Particulate matter in the workplace: effects of a mental models-based folder combined with a practical assignment.

BACKGROUND: With increasing knowledge on the adverse health effects of certain constituents of PM (particulate matter), such as silica, metals, insoluble ions, and black carbon, PM has been under the attention of work safety experts. Previously, we investigated the perceptions of blue-collar workers in highly exposed areas of work. Subsequently, we developed an instruction folder highlighting the most important aspects of PM risk and mitigation, and tested this folder in a digital experiment. The digital experiment yielded positive results with regards to acquired knowledge about PM, but did not on risk perception or safety behavior. METHODS: In this study, we investigate the effects of the folder when combined with a practical assignment involving a PM exposimeter, showing the amount of particulate matter in microgram per cubic meter in real time on its display for various activities. We tested this at six workplaces of four companies in the roadwork and construction branch. RESULTS: The results indicate that the folder itself yields an increased knowledge base in employees about PM, but the effects of the practical assignment are more contentious. Nevertheless, there is an indication that using the assignment may lead to a higher threat appraisal among employees for high exposure activities. CONCLUSION: We recommend implementing our folder in companies with high PM exposure and focusing further research on appropriate methods of implementation.

Development and usability of educational material about workplace particulate matter exposure.

BACKGROUND: Particulate matter (PM) exposure is an important health risk, both in daily life and in the workplace. It causes respiratory and cardiovascular diseases and results in 800,000 premature deaths per year worldwide. In earlier research, we assessed workers' information needs regarding workplace PM exposure, the properties and effects of PM, and the rationale behind various means of protection. We also concluded that workers do not always receive appropriate risk communication tools with regards to PM, and that their PM knowledge appears to be fragmented and incomplete. METHODS: We considered several concepts for use as an educational material based on evaluation criteria: ease of use, costs, appropriateness for target audiences and goals, interactivity, implementation issues, novelty, and speed. We decided to develop an educational folder, which can be used to inform employees about the properties, effects and prevention methods concerning PM. Furthermore, we decided on a test setup of a more interactive way of visualisation of exposure to PM by means of exposimeters. For the development of the folder, we based the information needs on our earlier mental models-based research. We adjusted the folder based on the results of ten semi-structured interviews evaluating its usability. RESULTS: The semi-structured interviews yielded commentaries and suggestions for further improvement, which resulted in a number of alterations to the folder. However, in most cases the folder was deemed satisfactory. CONCLUSION: Based on this study, the folder we developed is suitable for a larger-scale experiment and a practical test. Further research is needed to investigate the efficacy of the folder and the application of the exposimeter in a PM risk communication system.

Psychological factors associated with the intention to choose for risk-reducing mastectomy in family cancer clinic attendees.

OBJECTIVES: Women seeking counseling because of familial breast cancer occurrence face difficult decisions, such as whether and when to opt for risk-reducing mastectomy (RRM) in case of BRCA1/2 mutation. Only limited research has been done to identify the psychological factors associated with the decision for RRM. This study investigated which psychological factors are related to the intention to choose for RRM. MATERIALS & METHODS: A cohort of 486 cancer-unaffected women with a family history of breast cancer completed the following questionnaires prior to genetic counseling: the Cancer Worry Scale, Positive And Negative Affect Scale, Perceived Personal Control Scale, Hospital Anxiety and Depression Scale and State Anxiety Scale and questions regarding socio-demographic characteristics, family history, risk perception and RRM intention. Multivariate logistic regression was used to analyze the relation between psychological factors and women's intention to choose for RRM. RESULTS: Factors associated with RRM intention were high positive affect (OR = 1.86, 95%CI = 1.12-3.08), high negative affect (OR = 2.52, 95%CI = 1.44-4.43), high cancer worry (OR = 1.65, 95%CI = 1.00-2.72), high perceived personal control (OR = 3.58, 95%CI = 2.18-5.89), high risk-perception (OR = 1.85, 95%CI = 1.15-2.95) and having children (OR = 2.06, 95%CI = 1.21-3.50). CONCLUSION: Negative and positive affects play an important role in the intention for RRM. Furthermore, perceived personal control over the situation is associated with an intention for RRM. In addition to focusing on accurate risk communication, counseling should pay attention to the influence of perceived control and emotions to facilitate decision-making.

