"PHC Leadership: Are Health Centres in Good Hands?Perspectives from 3 districts in Malawi"""

"The study aimed to document the kinds of leadership styles are practiced at health centres (H/C) and how these styles can be explained by the contexts; characteristics of the health centre in charge (IC) and subordinate trained health staff (STHS). Methods A well-researched leadership style model was applied; which included task; relation and change styles. This is a cross-sectional study using self-administered questionnaires in 47 H/C in 3 districts. 347 STHSs (95) and 46 ICs (98) responded. Questions explored background data and perceived leadership behaviour. Style items were factor analysed; and bivariate analyses and hierarchical regressions determined how styles could be explained. Results Two leadership styles were revealed: ""Trans""style contained all relation and the majority of task and change items; ""Control"" style focused on health statistics (Health Management Information System); reporting and evaluation. STHS and IC had a median age/median work experience of 34/5 years and 38;5/2 years; respectively. 48"

"PHC leadership: are health centres in good hands? Perspectives from 3 districts in Malawi".

AIM: The study aimed to document the kinds of leadership styles are practiced at health centres (H/C) and how these styles can be explained by the contexts, characteristics of the health centre in charge (IC) and subordinate trained health staff (STHS). METHODS: A well-researched leadership style model was applied, which included task, relation and change styles. This is a cross-sectional study using self-administered questionnaires in 47 H/C in 3 districts. 347 STHSs (95%) and 46 ICs (98%) responded. Questions explored background data and perceived leadership behaviour. Style items were factor analysed, and bivariate analyses and hierarchical regressions determined how styles could be explained. RESULTS: Two leadership styles were revealed: "Trans" style contained all relation and the majority of task and change items; "Control" style focused on health statistics (Health Management Information System), reporting and evaluation. STHS and IC had a median age/median work experience of 34/5 years and 38,5/2 years, respectively. 48% of IC reported having no management training. CHAM H/Cs had the lowest score on "Control" style. Distance to referral hospital had no impact on style scores. No contexts or STHS characteristics predicted any leadership styles. For ICs, young age and increasing work experience were significant predictors for both styles, while Nurse ICs were negative predictors for "Control style". Management training was not a significant predictor for any style. CONCLUSION: Frontline PHC leadership may be forced by situation and context to use a comprehensive style which could lack the diversity and flexibility needed for effective leadership. The missing associations between staff characteristics and leadership styles might indicate that this group is not sufficiently considered and included in leadership processes in the PHC organization. Leadership competency for the ICs seems not to be based on formal training, but substituted by young age and work experience. Health centre organization could also influence the options for leadership behaviour. In conclusion this calls for a reassessment of H/C leadership and formal leadership training.

Heart murmurs recorded by a sensor based electronic stethoscope and e-mailed for remote assessment.

BACKGROUND: Heart murmurs are common in children, and they are often referred to a specialist for examination. A clinically innocent murmur does not need further investigation. The referral area of the University Hospital is large and sparsely populated. A new service for remote auscultation (telemedicine) of heart murmurs in children was established where heart sounds and short texts were sent as an attachment to e-mails. AIM: To assess the clinical quality of this method. METHODS: Heart sounds from 47 patients with no murmur (n = 7), with innocent murmurs (n = 20), or with pathological murmurs (n = 20) were recorded using a sensor based stethoscope and e-mailed to a remote computer. The sounds were repeated, giving 100 cases that were randomly distributed on a compact disc. Four cardiologists assessed and categorised the cases as having "no murmur", "innocent murmur", or "pathological murmur", recorded the assessment time per case, their degree of certainty, and whether they recommended referral. RESULTS: On average, 2.1 minutes were spent on each case. The mean sensitivity and specificity were 89.7% and 98.2% respectively, and the inter-observer and intra-observer variabilities were low (kappa 0.81 and 0.87), respectively. A total of 93.4% of cases with a pathological murmur and 12.6% of cases with an innocent murmur were recommended for referral. CONCLUSION: Telemedical referral of patients with heart murmurs for remote assessment by a cardiologist is safe and saves time. Skilled auscultation is adequate to detect patients with innocent murmurs.

