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PubMed2003

Prevention of smoking in adolescents with lower education: a school based intervention study.

OBJECTIVE: To assess the effect of an antismoking intervention focusing on adolescents in lower education. Students with lower education smoke more often and perceive more positive norms, and social pressure to smoke, than higher educated students. An intervention based on peer group pressure and social influence may therefore be useful to prevent smoking among these students. DESIGN: Group randomised controlled trial. SETTING: 26 Dutch schools that provided junior secondary education. SUBJECTS: 1444 students in the intervention and 1118 students in the control group, all in the first grade, average age 13 years. INTERVENTION: Three lessons on knowledge, attitudes, and social influence, followed by a class agreement not to start or to stop smoking for five months and a class based competition. MAIN OUTCOME MEASURES: Comparison of smoking status before and immediately after and one year after the intervention, using multilevel analysis. RESULTS: In the intervention group, 9.6% of non-smokers started to smoke, in the control group 14.2%. This leads to an odds ratio of 0.61 (95% CI= 0.41 to 0.90) to uptake smoking in the intervention group compared with the control group. One year after the intervention, the effect was no longer significant. CONCLUSIONS: In the short-term, an intervention based on peer pressure decreases the proportion of adolescents with lower education who start smoking. Influencing social norms and peer pressure would therefore be a promising strategy in terms of preventing smoking among adolescents. The results also suggest that additional interventions in later years are needed to maintain the effect.

Adolescent↗
PubMed2004

Worksite health promotion using individual counselling and the effectiveness on sick leave; results of a randomised controlled trial.

AIMS: To investigate the effectiveness of a worksite health promotion programme by individual counselling on sick leave. METHODS: Three municipal services of Enschede, the Netherlands, participated in this trial. A total of 299 civil servants were measured at baseline and were randomised by cluster into the intervention (n = 131) or the control group (n = 168). During nine months, subjects in the intervention group received a total of seven consultations, particularly aimed at increasing their physical activity level and improving their dietary habits. Both the intervention and the control subjects received written information as to several lifestyle factors. Sick leave data regarding the nine month intervention period (from May until January) were collected from each municipal service's personnel department. In addition, sick leave data concerning the nine month period pre- and post-intervention were collected. Sick leave data were analysed using multilevel analysis. RESULTS: For both groups, the mean sick leave rate during the intervention increased compared to before the intervention. After the intervention period, the control group increased even more (from 22.9 to 27.6 days), whereas the intervention group slightly decreased (from 21.5 to 20.5 days). Median values of sick leave rate decreased for both groups. No statistically significant intervention effect was found. In both groups, the mean sick leave frequency slightly decreased over time (intervention effects were not significant). CONCLUSIONS: Results showed no significant effect of individual counselling on sick leave. Continued research investigating the effectiveness of this individual counselling programme on several health related outcomes is useful to clarify the trend observed in sick leave.

Adult↗
PubMed2006

Measuring population health: a review of indicators.

This article reviews the historical development of population health indicators. We have long known that environmental, socioeconomic, early life conditions, individual actions, and medical care all interact to affect health. Present quantitative reporting on the impact of these factors on population health grew out of Bills of Mortality published in the 1500s. Since then, regular censuses, civil registration of vital statistics, and international classification systems have improved data quality and comparability. Regular national health interview surveys and application of administrative data contributed information on morbidity, health services use, and some social determinants of health. More recently, traditional health databases and datasets on "nonhealth" sector determinants have been linked. Statistical methods for map-making, risk adjustment, multilevel analysis, calculating population-attributable risks, and summary measures of population health have further helped to integrate information. Reports on the health of populations remain largely confined to focused areas. This paper suggests a conceptual framework for using indicators to report on all the domains of population health. Future ethical development of indicators will incorporate principles of justice, transparency, and effectiveness.

Canada↗
PubMed2004

Ligation of the uterine artery and early postnatal food restriction - animal models for growth retardation.