[Information is more than just the number]. / Informatie is meer dan alleen het getal.

In order to be able to make informed choices, it is important that patients have transparent information about the pros and cons of treatment. When using the number unnecessarily treated (NUT) as information for patients, we should take the following into account. First, patients should understand that non-effective treatment may still do harm. This might be in contradiction with their ideas about the effects of treatment. Second, as many patients have difficulties understanding numbers and probabilities, the usefulness of NUT may be limited. Third, it is very important to use the proper presentation format to make the information intuitively meaningful for patients. A natural frequency tree and not a population diagram appears to be the optimal format for this purpose. When giving patient information the premise is that the form of the message is more important than the numbers.

Knowledge and Informed Decision-Making about Population-Based Colorectal Cancer Screening Participation in Groups with Low and Adequate Health Literacy.

Objective. To analyze and compare decision-relevant knowledge, decisional conflict, and informed decision-making about colorectal cancer (CRC) screening participation between potential screening participants with low and adequate health literacy (HL), defined as the skills to access, understand, and apply information to make informed decisions about health. Methods. Survey including 71 individuals with low HL and 70 with adequate HL, all eligible for the Dutch organized CRC screening program. Knowledge, attitude, intention to participate, and decisional conflict were assessed after reading the standard information materials. HL was assessed using the Short Assessment of Health Literacy in Dutch. Informed decision-making was analyzed by the multidimensional measure of informed choice. Results. 64% of the study population had adequate knowledge of CRC and CRC screening (low HL 43/71 (61%), adequate HL 47/70 (67%), p > 0.05). 57% were informed decision-makers (low HL 34/71 (55%), adequate HL 39/70 (58%), p > 0.05). Intention to participate was 89% (low HL 63/71 (89%), adequate HL 63/70 (90%)). Respondents with low HL experienced significantly more decisional conflict (25.8 versus 16.1; p = 0.00). Conclusion. Informed decision-making about CRC screening participation was suboptimal among both individuals with low HL and individuals with adequate HL. Further research is required to develop and implement effective strategies to convey decision-relevant knowledge about CRC screening to all screening invitees.

Employees are ambivalent about health checks in the occupational setting.

BACKGROUND: Employees are increasingly provided with preventive health checks. However, participation rates are low and several ethical issues arise, such as a potential perceived threat to autonomy and privacy. AIMS: To assess what employees think about preventive health checks in the occupational setting. METHODS: Samples of construction workers and the general working population in the Netherlands completed a survey about preventive health checks in the occupational setting. We asked half of each sample about potential benefits and drawbacks of health checks, and the other half about how they should be offered. We employed explorative factor analysis to identify constructs related to perceived benefits and drawbacks, and the way health checks should be provided. We then conducted descriptive analyses and t-tests to compare subgroups of respondents. RESULTS: A total of 482 (27%) of construction workers and 738 (65%) employees from the general population responded. The overall survey response rate was 42% with 41% completing the first questionnaire and 42% the second. We identified three constructs related to perceived benefits and drawbacks: self-control over health, disturbance and negative emotion and lack of autonomy. Participants rated 'self-control over health' as the highest potential benefit (mean = 3.40; SD = 0.69), and 'your employer interfering in your personal life' as the most important potential drawback (mean = 3.27; SD = 1.00). Participants indicated that they would like to receive help from their occupational physician when an increased health risk is identified (mean = 4.02; SD = 0.69). CONCLUSIONS: Employees are ambivalent and hesitant concerning preventive health checks in the occupational setting.

Being at risk for cardiovascular disease: perceptions and preventive behavior in people with and without a known genetic predisposition.

