Sociodemographic predictors of self-rated health in patients with diabetes of short duration.

AIMS: To examine the impact of gender and socioeconomic factors on health-related quality of life (HRQoL) one year and eight years after diabetes diagnosis. METHODS: Two national incidence cohorts who contracted diabetes between the ages of 15 and 34 years (n=554) and matched control groups from the general population of Sweden (n=1,029) were surveyed. Data on HRQoL, diabetes treatment, marital status, education, social class, and employment were collected via a questionnaire mailed to the younger cohort (aged 16-35) one year after diagnosis and to the older cohort (aged 23-42) eight years after diagnosis. Response rates were 73% among people with diabetes and 68% among the controls. Multivariable linear regression models were used to analyse the impact of gender and socioeconomic factors on HRQoL in the diabetic and control groups. The dependent variable was the "general health perceptions" score of the SWED-QUAL instrument, which corresponds to the "global self-rated health" concept. RESULTS: A model including all the sociodemographic variables explained 6% of the variance in self-rated health one year after diabetes diagnosis and 13% of the variance eight years after diagnosis. In the control groups, the level of explanation was 2-3%. Female gender was an independent predictor of poor self-rated health in the older diabetic cohort, but not in the younger cohort. CONCLUSIONS: Gender and socioeconomic factors were more closely associated with self-rated health eight years after diabetes diagnosis than one year after diagnosis, indicating early sociodemographic stratification in the health of the diabetic populations studied.

Gender equity in health care: the case of Swedish diabetes care.

To explore the issue of gender equity in diabetes care in Sweden and to develop strategies for monitoring gender equity in health care, population-based studies and statistics published since 1990 were reviewed that contained gender-specific data on health care utilization, glycemic control, patient satisfaction, health-related quality of life, and mortality from diabetes. The review shows that diabetic women in Sweden report more frequent outpatient contacts, less patient satisfaction, and a lower health-related quality of life than diabetic men. No gender differences were found in the level of glycemic control. Young and middle-aged men with diabetes have a high excess all-cause mortality as compared with nondiabetic men. A trend toward stronger social gradient in mortality among women than men with diabetes was observed in a large nationwide study.

Diabetes mellitus and health service utilization: a case-control study of outpatient visits 8 years after diagnosis.

All incident cases of diabetes mellitus in the age group 15 to 34 years have been prospectively registered in Sweden since January 1983. To analyse the utilization of outpatient services 8 years after disease onset, we selected the cases registered in 1983 and two controls per case from the general population, matched by age, gender, and county of residence. In 1991, retrospective data about utilization patterns during a 3-month period were collected via a mailed questionnaire, returned by 317 (72%) patients with diabetes and 586 (68%) controls. Seventy-four percent of the cases and 19% of the controls reported at least one visit to a hospital outpatient clinic, including accident and emergency departments. The odds ratio for one visit was 14 (95% CI 9.6-20), for two visits 11 (95% CI 7.0-18), and for three or more visits 8.9 (95% CI 5.6-14). Even when specialized diabetes clinics were excluded from the analysis, the cases had higher odds for visits to internal medicine clinics, to ophthalmology clinics, and to gynaecology clinics, but not for visits to surgical clinics or to accident and emergency departments. Of non-hospital outpatient services, only visits to nurse practitioners were reported by a higher percentage of diabetic responders. Twenty-seven percent of patients with diabetes, as compared to 9% of the controls, had visited both hospital and non-hospital outpatient offices. Females were overrepresented among diabetic high-consumers. The results indicate that most young to middle-aged Swedish persons with diabetes are monitored at hospital outpatient offices, but considerable overlap exists between hospital and non-hospital outpatient services. Further research is needed into the determinants of utilization patterns in diabetes, such as gender.

The future of global health cooperation: designing a new World Health Organization.

