The psychosocial quality of work determines whether employment has benefits for mental health: results from a longitudinal national household panel survey.

OBJECTIVES: Although employment is associated with health benefits over unemployment, the psychosocial characteristics of work also influence health. We used longitudinal data to investigate whether the benefits of having a job depend on its psychosocial quality (levels of control, demands and complexity, job insecurity, and unfair pay), and whether poor quality jobs are associated with better mental health than unemployment. METHOD: Analysis of seven waves of data from 7,155 respondents of working age (44,019 observations) from a national household panel survey. Longitudinal regression models evaluated the concurrent and prospective association between employment circumstances (unemployment and employment in jobs varying in psychosocial job quality) and mental health, assessed by the MHI-5. RESULTS: Overall, unemployed respondents had poorer mental health than those who were employed. However the mental health of those who were unemployed was comparable or superior to those in jobs of the poorest psychosocial quality. This pattern was evident in prospective models: those in the poorest quality jobs showed greater decline in mental health than those who were unemployed (B = 3.03, p<0.05). The health benefits of becoming employed were dependent on the quality of the job. Moving from unemployment into a high quality job led to improved mental health (mean change score of +3.3), however the transition from unemployment to a poor quality job was more detrimental to mental health than remaining unemployed (-5.6 vs -1.0). CONCLUSIONS: Work of poor psychosocial quality does not bestow the same mental health benefits as employment in jobs with high psychosocial quality.

Knowledge of treatment intent among patients with advanced cancer: a longitudinal study.

Increasingly, patients with cancer wish to be more fully informed about their disease, treatment and prognosis, and to participate in decision making. The objective of this study was to assess knowledge of diagnosis and goals of treatment among patients with advanced cancer, and also to assess whether this knowledge changed over time. A cohort of 181 subjects with advanced cancer receiving palliative therapies were interviewed at entry and again 12 weeks later. Knowledge of disease diagnosis, treatment intent, and the main sources of information were determined. Twenty per cent of subjects considered their illness to be non-life threatening, and 46% correctly perceived treatment intent as non-curative; 29% believed the intent of treatment was cure. Subjects resident in rural areas were more likely to misunderstand the goal of their treatment. Treatment modality was significantly associated with knowledge of treatment intent, and subjects in the last 6 months of life had clearer understanding that treatment intent was non-curative. Many patients with advanced cancer do not understand the goals of treatment. Excessive optimism may lead to impaired decision making. Further empirical research into information transfer and predictors of accurate patient understanding would assist clinicians in their discussions of prognosis and potential treatment outcomes with patients.

Work and health in a contemporary society: demands, control, and insecurity.

OBJECTIVE: To examine independent associations of job strain (high demands and low control) and job insecurity with mental and physical health outcomes. DESIGN: Cross sectional general population study conducted in 2000 using a self completed questionnaire. SETTING: Two adjoining cities in south east Australia. SUBJECTS: 1188 employed professionals, aged 40-44 years, 55% (n = 655) male. MAIN OUTCOME MEASURES: Depression, anxiety, physical, and self rated health (SRH). RESULTS: Adverse job conditions were relatively prevalent as 23% of the sample reported high job strain, while 7.3% and 23% reported high and moderate job insecurity respectively. Associations between job conditions and health persisted after adjustment for gender, education, marital status, employment status, major life events, and negative affectivity (personality). When adjusted for job strain, high job insecurity was independently associated with a greater than threefold increase in odds for poor SRH, depression and anxiety (OR (95% confidence intervals) poor SRH: 3.72 (1.97 to 7.04) depression: 3.49 (1.90 to 6.41), anxiety: 3.29 (1.71 to 6.33)), and a twofold increase for physical health 2.19 (1.21 to 3.95). High job strain also showed significant independent associations with depression: 2.54 (1.34 to.4.75) and anxiety: 3.15 (1.48 to 6.70). CONCLUSION: In this relatively privileged socioeconomic group, insecure employment and high job strain showed independent, consistent, and strong associations with physical and mental health. These adverse job conditions are on the increase, particularly insecure employment, and the influence of these two work conditions are an important focus for future public health research and their prevalence and impact should be examined in other occupations.

Consultation length and chronic illness care in general practice: a qualitative study.