This study compares and explains differences in perceptions of cardiovascular disease (CVD) risk and preventive behaviors in people with and without a known genetic predisposition to CVD. A cross-sectional study using two samples was performed. The first sample (genetic predisposition; n = 51) consisted of individuals recently diagnosed with familial hypercholesterolemia (FH) through DNA testing. The second sample (no genetic predisposition; n = 49) was recruited among patients with CVD-risk profiles based on family history of CVD, cholesterol levels, and blood pressure, registered at general practices. Participants filled out a postal questionnaire asking about their perceived risk, causal attributions (i.e. genetic and lifestyle), and about perceived efficacy and adoption of preventive behavior (i.e. medication adherence and adoption of a healthy diet and being sufficiently active). Perceived comparative risk, genetic attributions of CVD, and perceived efficacy of medication were higher in the "genetic predisposition" sample than in the "no genetic predisposition" sample. The samples did not differ on lifestyle attributions, efficacy of a healthy lifestyle, or preventive behavior. Individual differences in perceived risk, genetic attributions, perceived efficacy of medication, and adoption of a healthy lifestyle were best explained by family history of CVD. Our findings suggest that in people diagnosed with a single gene disorder characterized by a family disease history such as FH, family disease history may be more important than DNA information in explaining perceptions of and responses to risk.

Exploring the causes of adverse events in hospitals and potential prevention strategies.

OBJECTIVES: To examine the causes of adverse events (AEs) and potential prevention strategies to minimise the occurrence of AEs in hospitalised patients. METHODS: For the 744 AEs identified in the patient record review study in 21 Dutch hospitals, trained reviewers were asked to select all causal factors that contributed to the AE. The results were analysed together with data on preventability and consequences of AEs. In addition, the reviewers selected one or more prevention strategies for each preventable AE. The recommended prevention strategies were analysed together with four general causal categories: technical, human, organisational and patient-related factors. RESULTS: Human causes were predominantly involved in the causation of AEs (in 61% of the AEs), 61% of those being preventable and 13% leading to permanent disability. In 39% of the AEs, patient-related factors were involved, in 14% organisational factors and in 4% technical factors. Organisational causes contributed relatively often to preventable AEs (93%) and AEs resulting in permanent disability (20%). Recommended strategies to prevent AEs were quality assurance/peer review, evaluation of safety behaviour, training and procedures. For the AEs with human and patient-related causes, reviewers predominantly recommended quality assurance/peer review. AEs caused by organisational factors were considered preventable by improving procedures. DISCUSSION: Healthcare interventions directed at human causes are recommended because these play a large role in AE causation. In addition, it seems worthwhile to direct interventions on organisational causes because the AEs they cause are nearly always believed to be preventable. Organisational factors are thus relatively easy to tackle. Future research designs should allow researchers to interview healthcare providers that were involved in the event, as an additional source of information on contributing factors.

Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study.

OBJECTIVE: This study determined the incidence, type, nature, preventability and impact of adverse events (AEs) among hospitalised patients and potentially preventable deaths in Dutch hospitals. METHODS: Using a three-stage retrospective record review process, trained nurses and doctors reviewed 7926 admissions: 3983 admissions of deceased hospital patients and 3943 admissions of discharged patients in 2004, in a random sample of 21 hospitals in the Netherlands (4 university, 6 tertiary teaching and 11 general hospitals). A large sample of deceased patients was included to determine the occurrence of potentially preventable deaths in hospitals more precisely. RESULTS: One or more AEs were found in 5.7% (95% CI 5.1% to 6.4%) of all admissions and a preventable AE in 2.3% (95% CI 1.9% to 2.7%). Of all AEs, 12.8% resulted in permanent disability or contributed to death. The proportion of AEs and their impact increased with age. More than 50% of the AEs were related to surgical procedures. Among deceased hospital patients, 10.7% (95% CI 9.8% to 11.7%) had experienced an AE. Preventable AEs that contributed to death occurred in 4.1% (95% CI 3.5% to 4.8%) of all hospital deaths. Extrapolating to a national level, between 1482 and 2032 potentially preventable deaths occurred in Dutch hospitals in 2004. CONCLUSIONS: The incidence of AEs, preventable AEs and potentially preventable deaths in the Netherlands is substantial and needs to be reduced. Patient safety efforts should focus on surgical procedures and older patients.

