Self-administered questionnaire compared with a personal diary for assessment of current use of hormone therapy: an analysis of 16,060 women.

A personal diary may be more appropriate than a questionnaire for assessing self-reported current use of hormone therapy (estrogens, progestagens, or their combination); however, use of a questionnaire is more feasible and less expensive. The authors compared both methods for 16,060 Swedish women aged 45-73 years from the Malmo Diet and Cancer Study (baseline, 1991-1996). In a reliability analysis, the authors investigated the agreement (kappa value) between the questionnaire and the diary regarding current hormone therapy use (yes vs. no), studying the ability to replicate results whether or not they were correct. They also explored associations between discrepancy and individual characteristics. A validity analysis was conducted to determine whether use of the questionnaire achieved an outcome without systematic error (i.e., high specificity and sensitivity); the personal diary was considered the "gold standard." Agreement between both methods was high: 95.5% (kappa = 0.840). The sensitivity was 84.9% and the specificity 97.7%. Higher body mass index and being a widow were associated with agreement, whereas age (50-59 years), use of anxiolytics/hypnotics or opiates, high alcohol consumption, past smoking, and higher educational level were associated with discrepancy. Compared with a personal diary, a simple self-administered questionnaire is a valid method for assessing current use of hormone therapy.

Quality of life and hormone therapy in women before and after menopause.

OBJECTIVE: To study how women evaluate their quality of life (QoL) in relation to age, menopause and hormone therapy (HT). DESIGN: An anonymous postal questionnaire comprising the Gothenburg QoL Instrument and items concerning menopause, symptoms, diseases, drugs and smoking. SETTING: A primary care district in southern Sweden. SUBJECTS: All women aged 45, 50, 55 and 60 in 1995 (n = 126), 1996 (n = 130), 1997 (n = 134) and 1998 (n = 145). MAIN OUTCOME MEASURES: QoL (global, social, physical/mental well-being) and number of symptoms (psychological, physical) reported during the past 3 months. RESULTS: The older women rated their QoL, especially social well-being (p < 0.001), higher and reported a lower number of symptoms, particularly psychological symptoms (p = 0.02), than the younger women did. Pre- and post-menopausal women in the various age groups did not differ on the main outcome measures. A history of HT and use of hormonal contraceptives tended to be associated with lower well-being and a greater number of symptoms, an association found in women 55 years of age to be highly significant (p < 0.01-0.001) for all the main outcome measures. CONCLUSION: The effects of menopause on QoL seemed generally to be of minor importance. QoL in women was lower in those with a history of HT than in those with no such experience.

Qualitative study of pregnancy and childbirth experiences in Somalian women resident in Sweden.

OBJECTIVE: To explore the attitudes, strategies and habits of Somalian immigrant women related to pregnancy and childbirth, in order to gain an understanding as to how cultural factors might affect perinatal outcome. METHODS: Interpreter assisted qualitative in depth interviews around topics such as attitudes and strategies regarding childbirth. PARTICIPANTS: Fifteen women from the Somalian community in a city in Sweden, between the ages of 20 and 55 years with delivery experience in Somalia and Sweden. RESULTS: The interviews describe how the women themselves perceived their experiences of childbirth in the migrant situation. Many voluntarily decreased food intake in order to have a smaller fetus, an easier delivery and to avoid caesarean section. The participants considered a safe delivery to be the same as a normal vaginal delivery They reduced food intake in order to diminish the growth of the fetus, thereby avoiding caesarean section and mortality. The practice of food intake reduction, while rational for the participants when in Somalia, was found less rational in Sweden and may lead to suboptimal obstetric surveillance. CONCLUSIONS: Somalian women have childbirth strategies that differ from those of Swedish women. These strategies should be seen as 'survival behaviours' related to their background in an environment with high maternal mortality. The hypothesis generated is that there is a relationship between the strategies during pregnancy and adverse perinatal outcome among Somalian immigrants. Considering the strong association of the habits to safe birth, it seems doubtful whether the women will change their habits as long as health care providers are unaware of their motives. We suggest a more culturally sensitive perinatal surveillance.

[Climacteric--medicalization, minimalization or normalization?]. / Klimakteriet--sjukligt, bagatelliserat eller normalt?

Women's experiences and ideas about the climacteric are not in accord with the biomedical model, in which the climacteric and the menopause are characterized as being a risk factor for various diseases and a cause of "estrogen deficiency", a hormonal disease which is assumed to persist during the rest of life. The biomedical model may lead to medicalization and pathologizing, increasing the subordination of women and making them dependent on the health care system. Women who use hormonal therapy during the climacteric have many characteristics differentiating them from women who do not use such therapy. Thus, epidemiological studies will be difficult to interpret with respect to the long term effects of hormonal therapy. It is argued that the consultation for women of middle-age should be characterized by a holistic view of the woman taking account of her gender identity, life conditions and life situation. Such a view should focus on the woman's own ideas as to diagnostic procedures, treatment and solutions. In view of the lack of knowledge about the pros and cons of hormonal therapy, women themselves should make the decision, and such decisions should be encouraged. Also, the efforts directed towards women's compliance to hormonal therapy can be questioned. Women's climacteric symptoms should neither be medicalized, pathologized or minimized.

