Enhancing global capacity in the surveillance, prevention, and control of chronic diseases: seven themes to consider and build upon.

BACKGROUND: Chronic diseases are now a major health problem in developing countries as well as in the developed world. Although chronic diseases cannot be communicated from person to person, their risk factors (for example, smoking, inactivity, dietary habits) are readily transferred around the world. With increasing human progress and technological advance, the pandemic of chronic diseases will become an even bigger threat to global health. METHODS: Based on our experiences and publications as well as review of the literature, we contribute ideas and working examples that might help enhance global capacity in the surveillance of chronic diseases and their prevention and control. Innovative ideas and solutions were actively sought. RESULTS: Ideas and working examples to help enhance global capacity were grouped under seven themes, concisely summarised by the acronym "SCIENCE": Strategy, Collaboration, Information, Education, Novelty, Communication and Evaluation. CONCLUSION: Building a basis for action using the seven themes articulated, especially by incorporating innovative ideas, we presented here, can help enhance global capacity in chronic disease surveillance, prevention and control. Informed initiatives can help achieve the new World Health Organization global goal of reducing chronic disease death rates by 2% annually, generate new ideas for effective interventions and ultimately bring global chronic diseases under greater control.

Patients with alcohol problems in primary care: understanding their resistance and motivating change.

How can physicians motivate patients with alcohol problems when they resist advice to change? A framework for understanding patient resistance is described to help physicians use this motivational approach more effectively with patients.

Active living: just a passing fad?

The shift from a prescriptive exercise model to Canada's Active Living has created considerable tension in the public health and fitness fields. This study examined areas of consensus and debate about Active Living. Semistructured interviews of 42 stakeholders were conducted to capture competing perspectives. Several assumptions concerning the meaning of Active Living were challenged, such as Active Living being an inclusive and holistic concept. Limitations associated with the breadth of Active Living were noted (e.g., operationalization and measurement). Finally, areas of tension were identified: government turf battles,-top-down pressure, fear of replacement/role-loss, perceived lack of expertise, and discomfort associated with the perception of Active Living as a political construct. If Active Living is to be more than just a passing fad, then several challenges must be addressed: 1) clarification and communication of Active Living, 2) establishment of a research base, and 3) enhanced government and organizational support.

Shifting students and faculty to a PBL curriculum: attitudes changed and lessons learned.

BACKGROUND: The University of Toronto Faculty of Medicine is implementing a new undergraduate curriculum that emphasizes active, self-directed learning. The aims of this study were to (1) evaluate shifts in students' attitudes after initial direct experience with problem-based learning (PBL), (2) describe faculty experiences, and (3) develop guidelines for further implementation of PBL. METHOD: Questionnaires were administered at the beginning of the first PBL session and at the close of the last session (five weeks later) to the 250 second-year students in 1992-93 and to their 15 faculty tutors. Quantitative data were analyzed using multivariate analysis of variance and univariate tests. Open-ended questions were categorized based on common patterns that emerged. RESULTS: Of the 250 students, 196 (78%) responded to the pretest, and 207 (83%) responded to the posttest. There was a statistically significant shift in the students' perceptions from pretest to posttest in agreeing that PBL is more effective than traditional teaching methods (increasing from 38% to 52%). The students rated traditional methods as better for knowledge acquisition, whereas PBL methods were rated better for improving teamwork and doctor-patient relationships. At pretest, the most common themes concerned a perceived danger that PBL would result in knowledge gaps, reinforce the wrong information, and make inefficient use of valuable time. Perceived advantages of PBL included that it is more stimulating and enjoyable, and it teaches students how to learn rather than to memorize. At posttest, there was an increase in favorable comments by the students. Virtually all of the attitudes expressed by the students were shared by the faculty. In addition, at pretest the faculty were anxious about the perceived lack of structure in PBL. CONCLUSION: Direct experience with PBL led to more favorable attitudes among the students and faculty. Recommendations are suggested for other schools and programs seeking to implement PBL curricula.

Computer assessment of life-style in a gastroenterology clinic.

To examine the potential benefit of a computer-assisted interview about life-style in gastroenterology practice, 34 consecutive patients attending a gastroenterology clinic were questioned by a computer using software designed to obtain a comprehensive history of alcohol, caffeine, cigarette, and illicit drug use, together with an assessment of exercise, sexual activity, and nutrition. Comparisons of the information obtained by the computer with clinical records revealed that physicians documented only 3% of the patients as problem drinkers, 3% as caffeine abusers, and 17% as smokers, whereas the computer identified 10% of the patients as problem drinkers, 27% as caffeine abusers, and 43% as smokers. These findings imply that patients may be more apt to tell more about adverse life-style to the computer than to a physician during clinical interview. In a sample patient population from a gastroenterology clinic, a microcomputer provides an acceptable, efficient, and potentially cost-effective way to assess life-style.

