School-based tobacco-control programming and student smoking behaviour.

The study examined the association of a school-based tobacco-control program with students' smoking behaviour over time using three cross-sectional, provincial census datasets (grade 10 students in 1999, grade 11 students in 2000, grade 12 students in 2001). Data were collected from all secondary schools in Prince Edward Island (Canada) using the Tobacco module of the School Health Action, Planning and Evaluation System (SHAPES). The proportion of regular smokers increased from grade 10 (22.3%) to grade 12 (27.8%, chi(2) = 10.35, df = 1, p < 0.001). Being exposed to different school-based tobacco programs and policies in grades 10 and 11 was not associated with the smoking behaviour of grade 12 students. The strongest predictors of smoking behaviour were having friends or close family members who smoke. This preliminary evidence suggests that programs and policies associated with banning smoking and enforcing smoking restrictions at school may be insufficient unless they also address the influence of smoking peers and family members and link to comprehensive programming within the broader context of other community and policy level interventions.

Adolescent readers' responses to the booklet on sex.

PURPOSE: To investigate the reception and the readers' reactions to a booklet about sex, which is mailed annually to all 16-year old Finnish adolescents. METHODS: Eight hundred youngsters were randomly selected to the study. A questionnaire was sent to them six weeks after the mailing of the booklet, The Sextiin. After three rounds, a response rate of 65% (N = 521) was achieved. RESULTS: The booklet reached 97% of the respondents, of whom 72% read all of it. The respondents' attitudes towards and reactions to the Sextiin were mainly positive. They reacted least positively to the articles on homosexuality and masturbation. Twelve percent of the respondents indicated that they opened the condom package that was attached to the Sextiin. CONCLUSIONS: The study shows that the campaign reached its target group well. As the adolescents' reactions to the Sextiin proved to be mainly positive, a claim for further use of the mass media for educational purposes is justified.

A multilevel analysis examining the association between school-based smoking policies, prevention programs and youth smoking behavior: evaluating a provincial tobacco control strategy.

This paper examined how smoking policies and programs are associated with smoking behavior among Grade 10 students (n = 4709) between 1999 and 2001. Data from the Tobacco Module from the School Health Action Planning and Evaluation System were examined using multilevel logistic regression analyses. We identified that (i) attending a school with smoking prevention programs only was associated with a substantial risk of occasional smoking among students with two or more close smoking friends and (ii) attending a school with both smoking prevention programs and policies was associated with substantial risk of occasional smoking among students who did not believe there were clear smoking rules present. Students attending schools where year of enrollment in high school starts in Grade 9 were more likely to be regular and occasional smokers. Each 1% increase in Grade 12 smoking rates increased the odds that a Grade 10 student was an occasional smoker. It appears that grade of enrollment, senior student smoking behavior, close friend's smoking behavior and clear rules about smoking at school can impact school-based tobacco control programming. These preliminary study findings suggest the need for further research targeting occasional smoking behavior and the transition stage into high school.

Use of a tracer activity for health centre evaluation.

The effectiveness of five Finnish health centres was assessed on the basis of a study of their physiotherapy units. This single area of activity proved to be a valid indicator of the general state of affairs in the centres.

Training for primary health care.

New courses in health services studies have been launched at Helsinki University. They offer undergraduates a chance to study this subject to degree and doctoral standards without previous medical training of any kind.

PIP: In 1981, 1st Finnish professorship in general practice (GP) was developed at the University of Helsinki to teach the functions of the health centers. In 1982, a new department of general practice and PHC was set up in Helsinki. This covered general practice teaching for undergraduates and continuing education for GPs. Another new teaching program, the degree program for health services studies, was started in the medical faculty using an integrated, multidisciplinary approach. Newly graduated high school students could apply. A minimum of 4 years of full-time university study is required for the new degree, Master of Health Care. The Department of General Practice and Primary Health Care is involved in undergraduate teaching during the last clinical course for 1 semester. There is a postgraduate course in health care which leads to a doctorate. 2 kinds of courses can lead to a master's degree: 1) the health care program; and 2) a health care teacher training program. The latter consists of: 1) nursing; 2) physical therapy; 3) x-ray technology; 4) laboratory work; and 5) occupational therapy. The health care program consists of nursing and management study lines. The number of students in the health care programs is about 280. Students take entrance exams for admittance. About 60 new students are accepted per year; 20 for nursing; 15 for management; and 20 for the teacher training program. Also, 5-10 Swedish-speaking students are accepted every year. The department is connected with the Helsinki health center. In Finland, a health center is an organization, not a building. Continuing education is organized for GPs and other PHC personnel. Every year 15-17 1-week continuing education courses are offered. In 1988, the department became responsible for vocational training in general practice at the University of Helsinki. In teaching there is close cooperation between the faculties of political science, education, and medicine. 30 weeks of medical studies are required out o f 160--10 weeks of clinical medicine, 10 weeks of biomedicine and 10 weeks of public health science. Many PHC research projects are being undertaken. A project on methods used in continuing education has just been completed. About 20 master's degree theses are being prepared. The 1st students graduated in the fall of 1987. 1st doctoral students in health care began studying in the spring of 1988.