Measurement of C-reactive protein and the erythrocyte sedimentation rate in general practice.

OBJECTIVE: To evaluate the NycoCard:::CRP test (Nycomed A/S, Oslo, Norway) in relation to ESR in consecutive patients in general practice. NycoCard:::CRP test was also compared with a reference method for CRP quantitation. DESIGN: C-reactive protein and ESR were simultaneously measured in 607 consecutive patients at four community health centres. SETTING: Four community health centres in southern Sweden. RESULTS: We obtained consistent results in 71% of the cases. In 20% CRP was increased more than ESR, while ESR was increased more than CRP in 9%. CRP was increased in 16% while ESR was below the upper reference limit for age and sex. On the other hand ESR was increased while CRP was below 10 mg/l in five % of the patients. In most of the cases where there was a discrepancy- for example, in infectious diseases-the CRP results were more clear-cut. Using the NycoCard test the CRP concentration can be measured directly in a whole blood sample with the result available within minutes. Comparison of the NycoCard:::CRP test with the reference method for CRP quantitation showed good agreement. CONCLUSION: In clinical situations with suspected inflammatory diseases, the CRP test appears often to yield more useful results than the ESR. The NycoCard:::CRP test is suitable for use in general practice.

Drug prescription attitudes and behaviour of general practitioners. Effects of a problem-oriented educational programme.

A producer-independent, problem-oriented, group-education programme with 2-day meetings on drug treatment in primary health care (PHC) was developed and evaluated. Initially, it was tested on a selected group of general practitioners (district physicians), using a non-exposed group as control. A comprehensive questionnaire was used to test changes in attitudes. There was a significant change in attitudes concerning both general opinions on drugs and drug use, on information about drug treatment, and on use of drugs in selected therapeutic areas. Also, the district physicians became more critical towards information from pharmaceutical companies. Prescribing patterns tended to change in accordance with the attitude changes. Subsequently, the programme was offered to all district physicians (about 550) in the southern Swedish health care region for a 10-year period, with 20-25 district physicians per 2-day meeting. The impact of the programme on the prescribing of a selected group of drugs (antibiotics) was assessed by voluntary registration of prescription by the participants, by regional prescription analyses and by analyses of drug sales data. There were significant, consistent, and sustained changes in the prescribing of antibiotics. The study supports the view that, if drug prescribing in general practice is to be improved, producer-independent, problem-oriented, face-to-face, small-group education on drug treatment is worthwhile.

Vaginal discharge--comparison of clinical, laboratory and microbiological findings.

Of 101 fertile women (15-50 years of age) consulting in general practice due to vaginal discharge and/or genital malodor, bacterial vaginosis was diagnosed in 34% and vaginal candidiasis in 23%. The presence of Chlamydia trachomatis, Trichomonas vaginalis, genital herpes virus and Neisseria gonorrhoeae was demonstrated in 15%, 9%, 7%, and 1% of cases, respectively. No specific genital tract pathogens were found in 25 patients, where the clinical diagnosis was psychological factors (n = 5), intra-uterine device-associated discharge (n = 5), cytolytic vaginosis (n = 5), urinary tract infection (n = 3), or other/unknown causes (n = 7). In most cases diagnosis of bacterial vaginosis, vaginal candidiasis or trichomoniasis was established by clinical examination and simple office tests (pH indicator paper, amine test, microscopy of wet smear, yeast culture kit). C. trachomatis and N. gonorrhoeae were diagnosed by means of culture, cervicitis being diagnosed clinically in five of 15 cases with culture-confirmed chlamydial infection, while gonorrhoea was suspected from findings in a stained cervical smear. Sexually transmitted micro-organisms were detected in 16% of women with bacterial vaginosis or candidiasis. Of 29 women with sexually transmitted agents, 14% harbored more than one such organism.

Antibiotics prescription in primary care: a 5-year follow-up of an educational programme.

An educational programme on the use of antibiotics for respiratory tract infections (RTIs) in primary care, initiated among district physicians at the Community Health Centre of Höör, Sweden in 1985, resulted in an overall reduction in prescriptions for antibiotics, particularly broad-spectrum antibiotics. The aim of the present study was to evaluate the long-term effects of the programme on antibiotic prescription patterns at the centre. Since 1985, computerized records have been kept of every consultation at the centre, including details of the attending physician, the patient, diagnosis and type of antibiotic prescribed. Moreover, during a 3-month period in 1991, each pharmacy in the region recorded details of all prescriptions for antibiotics dispensed. Estimated immediately after the programme, the proportion of RTI patients prescribed antibiotics had fallen to 44%, a figure virtually unchanged 5 years later. During the subsequent five-year period, antibiotics dispensed at the pharmacy in Höör were further reduced from 14.1 to 13.2 defined daily doses 1000 inhabitants-1 day-1. As compared with district physicians at other community health centres in the region, those at Höör prescribed more penicillin V (80% of all antibiotic prescriptions) and less broad-spectrum antibiotics. The educational programme, combined with an active interest among district physicians at Höör in current research into antibiotic usage, has thus wrought enduring changes in the pattern of antibiotic prescription. A probable contributory factor was the district physicians' awareness that the computerized registration of diagnosis and treatment enables prescription patterns to be audited at an individual level.