Reconsidering prenatal screening: an empirical-ethical approach to understand moral dilemmas as a question of personal preferences.

In contrast to most Western countries, routine offer of prenatal screening is considered problematic in the Netherlands. The main argument against offering it to every pregnant woman is that women would be brought into a moral dilemma when deciding whether to use screening or not. This paper explores whether the active offer of a prenatal screening test indeed confronts women with a moral dilemma. A qualitative study was developed, based on a randomised controlled trial that aimed to assess the decision-making process of women when confronted with a test offer. A sample of 59 women was interviewed about the different factors balanced in decision-making. Participants felt themselves caught between a need for knowledge and their unwillingness to take on responsibility. Conflict was reported between wishes, preferences and ethical views regarding parenthood; however, women did not seem to be caught in a choice between two or more ethical principles. Participants balanced the interests of the family against that of the fetus in line with their values and their personal circumstances. Therefore, we conclude that they are not so much faced with an ethical dilemma as conflicting interests. We propose that caregivers should provide the opportunity for the woman to discuss her wishes and doubts to facilitate her decision. This approach would help women to assess the meaning of testing within their parental duties towards their unborn child and their current offspring.

Primary prevention of cardiovascular diseases in general practice: mismatch between cardiovascular risk and patients' risk perceptions.

OBJECTIVE: Guidelines on primary prevention of cardiovascular disease (CVD) emphasize identifying high-risk patients for more intensive management, but patients' misconceptions of risk hamper implementation. Insight is needed into the type of patients that general practitioners (GPs) encounter in their cardiovascular prevention activities. How appropriate are the risk perceptions and worries of patients with whom GPs discuss CVD risks? What determines inappropriate risk perception? METHOD: Cross-sectional study in 34 general practices. The study included patients aged 40 to 70 years with whom CVD risk was discussed during consultation. After the consultation, the GPs completed a registration form, and patients completed a questionnaire. Correlations between patients' actual CVD risk and risk perceptions were analyzed. RESULTS: In total, 490 patients were included. In 17% of the consultations, patients were actually at high risk. Risk was perceived inappropriately by nearly 4 in 5 high-risk patients (incorrect optimism) and by 1 in 5 low-risk patients (incorrect pessimism). Smoking, hypertension, and obesity were determinants of perceiving CVD risk as high, whereas surprisingly, diabetic patients did not report any anxiety about their CVD risk. Men were more likely to perceive their CVD risk inappropriately than women. CONCLUSION: In communicating CVD risk, GPs must be aware that they mostly encounter low-risk patients and that the perceived risk and worry do not necessarily correspond with the actual risk. Incorrect perceptions of CVD risk among men and patients with diabetes were striking.

Waiting for elective general surgery: impact on health related quality of life and psychosocial consequences.

BACKGROUND: Long waiting times for elective surgical treatment threaten timely care provision in several countries. The purpose of this study was to assess the impact of waiting for elective general surgery on the quality of life and psychosocial health of patients. METHODS: A cross-sectional questionnaire study with postoperative follow-up was performed among patients on waiting lists for surgical treatment of varicose veins (n = 176), inguinal hernia (n = 201), and gallstones (n = 128) in 27 hospitals. RESULTS: In each group the waiting period involved worse general health perceptions (GHPQ), more problems in quality of life (EuroQoL), and raised levels of anxiety (STAI) as compared to after surgery (all differences: p < 0.05). Quality of life was not affected in 19-36% of patients. Emotional reactions to waiting were most negative among patients with gallstones. Prior information about the duration of the wait reduced the negativity of these reactions (p < 0.05). Social activities were affected in 39% to 48% of the patients and 18%-23% of employed patients reported problems with work during the wait. Having waited a longer time was associated with worse quality of life among patients with inguinal hernia. Longer waited times also engendered more negative reactions to waiting among patients with inguinal hernia and gallstones (multilevel regression analysis, p < 0.01). CONCLUSION: Waiting for general surgery mainly involves a prolonged period of decreased health and an affected psychological and social life of the patient in waiting. Variation in the severity of these consequences across patients indicates that the prioritisation of patients could reduce the overall burden of waiting. Early information about the duration of the delay could further promote a patient's acceptance of waiting.