PIP: This article discusses some needed changes to the functioning and management of the World Health Organization (WHO). WHO is unable to meet new challenges and needs reform. The Executive Board of WHO initiated an internal review in 1992 that led to a management-related focus, while informal groups within the agency tackled funding constraints. Some governments and nongovernmental groups have proposed reorganization of international health assistance. The authors urge that the public health sector and researchers join the reform effort. WHO was established in 1948 and was the sole global health agency. The demand for greater international health cooperation has increased over time. WHO is an association of sovereign states. WHO demonstrated success in eliminating smallpox, promotion of health policy, collection and dissemination of epidemiologic information, and establishment of standards in health care and medical ethics. WHO staff comprises about 5000 persons. The annual budget is too small at about US$900 million. In 1995 only 56% of receipts were collected. WHO's constitution mandates complete health for all, but there has been a widening gap between rich and poor and those with access to health services and those without. Absolute and relative poverty are the main determinants of premature mortality and ill health. The major challenge for health policy is this disparity; the focus of international collaboration should be on this issue. The machine metaphor of organizational structure no longer works in today's world. The authors propose that WHO limit functions in health development and create a full mandate for dealing with determinants of health. WHO should be participatory, open to constituents, autonomous, and flexible. Member states must be more powerful in policy formulation. Program implementation should occur in independent programs in a decentralized system.^ieng

The effect of routine hospital care on the health of hypothermic newborn infants in Zambia.

A prospective cohort study was carried out at the University Teaching Hospital, Lusaka, Zambia, to investigate the prevalence of neonatal hypothermia, type of infant care and incidence of mortality. Two-hundred-and-sixty-one infants, aged 0-7 days, admitted to the pediatric unit during the 'warm' season were recruited to the study. Forty-four per cent of the infants were hypothermic (< 36 degrees C) on admission, and admission hypothermia correlated to admission weight and home delivery in the youngest age group (0-24 hours). Exclusively breastfed infants (age group 1-7 days) were less likely to be hypothermic at admission. 'Hypothermia' was not recorded as an admission diagnosis and no special attention was given to those infants in terms of clinical management. Mean time to reach a body temperature above 35.9 degrees C did not differ between infants kept in a cot and in an incubator. Total numbers of death was 82 (31 per cent) and the mortality was higher in infants who were hypothermic at admission compared to those who were not. This study demonstrates that a change of existing care routines is needed.

Effects of "group detailing" on the prescribing of lipid-lowering drugs: a randomized controlled trial in Swedish primary care.

The objective was to study the effect of "academic group detailing" on the prescribing of lipid-lowering drugs in Swedish primary care. A randomized controlled trial was conducted, randomization being by group. Groups of doctors at 134 community health centres were randomly allocated to an intervention and a control group. The 67 intervention health centres were offered four sessions, conducted by a pharmacist, with group information on guidelines for the management of hyperlipidaemia. The number of prescriptions of lipid-lowering drugs per month increased in the intervention health centres and the increase was statistically different from the corresponding change in the control health centres among women in the age group 30-65 years (p = 0.03). The prescription of first-line lipid-lowering drugs increased by 20% in the intervention health centres (p = 0.03). "Academic group detailing" by pharmacists to primary care doctors can be an effective method for influencing prescribing practices.

What future WHO?

New actors on the international health scene have emerged, challenging WHO's leadership in global health. The role and functions of WHO have been questioned. Changes in financing have eroded the influence of the governing bodies. The Nordic countries, which together provide a considerable share of the total voluntary contributions to WHO, have recently made a number of studies of WHO, pinpointing weaknesses and proposing reforms. A slow reform process is also taking place within WHO. The main conclusions from these studies are analyzed and the areas with the greatest need for reform are studied. This paper presents proposals for the far-reaching reforms needed for WHO to recapture its leadership role in international health.

Randomization by group in studying the effect of drug information in primary care.