Intrauterine growth restriction (IUGR) is one of the major causes of short stature in child- and adulthood. The cause of IUGR is unknown, however, an impaired uteroplacental function during the second half of human pregnancy might be an important factor, by affecting the programming of somatotropic axis and leading to postnatal growth failure into adulthood. Two rat models with perinatally induced growth retardation were used to examine the long-term effects of perinatal insults on growth. IUGR rats were prepared from pregnant dams, with a bilateral uterine artery ligation at day 17 of their pregnancy. Since the rat is relatively immature at birth, an early postnatal food restriction model was included as another model to broaden the time window of sensitive period of organogenesis. An individual growth curve was calculated of each animal (n = 813). From these individual growth curves the predicted growth curve for each experimental group was calculated by multilevel analysis. The proposed mathematical model allows us to estimate the growth potentials of these rat models with precision and could provide basic information to investigate the relationships among a number of other variables in future studies. Furthermore, we concluded that both pre- and early postnatal malnutrition leads to irreversible slowing down of postnatal growth.

Animals↗
PubMed2005

Psychosocial functioning of adolescents with idiopathic short stature or persistent short stature born small for gestational age during three years of combined growth hormone and gonadotropin-releasing hormone agonist treatment.

AIM: To examine psychosocial functioning of medically referred adolescents with idiopathic short stature (ISS) or persistent short stature born small for gestational age (SGA) during 3 years of combined growth hormone (GH) and gonadotropin-releasing hormone agonist (GnRHa) treatment. METHODS: Thirty-eight adolescents participated in a controlled trial with GH/GnRHa treatment or no intervention. Each year the adolescents and their parents completed questionnaires and structured interviews. Multilevel analysis was used to analyze data. RESULTS: The adolescents of the treatment group showed a worse outcome than the adolescents of the control group on 3 of 16 variables: perceived competence of scholastic (p < 0.01) and athletic ability (p < 0.05) and trait anxiety (p < 0.05). Adolescents in both the treatment and control groups perceived improved current height (p < 0.001) and self-appraisal of physical appearance (p < 0.05). The parents did not report changes in their children during treatment. CONCLUSION: The observation of some adverse psychological consequences as experienced by the adolescents indicates that it is useful to monitor psychosocial functioning during a combined GH/GnRHa treatment in adolescents with ISS or SGA. It is uncertain whether the hypothesized positive effects of the expected gain in final height by adulthood can sufficiently counterbalance possible short-term negative effects.

Adolescent↗
PubMed2006

Randomised controlled trial of a collaborative care model with psychiatric consultation for persistent medically unexplained symptoms in general practice.

BACKGROUND: Patients with persistent medically unexplained symptoms often exhibit general dysfunction and psychiatric comorbidity and frequently resist psychiatric referral. The aim of this study was to evaluate the efficacy of a collaborative care model including training for general practitioners (GPs) and a psychiatric consultation model for patients with persistent medically unexplained symptoms in general practice. METHOD: Randomised controlled trial. Cluster randomisation at GP practices and multilevel analysis were performed. A total of 81 patients from 36 general practices completed the study. A collaborative care model of training and psychiatric consultation in general practice in the presence of the GP was compared with training plus care as usual by the GP. Outcome assessment on the patients' well-being, functioning and utilisation of health care services was performed 6 weeks and 6 months later. RESULTS: All the patients had somatoform disorders (Whitely Index 7.46), and 86% had comorbid psychiatric disorders. In the intervention group, the severity of the main medically unexplained symptoms decreased by 58%. The patients' social functioning improved. The utilization of health care was lower than in the care as usual group. CONCLUSIONS: A collaborative care model combining training with psychiatric consultation in the general practice setting is an effective intervention in the treatment of persistent medically unexplained symptoms. Anxiety and depressive disorders are highly comorbid in this group. The findings warrant a larger study.