OBJECTIVE: To study the relationship between duration and content of general practice consultations for patients with chronic conditions. DESIGN: A qualitative analysis of transcripts of consultations. The major themes and concepts of psychosocial support were identified and coded using the Ethnograph computer package. SETTING: A mix of rural and urban general practices in two States of Australia in 1993-1994. PARTICIPANTS: 14 selected general practitioners and 50 of their patients with complex chronic conditions. RESULTS: Transcriptions of 106 consultations were analysed. General practitioners (GPs) led most consultation dialogue and emphasised disease management. The major themes were provision of information by the GP, review of treatment by the GP, review of illness by the GP, and description and explanations of their illness by patients (patient narrative). The first three themes predominated in consultations of all lengths. Longer consultations (20 minutes and over) contained more dialogue initiated by patients and more patient narrative about living with their illness. CONCLUSIONS: Patients with complex chronic conditions may require longer consultations to allow adequate time for review of their illness and treatment as well as an opportunity to raise issues and concerns about their illness, its impact on their lives and their personal management strategies. Longer consultations may thus provide the mechanism for what has been described as patient "enablement".

Embodied risk: my body, myself?

Risk has become a dominant way to interpret who gets sick and why. A distinction has been drawn between two categories of risk: those arising from the environment, and those resulting from an individual's lifestyle. We identify a third category that might be called corporeal or embodied risk which has received little scholarly attention. Embodied risks are so called because they are located in the body of the person said to be "at risk". Environmental risks are due to something that happens to a person; lifestyle risks occur because of something a person does or does not do, while embodied risks say something about who the person is. To investigate how people experience health risks--especially risks identified as characteristics of their bodies--we conducted detailed interviews with 29 women who were told they had an abnormal Pap smear. All health risks pose problems for people who are diagnosed as "at risk": They must translate probabilistic statements about populations into terms that have personal meaning; they must cope with uncertainty; they must consider what it means to be in danger of developing an illness even though most have no symptoms; and they must mobilise appropriate surveillance and perhaps risk reduction. However, limiting attention to environmental and lifestyle risk (and the distinction between them) neglects the additional challenges posed by corporeal risks: the simultaneous presence of disease now and the possibility of more consequential disease in the future; the necessity to submit to ongoing medical surveillance; a tendency to exacerbate the cartesian split between body and self; and the absence of medical or popular discourses through which to interpret and respond to embodied risk. We call upon medicine and public health practitioners to work together with people who are at risk to formulate languages and approaches that can reflect both scientific accuracy (as it is currently understood), and the needs of people to integrate health threats into their daily personal lives.

By women, for women: the continuing appeal of women's health centres.

During the 1970s and '80s, several dozen women's health centres (WHCs) were established in Australia. Most of these centres are government-funded feminist community health facilities run by women, for women. With other women's health initiatives, WHCs are subject to financial and political pressure. This paper draws on data from a study of nearly 400 women clients of women's health and generalist community health centres to examine the continuing appeal of WHCs in the increasingly conservative political environment of the late 1990s. I explore such questions as: Does Australia still need WHCs? Do they offer anything that cannot be obtained elsewhere, and if so, what? This discussion focuses particularly on women's comments about the centre where they were interviewed and their views--both positive and negative--about WHCs more generally. The appeal of WHCs appears to be based on several qualities and resources: best-practice in certain clinical domains; sympathetic care for clients who find it difficult to obtain good care elsewhere; time for complex or distressing health problems; both general and specific health information; sociability and empowerment through participation in groups; and opportunities for active health development. In some cases, a woman private practitioner might supply an alternative to a WHC. Other valued elements are probably results of the fact that these are publicly funded community health agencies with salaried staff and similar qualities might be found in a mixed-sex community health facility. But only women's health centres combine the two, and embed them in a feminist philosophy and analysis of women's health and health care. In addition, WHCs' influence on the mainstream may benefit many more women than those who go to a centre. WHCs serve as models, innovate and collaborate with mainstream agencies, train service providers, and develop information and educational resources. These twin aims of supplying gender-specific services and enriching the mainstream continue to guide the work of WHCs.

The best medicine: women using community health centres.