[Size of the patient list and quality of the general practice]. / Listestørrelse og kvalitet i fastlegeordningen.

BACKGROUND: A list patient system will be introduced in Norway from 2001. In England and Holland, countries with long experience with this system, the average consultation is much shorter than in the present Norwegian system. Research reports indicate a significant association between longer consultations and patient satisfaction with service as well as quality. The challenge in these countries has been to find mechanisms that reduce list size in order to enhance the quality of care. MATERIAL AND METHODS: On the basis of the author's own data and a summary of relevant literature, a model for estimating average list size in Norway is developed. RESULTS: The model shows the impact of various time-consuming factors in general practice on the workload associated with a patient list. INTERPRETATION: The article describes some objective criteria for calculating a list size which corresponds to a full normal medical man-year, with due consideration for quality of care.

[Is the system of assigned general practitioners more demanding for female than male physicians?]. / Er fastlegesystemet mer krevende for kvinnelige enn for mannlige leger?

The Ministry of Health has tried out and evaluated the personal doctor system in four municipalities in Norway (1993-96). We have explored the reported workload, and whether there were any reporting differences between female and male doctors. We also explored some of the possible factors explaining the reported increased workload. The doctors reported their workload by a postal questionnaire survey. The information from the questionnaires was linked to the doctors' lists received from the National Insurance Administration and were analysed separately for male and female doctors. Female doctors had more women and children on their patient lists, male doctors more men and elderly people. 50% of all the doctors reported that their workload was too heavy. There were no significant differences between male and female doctors in reporting too heavy total workload. 52% of male doctors and 82% of female doctors reported an increase in workload after the introduction of personal doctor system (p < 0.05). Of the explaining factors analysed, only women-dominated lists were associated with reported heavy workload among female doctors (p < 0.05). If the personal doctor system is to be introduced as a national system, it would seem important to have some control over the generation of lists to avoid too heavy workloads.

Non-migrainous headache, neck or shoulder pain, and migraine--differences in association with background factors in a city population.

OBJECTIVE: To study the pattern of association of background factors with reported migraine, non-migrainous headache, and neck or shoulder pain. DESIGN: In a cross-sectional survey the population of the municipality of Tromsø between 20 and 56 years of age was screened for risk factors of different diseases. Everybody attending the screening was given a questionnaire on psychosocial, lifestyle, and health factors. The odds ratios of reporting migraine, non-migrainous headache, and neck or shoulder pain were estimated by logistic regression for several background factors. SETTING: A population-based study conducted in the municipality of Tromsø, northern Norway. PARTICIPANTS: In a survey of risk factors for diseases in 1987/86, all the subjects between 20 and 56 years of age in the municipality of Tromsø were invited. The attenders were given a questionnaire about lifestyle, health, and psychosocial factors. Of the 18105 people who were given a questionnaire, 8537 men and 9162 women (97.7%) answered the questions about "non-migrainous headache", 8533 men and 9117 women (97.5%) answered the questions about neck or shoulder pain, and 8024 men and 7690 women (86.8%) the questions about migraine. MAIN RESULTS: "Self estimated health" had the strongest association with all three target conditions although the strength of the association between headache and neck or shoulder pain was far higher than that of migraine. The reporting of headache and neck or shoulder pain was associated with psychosocial factors, in contrast to migraine. The less educated women were prone to both headache and neck or shoulder pain, while there was no association between migraine and length of education. The explored lifestyle factors were not associated with any of the target conditions. CONCLUSIONS: Our findings underscore that migraine is reported by people with psychosocial backgrounds other than those of people who report chronic headache and neck or shoulder pain.

Headache and neck or shoulder pain--family learnt illnesses behaviour? The Bardu Muscoloskeletal Study, 1989-1990.