Adult↗
PubMed1997

Development of cardiovascular risk factors from ages 8 to 18 in Project HeartBeat! Study design and patterns of change in plasma total cholesterol concentration.

BACKGROUND: Project HeartBeat! is a longitudinal study of the development of cardiovascular risk factors as growth processes. Patterns of serial change, or trajectories, from ages 8 to 18 years for plasma total cholesterol concentration (TC) and percent body fat illustrate the design and synthetic cohort approach of the study. METHODS AND RESULTS: Six hundred seventy-eight children (49.1% female, 20.1% black) entered the study at ages 8, 11, and 14 years and were followed up with examinations every 4 months for < or = 4 years. Multilevel analysis demonstrated trajectories for population mean values of TC and percent body fat in sex-specific synthetic cohorts from ages 8 to 18 years. Polyphasic patterns of change in TC were confirmed, with notable sex differences in age patterns and with minimum mean values of TC of 3.85 mmol/L for females and 3.59 for males. As illustrated by data for males, the approximate 75th percentile values of mean TC ranged from 4.78 mmol/L at its early peak to 4.06 at its late-teen nadir. Percent body fat exhibited a trajectory closely parallel with that for TC only for males and appeared to be unrelated for females. CONCLUSIONS: The polyphasic trajectory for TC from ages 8 to 18 years differs between females and males, indicates marked age variation in 75th percentile values and, in males only, closely parallels the trajectory for percent body fat. These and other results indicate the value of both follow-up every 4 months across age intervals to detect rapid risk factor change and the synthetic cohort approach for gaining new insights into the dynamics and possible determinants of this change from ages 8 to 18 years.

Adipose Tissue↗
PubMed2000

Physician reimbursement and the medical encounter: an observational study in Dutch pediatrics.

Pediatrician reimbursement is shifting from fee-for-service to a fixed salary. In the Netherlands, as physicians working on a fee-for-service basis have a financial interest in talking less and in carrying out more diagnostic tests and investigations, it may be questioned whether this will influence the structure and content of medical visits. With use of 302 videotaped outpatient encounters with either salaried or fee-for-service pediatricians, differences were examined in visit length, number of requests for diagnostic tests and investigations (laboratory test, endoscopy, and radiography), pediatrician-parent communication behaviors, and patient satisfaction. This investigation was carried out by means of bivariate and multilevel analysis. The results showed that the visits with salaried pediatricians lasted almost 4 minutes longer. This surplus time was not spent on social talk or on a more elaborate history taking but was used to provide more information and advice. In addition, salaried pediatricians engaged in more empathic behavior toward the patient, thereby facilitating a therapeutic relationship. No differences were found in the number of diagnostic tests and investigations or in patient satisfaction. It may be concluded that history taking and social talk took place in a fixed part of the visit. Salaried pediatricians spent more time on exchanging information with their patients and paid more attention to patient concerns and emotions. As the reimbursement shift is not likely to diminish the number of diagnostic tests and investigations and will increase the length of the medical visits, overall financial benefits may be limited.

Adult↗
PubMed2004

School and county characteristics as predictors of school rates of drug, alcohol, and tobacco offenses.

Despite evidence that school factors are associated with differences in various types of student behavior, little research has explored the predictive utility of school factors for school-level substance offense rates. Using data from the State of Florida Department of Education and the Census, we explore the associations between school climate and school substance offense rates, controlling for county level characteristics. Results from a multilevel analysis show that school culture, school organization, and social milieu predict variation in school substance incident rate. We interpret the findings as consistent with research utilizing the "school culture/school effectiveness" model.

Adolescent↗
PubMedDate not supplied

Do people value their own future health differently from others' future health?