Assessment of medical certificates with a diagnostic outcome method.

This study which focused on the 169 approved certificates for patients applying for the right for "free" medication in a sickness insurance district during one year in Finland shows two interesting findings. These, cannot of course be generalized because of the low number of observations and of doctors involved (total of 17, of whom three had written the majority of the certificates): the strict application of the official criteria to the certificates would have caused 93% of them to be turned down as very deficient, i.e. not qualifying for insurance fund coverage of medication costs, compared with the 33% when using the generally accepted and tested valid criteria. The proportion of the false negatives when using the minimum number of the official criteria would have been 89%. However, all the 169 certificates had been accepted by the sickness insurance board on the advice of the physician member of the board; It was also found that the control of the BP after a treatment period of four months or longer before qualifying for "free" medication was far from adequate according to these data. Indeed, the longer the treatment period the worse the level of control. Although this does not tell anything about the level of control after granting the right for "free" medicines, it raises very serious questions and obviously needs a thorough clarification. If this finding were to be generalised which as yet it is not, it would mean that the whole system of free medication for chronic hypertension became questionable and that urgent measures would be needed to correct this weakness. The problem is of considerable importance from the economic point of view.

Changing status of doctors in Finland.

This short sociological study discusses the changing status of doctors, in regard to both non-medical administrators and the public. Though based on observations in Finland I also see similar trends in other countries, trends which are associated with rapid social change in the West generally. These developments will lead to changes in the esteem in which a community holds its doctors.

The operation of a health centre after a catastrophe in Finland.

In April 1976 the most disastrous peace-time accident in Finland took place in the town of Lapua, where a cartridge-filling station in an ammunition factory exploded and 40 people were killed. I was in charge of the local health centre activities, and describe what happened.

Training managers for primary health care.

The University of Helsinki has devised a powerful in-service training course for managers of health centres. By working together at the University and their own centres on setting objectives, analysing data and solving problems, the participants greatly enhance their management and teamwork skills.

PIP: The University of Helsinki has devised a powerful in-service training course for managers of health centers. In Finland there are 220 health centers responsible for the primary health care of the population within their districts. The average health center has a staff of 150-180, including 8-15 general practitioners, 12-16 public health nurses, and 4-10 registered nurses. There are also 2-4 laboratory technicians, 1-2 X-ray technicians, 6-8 dentists, 1-2 psychologists, and other staff. The population cared for by most centers is up to 30,000 people. In 1990, the Department of General Practice and Primary Health Care at the University of Helsinki arranged a training course for these managers. By the end of the course the participants were supposed to know: how to set objectives for the activities of the health center; how to monitor the effectiveness of activities and the allocation of resources; how to manage their staff; how to collaborate with the other members of the management team; and how to support collaboration between the different professional groups in the health center. Over 100 centers applied for the course, 11 of which were selected. The course had 13 medical directors, 7 leading nurses, and 9 treasurers. The course consisted of 8 intensive training sessions in Helsinki and 7 assignments to be carried out at the workplace during the 2 months between each session. The most demanding part of the course were the assignments between intensive sessions, which ranged from an evaluation of one's own work to an analysis of survey data on the population served by the participants' own center. The last session was held in the Netherlands, where the participants also learned about the Dutch health system and primary health care. The feedback and discussion on the results of each assignment proved to be extremely valuable.

Assessing the adequacy of antihypertensive treatment in a health centre in finland.

The Finnish sickness insurance scheme provides for free medicines for patients suffering from certain chronic diseases, such as hypertension. The level of control of hypertension among a group of 169 patients receiving free medicine was found to be inadequate. There are implications both for the prognosis of the patients and the cost-effectiveness of the free medicine programme.

Use of illness-related ambulatory physician services in Finland.

The total utilization rate of ambulatory illness-related physician services in Finland is higher in big urban health center areas than in rural areas. When only the health center physician utilization rates were studied the finding was opposite. A notable finding related to the impact of the national health planning were the surprisingly equal average utilization rates of public sector health services (health center physician and general hospital outpatient services combined) in both areas. In fact, use of cheaper public services was greater in rural than in urban areas. The difference in total use rates was almost entirely due to the larger use of more expensive private physician services in urban areas. At present, there is a great pressure for increasing the supply of health center services in urban areas to the same level as in rural districts. One of the fundamental questions seems to be the pricing of the two service sectors--public and private.

Analysis of relationships between the availability of resources and the use of health services in Finland. a cross-sectional study.

