and the elements which shape them, and then draws out the implications for medicine and the and the medicalization thesis. In the first part of the paper we outline the macro-theoretical debates about medicalization and the role of medical technology in this process, and the consequences for those who use health care. The implications for women are given particular attention as they have a higher level of contact with health care than men. We then evaluate the arguments of these macro-theorists against evidence from two ethnographic studies, concerning women patients' and their doctors' attitudes to the use of minor tranquillizers and women's evaluations of medicine and medical practice. This provides a basis for questioning some of the assumptions of the macro-theorists regarding the social relations of medical technology and the medicalization thesis.

The economy of time in general practice: an assessment of the influence of list size.

A lack of time is one of the major reasons given to account for low quality care provided in general practice. One of the basic assumptions inherent in this explanation is that activities in general practice are shaped by the level of patient demand and general practitioners have little control over their work. The objective of this study is to explore empirically this assumption that general practice is demand led by examining the relationship between list size and the time general practitioners spend at work-related activities. The analysis uses data gathered from a survey carried out on a nationally representative sample of unrestricted principals (N = 1419) living in England and Wales. The results show that list size is statistically significantly associated with each of the different indices of time allocation, although it is only relatively strongly associated with hours spent on surgery consultations and surgery consultation rates. The implications of these findings are discussed and it is suggested that the demand led model provides only a partial explanation for variations in time allocation in general practice.

Do health beliefs predict health behaviour? A follow-up analysis of breast self-examination.

In a previous paper, we suggested that women who attended classes on breast self-examination showed significant improvements in behaviour, and that part of the reason was a change in their beliefs. Further analysis of our data confirms the original conclusion, and indicates that the perceived value of doing the behaviour is a more important predictor than perceived vulnerability to cancer.

Do health beliefs predict health behaviour? An analysis of breast self-examination.

The purpose of this paper is to explore the relationships between health beliefs and health behaviour. The study we report was conducted as part of a national campaign to evaluate the benefits of breast self-examination in the early detection of breast cancer, and the purpose of our analysis was to test the Health Belief Model of Becker and his colleagues. Three groups of women were investigated--278 who accepted an invitation to attend self-examination classes and were taught the techniques in detail, 262 who declined the invitation and 594 controls to whom no classes were offered--and beliefs and self-reported behaviour were measured shortly before the classes took place and again a year later. The campaign, it emerged, produced marked changes in both beliefs and behaviour, but the relationships between beliefs and behaviour were much weaker than the model had led us to expect and accounted for no more than a quarter of the variance. Alternative models are considered, notably Fishbein and Ajzen's Theory of Reasoned Action, and the paper concludes with some suggestions for improving health campaigns.

The reprofessionalisation of community pharmacy? An exploration of attitudes to extended roles for community pharmacists amongst pharmacists and General Practioners in the United Kingdom.

In the light of recent developments within the British National Health Service some sociologists have suggested that the medical profession's status is under threat. They have specified a range of factors contributing to this state of affairs, such as the new consumerism; however, it is thought that attempts by other, related occupations at reprofessionalisation are particularly significant in this trend. It may be possible to understand recent initiatives at extending community pharmacists' role within this framework. This paper suggests that while community pharmacy is developing strategies to enhance its professional status, it is not so much an attempt at usurping general practitioners'(GPs) (primary care doctors') role as a bid for survival, especially on the part of the rank and file. However, GPs do not necessarily see the initiatives in this light. Although many GPs are accommodating some changes in community pharmacy, they also perceive some of the initiatives as a threat to their autonomy and control, this was especially evident in representative bodies such as the Local Medical Committee. Doctors' accommodating attitudes were qualified with traditional attitudes of dominance such as 'limitation' and 'exclusion'. Such attitudes could prevent community pharmacy from achieving professional status. However, there is also evidence that pharmacists themselves contribute to this situation because many of them also attribute ultimate authority to doctors. Moreover, they are held back by internal occupational divisions particularly between retail pharmacists and employee pharmacists, with the former being the most insecure.

Convergence and divergence: assessing criteria of consumer satisfaction across general practice, dental and hospital care settings.

This paper describes the results of the first-stage of a study carried out in the spring of 1988 in the South East of England. The study looked at general and specific aspects of consumer satisfaction with general practitioner services, general dental care services and hospital in-patients care. It also examined which specific consumer criteria were the key predictors of overall satisfaction within each of these particular medical care settings. A related aim was to assess the degree of congruence or divergence of consumer criteria across these differing medical care settings. The evidence suggests that whilst general levels of consumer satisfaction are high (i.e. 83-97%), questions of a more detailed and specific nature revealed greater levels of expressed dissatisfaction (e.g. 38% of the sample felt that they could not discuss personal problems with their GP, 51% felt their dentist was not easy to reach at weekends/holidays, whilst 35% felt hospital doctors did not give sufficient information). Whilst different areas of dissatisfaction were found in each specific medical care setting examined, what was particularly striking was the degree of convergence of the key predictors of overall consumer satisfaction across the medical care settings. That is to say, our findings clearly suggest that issues concerning 'professional competence', together with the nature and quality of the patient-professional relationship, are the key predictors of overall consumer satisfaction with general practice, dental and hospital care [e.g. GP giving sufficient information correlated 0.64 (P less than 0.001) with overall GP satisfaction scores; competent dentist 0.52 (P less than 0.001) with overall dental satisfaction scores; and full confidence in hospital doctors 0.49 (P less than 0.001) with overall hospital satisfaction scores]. The theoretical importance and policy implications of these findings, particularly in the light of the recent NHS reforms, are discussed.