The purpose of this study was to investigate whether time preferences for own health are the same as time preferences for others' health. A random sample of the general public was sent a postal questionnaire containing six choices between ill health in the near future and ill health in the further future. They were asked to indicate the maximum duration of more distant ill health they would be willing to accept in return for a specified delay in the onset of the period of ill health. For half of the sample the questions were set in the context of their own health and for the other half in terms of others' health. The median implied discount rates were not statistically different, 0.061 for own health and 0.062 for others' health. A multilevel analysis of the determinants of these implied discount rates provided additional evidence of the similarity of time preferences for own health and others' health.

Adult↗
PubMedDate not supplied

Bahia-Carolina Program in Environmental and Occupational Health: A North-South partnership for workplace and environmental justice.

The Bahia-Carolina Program in Environmental and Occupational Health is an interdisciplinary collaborative program in research and training linking the Institute for Collective Health (ISC), the Federal University of Bahia, Brazil, and the School of Public Health, University of North Carolina at Chapel Hill. An important goal of this Fogarty Center-funded project is to improve workplace and environmental conditions and the well-being of the general population, particularly those workers in the informal sector. Major accomplishments include training taking place in the United States, training in Brazil, and support of Brazilian institutions. Brazilians studying in the United States have researched occupational risk factors for non-Hodgkin's lymphoma, the effectiveness of an environmental sanitation program, the health of refinery workers, and statistical methods for multilevel analysis, among other topics. The program also emphasizes the opportunity for U.S. faculty and students to learn from Brazilian colleagues. Challenges encountered in the collaboration process are described.

Brazil↗
PubMed2006

Contribution of main causes of death to social inequalities in mortality in the whole population of Scania, Sweden.

BACKGROUND: To more efficiently reduce social inequalities in mortality, it is important to establish which causes of death contribute the most to socioeconomic mortality differentials. Few studies have investigated which diseases contribute to existing socioeconomic mortality differences in specific age groups and none were in samples of the whole population, where selection bias is minimized. The aim of the present study was to determine which causes of death contribute the most to social inequalities in mortality in each age group in the whole population of Scania, Sweden. METHODS: Data from LOMAS (Longitudinal Multilevel Analysis in Skåne) were used to estimate 12-year follow-up mortality rates across levels of socioeconomic position (SEP) and workforce participation in 975,938 men and women aged 0 to 80 years, during 1991-2002. RESULTS: The results generally showed increasing absolute mortality differences between those holding manual and non-manual occupations with increasing age, while there were inverted u-shaped associations when using relative inequality measures. Cardiovascular diseases (CVD) contributed to 52% of the male socioeconomic difference in overall mortality, cancer to 18%, external causes to 4% and psychiatric disorders to 3%. The corresponding contributions in women were 55%, 21%, 2% and 3%. Additionally, those outside the workforce (i.e., students, housewives, disability pensioners, and the unemployed) showed a strongly increased risk of future mortality in all age groups compared to those inside the workforce. Even though coronary heart disease (CHD) played a major contributing role to the mortality differences seen, stroke and other types of cardiovascular diseases also made substantial contributions. Furthermore, while the most common types of cancers made substantial contributions to the socioeconomic mortality differences, in some age groups more than half of the differences in cancer mortality could be attributed to rarer cancers. CONCLUSION: CHD made a major contribution to the socioeconomic differences in overall mortality. However, there were also important contributions from diseases with less well understood mechanistic links with SEP such as stroke and less-common cancers. Thus, an increased understanding of the mechanisms connecting SEP with more rare causes of disease might be important to be able to more successfully intervene on socioeconomic differences in health.

Adolescent↗
PubMed2004

Does managed care make a difference? Physicians' length of stay decisions under managed and non-managed care.