Drug information is a technology which is rarely evaluated. Practical and ethical considerations limit the use of a classical experimental method (a randomized controlled trial) in studying the effect of drug information in primary care. An alternative approach, randomization by group, is preferable for several reasons: it avoids contamination of the control group; the effect of information can be evaluated in the natural working environment; and the impact of information is increased via diffusion. This article describes the selection of a control group, the Hawthorne effect and 'blindness' in information experiments. Sample size tables and power calculations are presented when randomization by group is used. The study power is influenced by the number of health centres and the variance between them. The number of doctors per health centre plays a less important role, and the number of patients is relatively unimportant. There is also a need to use qualitative methods to prepare information and to understand factors influencing change of behaviour among prescribers.

Drug use and the role of patients and prescribers.

In order to move towards rational drug use in any national or local setting the methods of inquiry have to be expanded. Both the public and private sector have to be addressed. In the latter the pharmacists might be studied using a tracer, fictitious client. One important factor influencing prescribing, drug information, has rarely been assessed scientifically. Experimental studies using group randomization are, however feasible even in developing countries. The individual human being must be in the focus of drug studies and health care and health in the foreground. The combination of qualitative and quantitative methods will assist us to achieve rational drug use that is culturally acceptable, economically feasible and pharmacologically sound.

PIP: In the effort to improve rational drug use in local or national settings, especially in developing countries, the behavior of prescribers and users is the subject of the least research. The effectiveness of drugs depends on a complex set of factors involved in the situation of prescription and acquisition. One aspect that needs examination is the information given to prescribers by drug advertisers and detailers, a deficiency being addressed by an international network of prescribers. In many countries, the largest outlet for drugs is the private sector pharmacies, where drugs are often dispensed without prescription. A simple inexpensive way of researching prescription behavior is to use fictitious tracers to follow case management of given conditions, such as infant diarrhea. There are many factors involved in prescribing; the process must be studied with an epidemiologic approach, i.e., by description, analysis, intervention and evaluation. Standard treatment schedules, essential drugs lists, targeted intervention with treatment guidelines should be audited by local therapeutic committees. Drug information should also be scientifically evaluated by the same analytical principles. The experimental method of group randomization is suggested as a feasible choice for developing countries. In this technique groups of physicians are observed or interviewed, and quantitative outcome data are collected. Behavior of individual users is best studied by combining anthropological and biomedical approaches, from the case-study perspective. An example of a problem amenable to this approach is the possible use of shorter courses of antibiotic treatment to lessen the risk of development of resistant organisms.

Assessment of midwifery routines. Toward a north/south collaborative effort.

Cooperation in midwifery research between Zambia and Sweden is ongoing. Joint studies on gastric suctioning and maternity routines are used as examples, and breastfeeding is discussed from a global perspective. The midwife, who also interprets responses from mothers, is an important member of an assessment team. Cooperation over cultural boundaries is feasible and mutually rewarding.

Maternity care routines in a teaching hospital in Zambia.

At the University Teaching Hospital, Lusaka, Zambia, 59 uncomplicated, vaginally delivered mothers, were studied with regard to maternity care during the antenatal period and delivery. Information was collected from antenatal cards, labour records, observations during delivery and interviews with mothers. The average of more than five antenatal visits indicates that there was a sufficient demand for health care. The results suggest low application of the recommended maternity care routines, positive correlation between application of the maternity care and the mother's educational level and low staff encouragement of self-care among mothers. These findings suggest a need for systematic critical review and, if necessary, modification of current maternal care technologies and improved general and health education of women.

Anthropometry and subsequent mortality in groups of children aged 6-59 months in Guinea-Bissau.

To assess the importance of nutritional status for subsequent survival, 2228 children aged 6-59 mo were followed for 8-12 mo in four different areas of Guinea-Bissau. The overall death rate was 0.62/100 child-months of follow-up (126 deaths) and 0.63 for the 1756 children who were examined on entering the study (109 deaths). Mortality was twice as high in the periurban as in the rural areas due to an outbreak of measles. In a bivariate analysis the relationship between nutritional status indicators and mortality was confounded by the age dependence of both. Using Cox's regression technique, height-for-age but not weight-for-height was positively correlated with survival. The number of children in the household was a better discriminator for death from measles than was nutritional status. Long-term factors, probably of multiple social origin, are likely causes of both relatively short stature and high mortality.