OBJECTIVE: To explore the gender difference in reporting headache and neck or shoulder pain, we analysed the association between reported own headache and reporting the same complaints among first grade relatives. Based on these associations we discuss 'learning' of illnesses within the family structures. METHOD: A cross-sectional study based on a self-administered postal questionnaire of musculoskeletal complaints in the total population aged 20-70 years was carried out. A population based study was conducted in the municipality of Bardu, northern Norway. A total population of men and women aged 20-70, altogether 2409 people, were sent a questionnaire. After one postal reminder 1939 questionnaires were returned, a response rate of 80.5%. The return rate was slightly higher among the eldest. The sex distribution was the same in both the responders and the non-responders. RESULTS: The females in the family and the brothers and sisters were the main family members imprinting the way in which the children were deciphering symptoms like headache and neck or shoulder pain later in life. These illnesses were changed to a very little extent by the impact from the spouse.

The General Health Questionnaire: how many items are really necessary in population surveys?

This paper seeks to investigate whether only a few questions selected from the General Health Questionnaire (GHQ) may be used to measure the degree of mental distress in population surveys. Data from 2112 men and women, 18 to 70 years old from two cross-sectional studies conducted in northern Norway and the island Spitzbergen in the Arctic, were used. Correlation analysis of Likert scores from a 20-item version of GHQ (GHQ-20) with Likert scores based on four and six items selected by multiple regression analysis or by competent physicians was performed. The correlation coefficients between the scores from the subsets of four items and the full GHQ-20 questionnaire were high (greater than 0.80) in all examined subgroups of the populations. Increasing the number of questions from four to six only marginally increased the correlation coefficients. Thus, a simple linear sum of Likert scores based on a few GHQ items can be used to measure the degree of mental distress in populations surveys.

Headache and neck or shoulder pain--frequent and disabling complaints in the general population.

OBJECTIVE: to describe the prevalences of reported headache and neck or shoulder pain as unspecified complaints, and to explore the consequences of these complaints measured as unfitness for work. DESIGN: self-administered questionnaire as part of a general health screening. SETTING: all persons aged between 20 and 56 years, in the municipality of Tromsø were invited. Of 29,026 invited, 21,826 attended, and of these 20,026 answered the questionnaire. Some 17,700 answered the questions on headache, and 17,650 on neck or shoulder pain. RESULTS: 6.0% of the males reported weekly or more frequent headache, and 15.4% reported neck or shoulder pain. The corresponding prevalences in women were 13.1% and 24.9%. This female preponderance was present also among subjects expressing the complaints daily or monthly. The prevalences of reported neck or shoulder pain increased significantly with age, while the prevalences of reported headache were not influenced by age. Of the subjects with weekly headache, as many as 30% of both sexes reported being "seriously hampered or unable to perform ordinary work". CONCLUSIONS: many people in the general population live with disabling complaints, but the numbers seeking medical care for them are far fewer. It is important to demonstrate the high prevalence of headache and neck or shoulder pain, and also to understand the complexity of the causal factors, and the reason why only a proportion of sufferers seek professional help.

A computerized medical record. "The Balsfjord system".

The "Balsfjord system" is a fully computerized system of medical records. The system is developed by the University of Tromsö in cooperation with the district physicians in Balsfjord. It is designed for Norwegian general practice based on microcomputers. Each general practitioner has a computer terminal in his/her consulting room, and all the terminals can operate on the same file simultaneously. The main archive is a hard disc, in addition there is a a secondary diskette archive for old, out of date record versions. Each medical record is composed of seven components, where the medical information is logically organized. The system is able to print out prescriptions, sick-leave forms, and parts or the whole record. Included in the program are two statistical systems. One is based on data from encounters, and the other is a search and statistical system based on the individual record as the unit. The system has been very successful for the two and a half years it has been in use. Both the doctors and the ancilliary staff have appreciated the system in their daily work.