BACKGROUND: In this study we examined the influence of type of insurance and the influence of managed care in particular, on the length of stay decisions physicians make and on variation in medical practice. METHODS: We studied lengths of stay for comparable patients who are insured under managed or non-managed care plans. Seven Diagnosis Related Groups were chosen, two medical (COPD and CHF), one surgical (hip replacement) and four obstetrical (hysterectomy with and without complications and Cesarean section with and without complications). The 1999, 2000 and 2001--data from hospitals in New York State were used and analyzed with multilevel analysis. RESULTS: Average length of stay does not differ between managed and non-managed care patients. Less variation was found for managed care patients. In both groups, the variation was smaller for DRGs that are easy to standardize than for other DRGs. CONCLUSION: Type of insurance does not affect length of stay. An explanation might be that hospitals have a general policy concerning length of stay, independent of the type of insurance of the patient.

Arthroplasty, Replacement, Hip↗
PubMed2004

Profiling quality of care: Is there a role for peer review?

BACKGROUND: We sought to develop a more reliable structured implicit chart review instrument for use in assessing the quality of care for chronic disease and to examine if ratings are more reliable for conditions in which the evidence base for practice is more developed. METHODS: We conducted a reliability study in a cohort with patient records including both outpatient and inpatient care as the objects of measurement. We developed a structured implicit review instrument to assess the quality of care over one year of treatment. 12 reviewers conducted a total of 496 reviews of 70 patient records selected from 26 VA clinical sites in two regions of the country. Each patient had between one and four conditions specified as having a highly developed evidence base (diabetes and hypertension) or a less developed evidence base (chronic obstructive pulmonary disease or a collection of acute conditions). Multilevel analysis that accounts for the nested and cross-classified structure of the data was used to estimate the signal and noise components of the measurement of quality and the reliability of implicit review. RESULTS: For COPD and a collection of acute conditions the reliability of a single physician review was quite low (intra-class correlation = 0.16-0.26) but comparable to most previously published estimates for the use of this method in inpatient settings. However, for diabetes and hypertension the reliability is significantly higher at 0.46. The higher reliability is a result of the reviewers collectively being able to distinguish more differences in the quality of care between patients (p < 0.007) and not due to less random noise or individual reviewer bias in the measurement. For these conditions the level of true quality (i.e. the rating of quality of care that would result from the full population of physician reviewers reviewing a record) varied from poor to good across patients. CONCLUSIONS: For conditions with a well-developed quality of care evidence base, such as hypertension and diabetes, a single structured implicit review to assess the quality of care over a period of time is moderately reliable. This method could be a reasonable complement or alternative to explicit indicator approaches for assessing and comparing quality of care. Structured implicit review, like explicit quality measures, must be used more cautiously for illnesses for which the evidence base is less well developed, such as COPD and acute, short-course illnesses.

Acute Disease↗
PubMed2002

Longitudinal study of fetal body movements: nomograms, intrafetal consistency, and relationship with episodes of heart rate patterns a and B.

Our objective was to investigate the longitudinal development of incidence parameters of fetal body movements to define normal reference ranges, to relate them to episodes of fetal heart rate patterns A and B, and to determine the intrafetal consistency for these parameters. Twenty-nine fetuses were studied longitudinally from 24 wk of gestation. Fetal body movements and heart rate were recorded at fortnightly intervals between 24 and 36 wk of gestation and weekly from 36 wk of gestation. Data were analyzed using multilevel analysis. Reference ranges were constructed for the percentage of observation time that movements were present, the number of movement bursts per hour, the mean burst duration, and the median onset-onset interval. The median percentage incidence of fetal body movements decreased from 17% at 24 wk to about 7% near term. The developmental course was the same during active episodes. Body movements also decreased during episodes of relative quiescence, in the course of pregnancy. Intrafetal variance was on average 40-80% of the total range of the four movement parameters. Normal reference ranges were developed for incidence parameters of fetal body movements from 24 wk of gestation onward. The overall decline in the incidence of movements during pregnancy appeared to be a developmental phenomenon and not due to progressively increasing episodes of fetal quiescence. Individual fetuses showed a degree of consistency in the percentage incidence of body movements, but intra- and interfetal variances were generally high, resulting in wide ranges.