The relationship between the availability of resources and the use of health services was studied. This study covered the whole population of Finland. The unit of study was a health center area. The method of analysis was multiple regression involving the following variables: supply of health center physicians; supply of hospital physicians (reflecting the private medical sector); supply of sick-ward beds in old-age homes; supply of health center hospital beds; supply of public health nurses; and supply of general hospital beds. Several background variables also were included in the equations. It was concluded that a considerable change in the pattern of health services use was dependent on the number of physicians working in primary care in health centers. An increase in the number of these physicians and in physicians working at the outpatient departments of general hospitals is associated with a considerable increase in the number of visits per population to these facilities, a reduction in the need to hospitalize the population, and a considerable reduction in the rate of private-sector contact outside hospitals. The role of public health nurses appeared to be relatively important in reducing the number of health center hospital days, which probably is because of the home nursing activities of these nurses in health centers. This study demonstrated a significant relationship between the availability of most health services resource variables and the use of various services when other variables known to affect utilization were controlled for.

Primary care physicians and use of health services in Finland.

This article presents results from a study investigating the relationships between the availability of resources and the use of health services in Finland focusing on the health centre physician supply variable. The study uses observations from other studies on the subject and knowledge of the Finnish and other health services as a point of departure. It tries, by using the systems approach, to examine the effects on use of the health services resources considered to be important from the organizational and health policy points of view. The specific aim of the study was to investigate the relationships between the health centre physicians and other health centre resources and use in various health care sectors. The results suggest that the organization of primary health care, including the primary care physicians, has a profound potential effect on the use and costs of the total health care system.

Quality assurance in primary medical care.

Some general ideas of the evaluation of the work of the physician applicable also to primary care physicians are taken up in this article. The presentation is not trying to be a complete review of the topic. It tries, however, to direct attention to the importance of the subject from the point of view of the practising physician and also to point out some ideas of the possible difficulties to be faced in connection with primary medical care. Certain basic weaknesses of the original audit method in the primary setting are indicated. The usefulness of the structure-process-outcome model and of the understanding of the complex interactions and relationships between the various components of this model are stressed. Finally, a couple of promising methods relating to the work of the primary care physician are described. From the practice point of view the basic problem is to decide to what extent either the process or outcome are valid indicators of quality. Here one should keep in mind that correlation between these two measurements may be low and that it has been expressed by some (1) that, fundamentally, validity depends on the strength of the relationship between process and outcome and on our understanding of that relationship.

Quality of care in general practice.

In this article the author discusses some of the principles of evaluation of quality of care in general practice and connects this with some empiric results of a study which attempted to evaluate the quality of work of the general practitioners in a Finnish health centre. Data were obtained by 1) recording all the 8701 persons visiting during one year; 2) drawing a systematic sample of 2540 persons from all those who visited; and 3) abstracting the required information from patient documents to specially planned precoded and pretested forms. The objectives of the study included the investigation of the quality aspects of the health centre doctor services, among other things also the continuity and coordination of care. The results raise questions concerning the quality of work. No general conclusions on the quality of care are drawn, since the data may not be adequate for that. According to the author, the findings emphasise the importance of at least three things: The consideration of what is done in the context of the patients' prognosis, the communication skills of the general practitioners and the communication between the general practitioners who work in the same place. In the light of the described and other findings of the study it is strongly recommended that the study of the contents of the work should be an integral part of today's general practice.

Leadership for motivation in health care.

For primary health care to achieve its potential the providers have to be strongly motivated. Supportive leadership can play a significant part in bringing this about. A study in Finnish health centres showed that leadership functions, such as the encouragement of doctors and nurses, were particularly important in helping staff to feel that they were doing worthwhile jobs.

Unnecessary visits to health centres as perceived by the staff.

The aim of this study was to assess the present situation concerning unnecessary visits to health centres as perceived by the primary health care staff. Associations of this perception with the internal work motivators were analysed. Data consisted of the personnel of four health centres located in various parts of Finland. A pretested questionnaire was employed with a response rate of 87%. The number of responders was 644, comprising 24 administrative staff, 146 general practitioners, 383 nursing staff, and 91 office staff. An estimate of the number of unnecessary visits (%) was obtained using a scale from 0 to 50%. Estimates less than 20% were regarded in the analyses as acceptable by the authors. The methods of analysis included cross tabulations and logistic regression. The theoretical framework for this research was a modification of the work motivation model by Hackman and Oldham. 41% of responders felt that at least 20% of patient visits could be characterized as unnecessary (49% of doctors, 37% of nursing staff). The health centres also differed from each other. The longer the doctors had worked in their present health centre, the less they regarded the visits as unnecessary. Among those doctors who had worked in the health centre less than four years, 63% indicated that 20% or more of all visits to doctors were unnecessary. There was no similar trend with nurses. With the doctors, the most important risk factors among the internal motivators for perceiving the proportions of unnecessary visits high were the lack of work significance and lack of task identity whereas with the nursing staff the important risk factors appeared to be the perceived lack of skill variety of the work and lack of task identity. The study suggests the need for specific postgraduate training for doctors who intend to work permanently in primary health care.