In an environment of scarce resources and competition for the health dollar, there is considerable pressure to close facilities viewed as specialist or to amalgamate them into the mainstream. Women's health services are presently among services subject to cuts and amalgamation, often on the assumption that they duplicate services available from private general practitioners. Another widespread belief is that women's health centres attract a small, elite clientele of 'worried well' feminist extremists. This study examined such assumptions, using questionnaire data collected from 388 women attending women's health centres (62 per cent) and mixed-sex community health centres (38 per cent). Findings showed that these clients of all community health facilities were disadvantaged compared with the population overall. When clients of women's health centres and community health centres were compared, the client profiles were either much alike or women's health centre clients were even more disadvantaged, challenging the stereotype of these centres being used only by a privileged elite. Instead, it appears that the centres offer a distinctive array of services to a socioeconomically vulnerable clientele, not a substitute for care available elsewhere.

Women's understanding of abnormal cervical smear test results: a qualitative interview study.

OBJECTIVE: To describe how women interpret their experiences of diagnosis and treatment of a cervical abnormality and how healthcare services for such women can be improved. DESIGN: Qualitative study using detailed individual interviews. SETTING: Australian gynaecology clinics. SUBJECTS: 29 Women who had a cervical cytological abnormality and who attended a gynaecologist. MAIN OUTCOME MEASURES: Women's views on their diagnosis and their information needs. RESULTS: Most women wanted to participate in decisions about their care but found it difficult to get the information they required from doctors because they were confused by what their doctors told them and felt unable to ask questions in the consultation. Medical terms such as wart virus and precancer were difficult to understand. Not being able to see their cervix also made it hard for women to understand what their abnormality meant and what treatment entailed. Most women tried to make sense of their abnormality in the context of their everyday lives. For some women their gynaecological care was not consistent with the way they understood their abnormality. CONCLUSIONS: The inherent power structure of medical practice combined with time pressures often make it difficult for doctors to give the detailed information and reassurance patients need when a diagnosis is distressing or when investigation and treatment are strange and upsetting.

Diagnosis in chronic illness: disabling or enabling--the case of chronic fatigue syndrome.

This paper examines doctors' and patients' views on the consequences of an increasingly common symptomatic diagnosis, chronic fatigue syndrome (CFS). Two studies were conducted: the first comprised interviews with 20 general practitioners; the second was a longitudinal study, comprising three interviews over a period of 2 years with 50 people diagnosed with CFS. Contrasts were apparent between doctors' practical and ethical concerns about articulating a diagnosis of CFS and patients' experiences with and without such a diagnosis. Seventy per cent of the doctors were reluctant to articulate a diagnosis of CFS. They felt constrained by the scientific uncertainty regarding its aetiology and by a concern that diagnosis might become a disabling self-fulfilling prophecy. Patients, by contrast, highlighted the enabling aspects of a singular coherent diagnosis and emphasized the negative effects of having no explanation for their problems.

Rethinking gender and drugs.

The necessity to 'do more with less' poses challenges for policy makers and service providers in the drug and alcohol field. In recent years, some services and research initiatives have been targeted at women in an effort to compensate for their previous neglect. The question now arises that such targeting is no longer appropriate since there are fewer resources, and men constitute the main population suffering drug-related harm. This review proposes other ways of considering the question that go beyond competition over scarce resources. It shows that the present attention to women is raising new questions with potential significance to men, and suggests that research and services to the whole population can be improved by paying attention to the gender of men as well as women.

The social distribution of illness: is Australia more equal?

The relationship between socioeconomic status and ill health has challenged researchers and health practitioners for many years. This paper outlines the way several basic measures of morbidity are related to occupation, income and education, with brief attention to class gradients in mortality and service utilization. The international literature contains many studies showing an inverse gradient in health by social standing: people who are socially and economically well off typically enjoy good health as well. Data from a recent health survey conducted in New South Wales, Australia do not confirm the British findings when occupational categories are studied, but when other measures of status are substituted for the crude occupation categories, a number of patterns appear. Income is significantly associated with the probability of chronic illness among middle-aged men and women, and among women over 65. The predicted pattern is also evident for recent illness among young men and for consulting among elderly respondents, but these associations are not statistically significant. Except among the elderly, better educated men and women are healthier than those with less education on most morbidity measures. The parallels and discrepancies between these findings from an Australian sample and overseas studies raise important research and policy questions.