PIP: To assess the importance of nutritional status for subsequent survival, 2228 children aged 6-59 months were followed for 8-12 months in 4 different areas of Guinea-Bissau. The overall death rate was 0.62/100 child-months of follow-up (126 deaths) and 0.63 for the 1,756 children who were examined on entering the study (109 deaths). Mortality was twice as high in the rural areas due to an outbreak of measles. In a bivariate analysis the relationship between nutritional status indicators and mortality was confounded by the age dependence of both. Using Cox's regression technic, height-for-age but not weight-for age was positively correlated with survival. The number of children in a household was a better discriminator for death from measles than was nutritional status. Long-term factors, probably of multiple social origin, are likely causes of both relatively short stature and high mortality.

Acute illnesses in young children and family response.

Swedish speaking parents of 446 children, all around one year of age and living in the suburbs of Stockholm, participated in a three-week diary study. The aim was to describe the pattern of illnesses in children and the measures taken in the family and to correlate the findings with the socio-economic conditions of the family. A health complaint, most frequently running or blocked nose or a cough, was recorded for about 1/3 of the days of observation. Some form of family action was recorded on 70% of these days. Medicines were given on 39% of the complaint days and relatives, friends or a health professional were contacted on less than 10% of the days. In case of acute respiratory infection medicines were given or a health professional contacted more often if the symptom was recorded as severe. Most frequently the Child Health Centre nurse was consulted. The measures taken by the parents were judged to be rational. However, one quarter of the parents expressed uncertainty about the care of the acute infectious disorders of the child. Correlations between family response and socioeconomic factors were weak.

Health problems and care in young families--load of illness and patterns of illness behaviour.

During a winter month 185 young suburban families reported in a diary on perceived health problems and measures taken in response to these problems. Information on socio-economical factors, medical experience and structure of the social network was obtained from a mailed questionnaire. As a mean every fourth individual-day a health problem was recorded. The majority (61%) of symptoms were infections and only 14% of illness days were classified as severe. On every sixth of all reported individual days measures were taken to handle health problems. Seven per cent of measures taken in response to a perceived health problem were taken in collaboration with the social network and in less than 1/10 of reported symptom days and 1/5 of reported illness episodes the professional medical system was contacted. For health problems in children 1/3 of the contacts were taken by telephone and often with the child welfare nurse. The demands for professional help was dependent on type and severity of symptoms, duration of illness episodes as well as on the category of family member. Within the family the health problems were preferentially handled by the mother and the dominating type of treatment was medication (73% of total activity). It is concluded that young families perceive and handle a huge amount of health problems without communication with the professional health care system.

Self-prescribing by way of pharmacies in three Asian developing countries.

The pattern of advice given and drugs dispensed at 75 Asian pharmacies in response to the presentation of a fictitious infant with diarrhoea were studied. Only 16 of the 75 pharmacies gave the appropriate advice--oral rehydration or consultation with a health worker. 19 of 25 pharmacies in Bangladesh, 16 of 25 in Sri Lanka, and 24 of 25 in Yemen Arab Republic dispensed drugs, with or without oral rehydration solution. Fixed-dose combinations of antibiotics and antidiarrhoeal drugs were common. The results are discussed in relation to national drug and diarrhoeal control policies. After further development of the method it might become a useful monitoring instrument.

Determinants of microangiopathy in growth-onset diabetes. With special reference to retinopathy and glycaemic control.