Prioritising patients on surgical waiting lists: a conjoint analysis study on the priority judgements of patients, surgeons, occupational physicians, and general practitioners.

The prioritisation of patients on waiting lists is ascribed high potential for diminishing the consequences of waiting times for elective surgery. However, consistent evidence is lacking about which factors determine patient priority and it is unclear whether different stakeholders have different opinions on this issue. This study, conducted in the Netherlands, investigates the judgements of patients, laypersons (i.e. patients on other waiting lists), and physicians on the priority of patients on waiting lists. Participants were former patients with varicose veins (N=82), inguinal hernia (N=86), and gallstones (N=89), 101 surgeons, 95 occupational physicians, and 65 general practitioners. Each participant judged the priority of paper vignettes of patients with varicose veins, inguinal hernia, and gallstones. The vignettes were designed according to conjoint analysis methodology and described the physical symptoms, the psychological distress, the social limitations, and impairments in work of patients. Multilevel regression analysis of the responses showed that all groups made significant distinctions in patient priority depending on the severity of each characteristic in the vignettes. The physical symptoms and impairments in work had on average the highest impact on priority, but the summed impact of non-physical factors exceeded that of the physical symptoms. The different groups of participants appraised only the importance of the physical symptoms differently, but opinions on priority varied widely within each group. Whereas the high level of agreement between the different groups would facilitate the acceptance and the implementation of explicit prioritisation of patients on the waiting list, the high inter-individual variation signifies that consensus criteria for prioritisation are needed to warrant equity and transparency in care provision.

[Quality of nuchal transluccency measurements: an exploratory study into their performance and evaluation]. / Kwaliteit van nekplooimetingen; een exploratief onderzoek naar de uitvoering en de beoordeling.

OBJECTIVE: To investigate the quality of nuchal translucency measurements that were done as part of a randomised study into screening for Down's syndrome. DESIGN: Exploratory. METHOD: In the period May 2001-April 2003, 396 nuchal translucency measurements were done by 55 sonographers in 13 different echography centres. The sonographers were questioned in writing regarding their training and experience, the procedure and technique used, and the quality assurance. A filled-in questionnaire was received from 42 sono0 images at random from the 2710measurements (70%o) that had been made in 6 centres. These were evaluatedby 3 experts on the basis of the 5 criteria that are used by the Fetal Medicine Foundation (FMF). Each measurement was given 2 points for every criterion that was fulfilled, after which the average of the 3 scores was calculated. RESULTS: Of the 42 respondents, 88% had taken a nuchal translucency measurement course and 45% were certified by the FMF. Calipers were placed incorrectly by 50% of the respondents; 62% of the respondents mentioned the absence of an intern quality check. Concerning the quality-assessment of the nuchal translucency measurements, the assessors unanimously considered i3%o of the 30 images to be suitable for prenatal screen4ngand 43% to be unsuitable; their opinions as to the remaining images differed. The average quality mark was 4.7. CONCLUSION: Many nuchal translucency measurements did not fulfil the quality criteria that are imposed in order to make the measurement reliable as a screening test. There was a lack of quality securance in the echography centres.

[Television watching and some eating habits of 6-14-year-old children in Amsterdam, the Netherlands; a cross-sectional study]. / Televisiekijken en enkele eetgewoonten bij Amsterdamse 6-14-jarigen; een transversaal onderzoek.