Measuring psychological outcomes following rehabilitation.

Recent literature leaves little doubt that people with disabilities experience depressive and adjustment disorders at a greater rate that those in the general population. Differences between rates detected in different studies, however, prompt researchers to explore the definition of depression as applied to people with a disability, and to challenge the long-held notions that everyone with a disability undergoes depression at one time or another as part of the process of adjustment to disability. The present study measures the two related, but theoretically distinct, constructs of depression and adjustment to disability in a sample of spinal cord injured adults interviewed at one, four and twelve months post-rehabilitation. On the basis of these data, a two-dimensional measurement model is empirically developed for psychological outcomes, with the two dimensions representing adjustment and depression. The measurement model is supported by data at all three time intervals and by a number of different analyses. These findings underline the importance of distinguishing between depression and adjustment both in clinical applications and in research.

Diagnostic validity of the MAST and the alcohol dependence scale in the assessment of DSM-III alcohol disorders.

The comparative validity of the Michigan Alcoholism Screening Test (MAST) and the Alcohol Dependence Scale (ADS) in screening for current DSM-III alcohol abuse/dependence disorders is evaluated. These scales were administered to 501 patients presenting for treatment of alcohol or drug problems. DSM-III alcohol disorders are diagnosed using the Diagnostic Interview Schedule. Receiver Operating Characteristic (ROC) analysis is used to determine optimum threshold scores for the MAST and ADS and to compare the screening ability of the two instruments. Optimum cut points for the MAST and the ADS are 12/13 and 8/9, respectively. The overall accuracy of classification for both instruments using these threshold scores is 88%. The areas under the ROC curves are .91 and .90 (SD = .02) and there are no significant differences between the MAST and the ADS in their ability to screen for alcohol abuse or dependence in this population. The MAST and the ADS correlate highly with each other (.79). The results reported in our study should be applicable to the revised DSM-III since a field trial found a high level of agreement on alcohol disorders between the diagnostic systems. Categorical versus dimensional approaches to the assessment of alcoholism are discussed.

Spectrum of drinkers and intervention opportunities.

Most adults in North America are either light drinkers or abstainers, so alcohol does not cause them problems. However, a small but often highly visible minority--approximately 5% of the adult population--show major symptoms of alcohol dependence. Between these extremes, there is a sizable group of about 20% of the population, particularly young men, who are drinking at risk levels and have encountered some problems related to their alcohol use. Traditionally, physicians' efforts have focused on diagnosing and treating patients with a substantial history of alcohol dependence, and relatively little attention has been given to early intervention with nondependent problem drinkers, such as identifying patients who present in primary care settings with alcohol-related morbidity or an accidental injury. Recent evidence indicates that early intervention by primary care physicians is an effective strategy for reducing alcohol problems among patients.

Preventing alcohol problems: survey of Canadian medical schools.

In preparation for a national conference on medical education in the prevention of alcohol problems, a survey of conference participants was conducted. Participants were undergraduate and postgraduate representatives from each Canadian medical school and representatives from 11 provincial and territorial alcohol and other drug agencies. There was agreement that physicians and medical schools have important roles in prevention and treatment of alcohol problems, with "traditional" medical roles seen as the most important. Current training is variable and was seen as inadequate, with more time devoted to treatment than prevention. To correct this situation, renewed priorities and faculty leadership are needed. Respondents felt that there should be uniform standards for assessing undergraduate students' skills in dealing with alcohol problems. Provincial alcohol and other drug agencies are underused in medical education in the prevention and treatment of alcohol problems.

Physicians' perception of personal risk of HIV infection and AIDS through occupational exposure.