In a quasi-experiment all diabetic children in a defined area were exposed either to an intense clinical treatment or served as a constructed control. The cohort of 146 diabetics was observed prospectively for at least 15 years as to diabetic control, mainly glycosuria, and cross-sectionally examined for microangiopathy on four occasions. Data on family background, social situation, smoking, blood pressure, biochemical status, anthropometry, HLA factors and mortality were also gathered. Throughout the analysis duration was considered and treated as a concomitant variable. Two different strategies have been followed in the analysis, one trying to predict microangiopathy at a fixed and predetermined duration, the other to study determinants of the pattern of microangiopathy occurrence over time. Multiple logistic regression and Cox analysis have been used to fit these strategies. The prevalence of microaneurysms or more advanced stages of retinopathy at 10 years duration was 30 per cent and within 20 years 81 per cent. About 52 per cent had haemorrhages after 20 years. Mild and severe nephropathy after 20 years have been contracted by 50 and 15 per cent respectively. No clear sex differences were seen. Variables significantly explaining retinopathy within 10 years were post-pubertal duration, blood pressure, place of medical supervision and the HLA/DR4 marker. The mean glycosuria was high during puberty irrespective of age at onset. The overall pattern of retinopathy occurrence seemed to be influenced by place of medical supervision, age at onset, blood pressure, family history of ischaemic heart disease and glycemic control. For the progression of retinopathy the role of factors reflecting medical supervision and control of diabetes seemed even greater. Even after accounting for degree of diabetic control the experimental group had a more favourable outcome, suggesting additional quality of care components. Mild nephropathy was less predictable from the above risk factors while previous findings of the important role of elevated blood pressure for severe nephropathy was confirmed. We estimate that half of retinopathy cases were preventable by the "experimental" care and conclude the near-normalization of glycaemia under routine conditions favourably influences the development of diabetic retinopathy.

The epidemiology of diabetes in Swedish children 0-14 years--a six-year prospective study.

Since 1 July 1977, all newly diagnosed diabetic children in Sweden aged 0-14 years have been reported to a central register. During the first 6 years, 2300 newly diagnosed diabetic children out of a population of 1.6 million children were registered. The degree of certainty was close to 100%. The mean of the yearly incidence rate for the whole 6 year period was 23.6 per 100000. The prevalence of insulin dependent diabetes mellitus on 1 July 1980 was 1.48 per 1000 and 1.52 on 1 July 1983. Comparing the first and second 3-year periods, an increase was found (22.7-25.1 per 100000). This increase was consistent when analyzing incidence rates by age, sex, and geographical distribution. Cumulative incidence rates revealed a risk of developing diabetes by the age of 15 years of 3.6 per thousand for boys and 3.2 per thousand for girls. The higher incidence for boys was consistent throughout the study period. Seasonal variations in the incidence rate were also consistent, showing yearly incidence peaks in the autumn and winter months. Incidence peaks were noted for both sexes in the pubertal ages. Age- and sex-standardized morbidity ratios varied significantly within the country. 12.8% of the probands had a first degree relative with Type 1 diabetes, and it was twice as common that this relative was a father as a mother. The high and rapidly increasing incidence of Type 1 diabetes in a genetically stable population such as Sweden calls for case-control studies directed towards the identification of environmental pathogens.

Utilization of emergency care by pre-school children in Stockholm suburbs.

The number of emergency visits (i.e. visits on the same day as the first contact for the problem in question was taken) by a defined population of pre-school children in Stockholm was studied during three months in 1977 and 1982. The aim was to describe the pattern of utilization of care. In 1982 we wanted to study whether instructions to integrate preventive and curative care at Child Health Centres (CHCs) had altered this pattern. All visits to nurses and physicians providing emergency care for children were recorded. The total number of visits was 33 per 1 000 children per week in 1977, and 39 (age-adjusted) in 1982. The increase was attributed to visits to the Child Health Centres. Thirteen and 28% of all the visits, respectively, were paid to the CHC nurses. Considering visits to a physician, there was only a slight increase from 1977 to 1982. In 1977 20% of the visits to a physician occurred within the primary health care organization. In 1982 the figure was 41%. A 29% decrease was recorded for the emergency services at the hospitals, from 1977 to 1982. Our findings show that the nurses at the Child Health Centres are a very important but little recognized resource for the care of sick children. At the CHCs the services are usually established in a way that follows the principles agreed on for the primary health care. It would seem suitable to use these resources also for curative care.