OBJECTIVE: To describe the time spent by children between the ages of 6-14 years watching television during a weekday and to examine associated factors. DESIGN: Cross-sectional questionnaire study. METHOD: Data were collected during a vaccination campaign against meningococci C in Amsterdam in September 2002. From a sample of 2910 parents of 6-14-year-old children 1775 agreed to participate in the study. Socio-demographic characteristics and data on television viewing the previous day, the presence of a television in the child's bedroom and on eating habits were collected by short interviews. RESULTS: In total 1587 children were included in the analyses, 805 boys and 782 girls. In total 40.1% of the boys and 36.5% of the girls had watched television for > or = 2 h during the previous day. Among the children < or = 10 years 28.7% had a television in their bedroom, among children > 10 years this was 45.7%. Age (> 10 years), ethnicity (notably Surinam origin) and having a television in the bedroom was related to spending more time watching television. Having parents with a high socioeconomic status (SES) was associated with less television viewing than having parents with a lower SES. Children who had not eaten fresh fruit or who had visited a snackbar the previous day had been watching television for > or = 2 h more often than children who had eaten fresh fruit (p < 0.001) or who had not visited a snackbar (p < 0.05). CONCLUSION: Children spent a lot of time watching television. In view of the relation between television viewing and overweight this is an alarming development. Possibilities for the prevention of overweight by reducing television viewing must be investigated.

Ideals of patient autonomy in clinical decision making: a study on the development of a scale to assess patients' and physicians' views.

OBJECTIVES: Evidence based patient choice seems based on a strong liberal individualist interpretation of patient autonomy; however, not all patients are in favour of such an interpretation. The authors wished to assess whether ideals of autonomy in clinical practice are more in accordance with alternative concepts of autonomy from the ethics literature. This paper describes the development of a questionnaire to assess such concepts of autonomy. METHODS: A questionnaire, based on six moral concepts from the ethics literature, was sent to aneurysm patients and their surgeons. The structure of the questionnaire was assessed by factor analysis, and item reduction was based on reliability. RESULTS: Ninety six patients and 58 surgeons participated. The questionnaire consisted of four scales. Two of the scales reflected the paternalistic and consumerist poles of the liberal individualist model, one scale reflected concepts of Socratic autonomy and of procedural independence, and the fourth scale reflected ideals of risk disclosure. DISCUSSION: The Ideal Patient Autonomy Scale is a 14 item normative instrument. It is clearly distinct from the generally used psychological preference questionnaires that assess preferences for physician-patient roles.

Genetic counselling and the intention to undergo prophylactic mastectomy: effects of a breast cancer risk assessment.

Scientific reports suggest that women at risk for familial breast cancer may benefit from prophylactic mastectomy. However, few data are available about how women decide upon this clinical option, and in particular, what role an objective risk assessment plays in this. The purpose of the present study is to assess whether this objective risk information provided in genetic counselling affects the intention for prophylactic mastectomy. Additionally, the (mediating) effects of breast cancer worry and perceived risk are investigated. A total of 241 women completed a questionnaire before and after receiving information about their familial lifetime breast cancer risk in a genetic counselling session. Path analysis showed that the objective risk information had a corrective effect on perceived risk (beta=0.38; P=0.0001), whereas the amount of breast cancer worry was not influenced by the counselling session. The objective risk information did not directly affect the intention for prophylactic mastectomy. The intention was influenced by perceived risk after counselling (beta=0.23; P=0.002), and by the precounselling levels of perceived risk (beta=0.27; P=0.00025) and breast cancer worry (beta=0.32; P=0.0001), that is, higher levels of perceived risk and breast cancer worry imply a stronger intention for prophylactic mastectomy. A personal history of breast cancer did not directly influence the intention for prophylactic mastectomy, but affected women who had undergone a mastectomy as surgical treatment were more positively inclined to have a prophylactic mastectomy than women who had had breast-conserving therapy. The impact of objective risk information on the intention for prophylactic mastectomy is limited and is mediated by perceived risk. Important determinants of the intention for prophylactic mastectomy were precounselling levels of breast cancer worry and perceived risk, suggesting that genetic counselling is only one event in the entire process of decision making. Therefore, interventions aimed at improving decision making on prophylactic mastectomy should explicitly address precounselling factors, such as personal beliefs and the psychological impact of the family medical history.