Physicians' response to acquired immune deficiency syndrome (AIDS) is poorly understood and often attributed to fear of human immunodeficiency virus (HIV) infection through occupational exposure. We surveyed 268 physicians from three geographic regions in North American with different specialties and responsibilities for HIV-positive patients. An important difference was found between the published risk and the physicians' perceived risk of infection after a single occupational exposure. Almost half of the respondents stated that they feared contracting AIDS more than other diseases. The physicians who perceived themselves to be at high physical risk were more likely than the others to report that AIDS had changed the way they interact with their patients (r = 0.26, p less than 0.001). No relation was found between the perception of physical risk and the number of HIV-infected patients (r = -0.07, p = 0.15). However, the perception of social risk showed a small inverse correlation (r = -0.15, p less than 0.02), in which the physicians with more HIV-infected patients reported less concern about negative social consequences. The physicians who perceived themselves to be at high personal risk were more likely than the others to report that surgeons have the right to refuse patients who do not wish to undergo HIV antibody testing (r = -0.16, p less than 0.01 for physical risk; r = -0.29, p less than 0.001 for social risk). Multiple regression analyses indicated that physicians' perception of physical risk was not related to age or sex but was modestly related to income source. The perception of social risk was related to sex and income source. Physicians' perception of personal risk is a crucial, yet often unacknowledged, component of the fight against AIDS. Our findings suggest that lack of attention to this issue is seriously compromising initiatives designed to facilitate physician participation in AIDS care.

Diagnostic validity of the drug abuse screening test in the assessment of DSM-III drug disorders.

Diagnostic validity of the DAST was assessed using a clinical sample of 501 drug/alcohol patients. Various DAST cut-points were validated against DSM-III drug abuse/dependence criteria, as assessed by the Diagnostic Interview Schedule. The DAST attained 85% overall accuracy in classifying patients according to DSM-III diagnosis. This accuracy was maintained between DAST score cut-points of 5/6 through 9/10. Receiver Operating Characteristic analysis indicated that 5/6 was the optimum threshold score. The DAST was also correlated with demographic variables, psychiatric history, and drug use. The results showed very good concurrent and discriminant validity. This study concluded that fairly accurate estimation of DSM-III drug criteria could be made using a brief self-administered questionnaire (DAST). However, caution must be expressed when generalizing these findings to other contexts (e.g. the justice system) where subjects may have stronger motivation to under-report drug involvement.

Understanding physicians' response to AIDS.

Attempts to comprehend physicians' extreme reaction to AIDS (acquired immune deficiency syndrome) have met with great difficulty since the disease brings into question traditional norms and assumptions. As the medical profession struggles to develop guidelines and policies to help it deal with this disease, it can draw on very little systematic research on the effect of AIDS on physicians' attitudes and practices. We suggest a framework developed from the literature on physicians' and society's response to other disorders that would provide a basis for organizing the ever-increasing amount of information on physicians and AIDS and would guide systematic research aimed at understanding and predicting physicians' participation in the prevention and management of AIDS. Within this framework we consider how characteristics of the disease, elements of the health care system and physicians' attitudes interact to influence clinical and personal practices. AIDS had led to new delineations of physicians' responsibility, modification of prevailing beliefs about physician autonomy and thus a redefinition of the role of the physician in North America.

Screening alcohol & drug use in a general practice unit: comparison of computerised and traditional methods.

Systematic screening of patients for areas of health risk in their lifestyle has much potential for primary health care clinicians as a cost-effective and time saving means to identify 'at risk' individuals. In the area of alcohol and drug problems, such early identification increases the likelihood of successful intervention. The present study, conducted at a general practice unit, compared the use of a computer to screen for alcohol and drug use with the two more traditional assessment methods of face-to-face interview and paper and pencil questionnaire. It was found that levels of reported consumption were similar across assessment methods. Although the interview method was strongly preferred overall, patients' preference for the computer increased significantly after use. The computer was also found to be more acceptable to patients reporting non-medical drug use, a potentially threatening and sensitive issue. There was a low refusal rate and most patients were willing to allow their doctor to see the assessment results. This indicates that screening for alcohol and drug use is acceptable to general practice patients, and that the computer can play a useful role as a prevention aid.

Clinical versus laboratory detection of alcohol abuse: the alcohol clinical index.

To determine reliable indicators of alcohol abuse a comprehensive set of clinical and laboratory information was acquired from three groups of subjects with a wide range of drinking histories: 131 outpatients with alcohol problems, 131 social drinkers, and 52 patients from family practice. Findings from clinical examination provided greater diagnostic accuracy than laboratory tests for detecting alcohol abuse. Logistic regression analysis produced an overall accuracy of 85-91% for clinical signs, 84-88% for items from the medical history, and 71-83% for laboratory tests in differentiating the three groups. Further analyses showed 17 clinical signs and 13 medical history items that formed a highly diagnostic instrument (alcohol clinical index) that could be used in clinical practice. A probability of alcohol abuse exceeding 0.90 was found if four or more clinical signs or four or more medical history items from the index were present. Despite recent emphasis on the laboratory diagnosis of alcohol abuse simple clinical measures seem to provide better diagnostic accuracy.