Female↗
PubMed2006

Anti-Müllerian hormone levels in the spontaneous menstrual cycle do not show substantial fluctuation.

CONTEXT: Anti-Müllerian hormone (AMH), a quantitative marker for ovarian reserve, has been suggested to be independent of the classical endocrine fluctuations of the menstrual cycle. OBJECTIVE: The objective of the study was to determine whether AMH levels are constant throughout the menstrual cycle, compared with those of FSH, LH, and estradiol. DESIGN/PATIENTS: Frequent blood sampling was performed in 44 fertile, regularly cycling, female volunteers during one full menstrual cycle. SETTING: The study was conducted at a university hospital. MAIN OUTCOME MEASURES: AMH, FSH, LH, and estradiol measurements were allocated to one of seven cycle phases, and a multilevel analysis was performed. Consistent fluctuation patterns were tested by fitting sine patterns to the data. Finally, the frequency in which randomly selected individual samples would remain in one of five preset level categories (quintiles) for each of the variables was studied. RESULTS: A sine pattern fitted to the AMH data was not statistically significant (P = 0.40). In contrast, sine patterns for FSH, LH, and estradiol were highly significant. Comparing the seven cycle phases, no significant differences could be observed between phase-specific AMH levels (P = 0.06). Repeated selection of AMH samples for each individual showed that in 71.5% of selections, AMH values remained in the same quintile, whereas in 27.9% values fell in an adjacent quintile. CONCLUSIONS: AMH levels measured through a full menstrual cycle did not show consistent fluctuation patterns in contrast to levels of FSH, LH, and estradiol. Furthermore, random fluctuations were small, indicating that AMH can be relied on as a cycle-independent marker for ovarian reserve.

Adult↗
PubMed2004

Do different types of nurses give different triage decisions in NHS Direct? A mixed methods study.

OBJECTIVES: To determine whether nurses with different clinical backgrounds make different triage decisions in NHS Direct, the 24-hour telephone helpline staffed by nurses. METHODS: Mixed methods including semistructured interviews with 24 nurses and a multilevel analysis of 60 794 calls triaged by 296 nurses. RESULTS: Nurse accounts helped to identify nurse characteristics that might affect decision-making. The proportion of calls triaged to self-care was 40% (24 049/60 794), varying by individual nurse from a 10th centile of 22% to a 90th centile of 60%, after adjustment for the age and sex of the patient and the time of the call. Variability was partly explained by the length of clinical experience of nurses and the type of software used: nurses with more than 20 years clinical experience were more likely to triage callers to self-care than those with less than ten years experience (42% versus 36%, respectively; odds ratio = 1.41, 95% confidence interval 1.13, 1.78). Proportions triaged to selfcare differed by the type of clinical decision support software used: 31%, 37% and 44%. There was no evidence that the clinical background of nurses (hospital or community), their length of experience in NHS Direct, the range of their experience, or their gender affected triage decisions. Interviews identified that nursing characteristics affected individual nurses in different ways and helped to generate a hypothesis for future research - that individual nurses' approaches to risk may influence triage decisions. CONCLUSION: There is no likely benefit in narrowing nurse recruitment to particular clinical backgrounds. The appropriateness of triage decisions still needs to be evaluated.

Adolescent↗
PubMed2000

Gender differences in gynecologist communication.

The intimate nature of gynecological health problems requires the physician's specific attention. On the basis of previous findings in primary care, female gynecologists are expected to communicate more affectively than men. This study addressed gender differences in gynecologist communication behavior by comparing videotapes of real-life outpatient encounters with female (N = 107) and male (N = 196) gynecologists by means of bivariate and multilevel analysis. Only a few gender differences were found: female gynecologists performed longer physical examinations, showed more global attentiveness, and asked fewer medical questions. Either the duration of the medical education or the type of statistical analysis may account for this lack of gender differences.

Communication↗