Dyspepsia in general practice: history and symptoms in relation to Helicobacter pylori serum antibodies.

BACKGROUND: This study was designed to explore the relationships between serologic Helicobacter pylori positivity and demographic, behavioural, and symptomatologic factors in patients consulting for dyspeptic symptoms in general practice. METHODS: H. pylori enzyme-linked immunosorbent assay results and checklist data were collected by general practitioners at three community health centers in southern Sweden from consecutive patients aged 18-65 years with upper abdominal pain or discomfort (dyspepsia). RESULTS: Of the 130 available patients with dyspepsia, 127 agreed to participate, 45 (mean age, 41.2 years) being classified as H. pylori-positive and 82 (mean age, 33.5 years) as H. pylori-negative. Manual workers were diagnosed as H. pylori-positive significantly more often than were non-manual workers (p < 0.05). Of those patients examined earlier by gastroscopy or roentgenography, H. pylori-positives reported stomach or duodenal ulcer significantly more often than did H. pylori-negatives (p < 0.01). H. pylori-positives reported stomach/duodenal ulcer in their parents/siblings to a significantly greater extent than did H. pylori-negatives (45.2% versus 10.1%, p < 0.001). H. pylori-negatives reported stress-generated symptoms significantly more often than did H. pylori-positives (82.9% versus 61.5%, p < 0.01). Hierarchical regression analyses showed that, when age and sex were controlled for, the ability of each of these measures to predict the serologic results remained significant. CONCLUSIONS: Higher levels of H. pylori antibodies in dyspeptic patients appear to be associated with a relatively low self-perception of stress, with manual work, with being older, and with the occurrence, both in the patients themselves and in their close relatives, of stomach/duodenal ulcer.

Dyspepsia in general practice: psychological findings in relation to Helicobacter pylori serum antibodies.

Questionnaire data based on traditional concepts for measuring hypochondriasis and depression were related to serological data on Helicobacter pylori antibodies in 110 of 130 consecutive patients, aged 18-65 yr, consulting for dyspeptic symptoms in general practice. Of the patients thirty-seven (33.6%) and seventy-three (66.4%) were classified as H. pylori positives and H. pylori negatives, respectively, the H. pylori positive patients being significantly older than H. pylori negative patients. Factor analyses of the questionnaire data indicated the heterogeneity of each of the traditional concepts for measuring hypochondriasis and depression but succeeded in differentiating orthogonally between two hypochondriasis factors and three depression factors. Hierarchical regression analyses of factor scores, controlling for the influence of age and sex, indicated higher H. pylori antibody activity to be associated with less hypochondriacal signs of anxiety and uneasiness. It is hypothesized, that in dyspepsia without signs of H. pylori infection, somatization may account to a substantial extent for the illness.

[Women's health and ill health from a gender theoretic perspective]. / Kvinnors hälsa och ohälsa ur ett könsteoretiskt perspektiv.

Accumulated knowledge of women's health remains incomplete, and its fragmentary nature may be explained by a variety of factors: the contrived 'invisibility' of women in research, normative male predominance, gender bias, an inadequate female power base, insufficient resources, etc. The health paradox--i.e., the relative longevity of women versus their greater proneness to disease and symptoms--is discussed and two models, a biological/genetic and a sociocultural model, are presented in an attempt to explain it. The adoption of a gender perspective in future research is suggested as a possible mean of eliciting new knowledge in this field.

Erythromycin versus metronidazole in the treatment of bacterial vaginosis.

Of 101 women, 15-50 years of age, presenting with vaginal discharge, 34 had bacterial vaginosis and were randomly assigned to a seven-day course of oral treatment with either erythromycin (0.5 g b.i.d.) or metronidazole (0.4 g b.i.d.) in a single-blind, cross-over study. Treatment failure (> or = three clinical signs of bacterial vaginosis) occurred in 13 (81%) of 16 patients given erythromycin, as compared with three (17%) of 18 women treated with metronidazole (p < 0.001). Persistence of Gardnerella vaginalis, Mobiluncus species and/or Mycoplasma hominis was found in 14 of 16 patients treated with erythromycin, and in four of 16 patients treated with metronidazole. Treatment with metronidazole was successful (< or = two clinical signs of bacterial vaginosis) in eight of 10 cases of erythromycin treatment failure. Neither of two cases of metronidazole treatment failure was cured with erythromycin. At three-month follow-up of 31 women, persistence or recurrence of bacterial vaginosis was diagnosed in 11 cases (36%).