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PubMed1991

Training for minor surgery in general practice during preregistration surgical posts.

OBJECTIVE: To study the teaching of minor surgery to preregistration house officers in surgery and their confidence in their skills. DESIGN: Questionnaire survey of consultants and vocational trainees. SETTING: Trent, Oxford, and East Anglian Regional Health Authorities. SUBJECTS: All consultant surgeons (n = 148) with preregistration house officers on their firm and all first year vocational trainees in general practice (n = 165). MAIN OUTCOME MEASURES: Time spent teaching minor surgery to preregistration house officers; source of teaching; trainees' confidence in their skills in 15 minor surgical procedures and degree of confidence that consultants expected their junior house officers to achieve. RESULTS: 137 (93%) consultants and 139 (84%) vocational trainees replied; 131 of the consultants' replies and all the trainees' replies were analysable. Only 14 consultants had a curriculum for teaching junior house officers, and 90 offered less than four hours' teaching a week. Only 11 trainees thought that their firm had had a curriculum, and 102 reported having received under two hours' teaching a week. The consultants indicated that they did most of the teaching, but the trainees reported having received most of their teaching from junior registrars. Seventy nine consultants attempted to teach minor surgery. They expected their junior house officers to acquire greater confidence in their skills in minor surgery than did the other consultants, but overall the confidence expected was low. The trainees were more confident than the consultants expected them to be, but overall confidence was still low. Those who had received more teaching were significantly more confident. CONCLUSIONS: The educational potential of the post of preregistration house officer in surgery seems underexploited, particularly with regard to teaching skills in minor surgery.

Attitude of Health Personnel↗
PubMed1991

Improving care: a study of orthopaedic outpatient referrals.

OBJECTIVE: To identify aspects of outpatient referral in which general practitioners', consultants', and patients' satisfaction could be improved. DESIGN: Questionnaire survey of general practitioners, consultant orthopaedic surgeons, and patients referred to an orthopaedic clinic. SETTING: Orthopaedic clinic, Doncaster Royal Infirmary. SUBJECTS: 628 consecutive patients booked into the orthopaedic clinic. MAIN OUTCOME MEASURES: Views of the general practitioners as recorded both when the referral letter was received and again after the patient had been seen, views of the consultants as recorded at the time of the clinic attendance, and views of the patients as recorded immediately after the clinic visit and some time later. RESULTS: Consultants rated 213 of 449 referrals (42.7%) as possibly or definitely inappropriate, though 373 of 451 patients (82.7%) reported that they were helped by seeing the consultant. Targets for possible improvement included information to general practitioners about available services, communication between general practitioners and consultants, and administrative arrangements in clinics. Long waiting times were a problem, and it seemed that these might be reduced if general practitioners could provide more advice on non-surgical management. Some general practitioners stated that they would value easier telephone access to consultants for management advice. It was considered that an alternative source of management advice on musculoskeletal problems might enable more effective use to be made of specialist orthopaedic resources. Conclusion--A survey of patients' and doctors' views of referrals may be used to identify aspects in which the delivery of care could be made more efficient. Developing agreed referral guidelines might help general practitioners to make more effective use of hospital services.

Attitude of Health Personnel↗
PubMed1991

Communication of results of necropsies in north east Thames region.

OBJECTIVE: To evaluate the adequacy of reporting of results of necropsy to referring clinicians and to general practitioners. DESIGN: Questionnaire survey of referring clinicians and general practitioners of deceased patients in four districts in North East Thames region. Patients were selected by retrospective systematic sampling of 50 or more necropsy reports in each district. SETTING: One teaching hospital, one inner London district general hospital, and two outer London district general hospitals. PARTICIPANTS: 70 consultants and 146 general practitioners who were asked about 214 necropsy reports; coroners' reports were excluded. MAIN OUTCOME MEASURES: Time taken for dispatch of final reports after necropsy, consultants' recognition of the reports, general practitioners' recognition of the reports or of their findings, and consultants' recall of having discussed the findings with relatives. RESULTS: Only two hospitals dispatched final reports including histological findings (mean time to dispatch 144 days and 22 days respectively). 42 (60%) consultants and 83 (57%) general practitioners responded to the survey. The percentage of reports seen by consultants varied from 37% (n = 13) to 87% (n = 36); in all, only 47% (39/83) of general practitioners had been informed of the findings by any method. Consultants could recall having discussed findings with only 42% (47/112) of relatives. CONCLUSIONS: Communication of results of necropsies to hospital clinicians, general practitioners, and relatives is currently inadequate in these hospitals. IMPLICATIONS AND ACTION: A report of the macroscopic findings should be dispatched immediately after necropsy to clinicians and general practitioners; relatives should routinely be invited to discuss the necroscopic findings. One department has already altered its practice.

Autopsy↗
PubMed1991

How do patients with HIV perceive their general practitioners?

OBJECTIVE: To study the perceptions of patients with HIV of their general practitioners in terms of knowledge, abilities, confidence, and satisfaction. DESIGN: Questionnaire survey of inpatients, outpatients, and members of a self help group. SETTING: Two city hospitals, three outpatient clinics, and one AIDS self help group in Munich and Berlin, Germany. SUBJECTS: All 402 patients available between 1 September 1988 and 31 May 1989. MAIN OUTCOME MEASURES: General practitioners' attitudes towards the patients' HIV status; patients' experience of treatment rejection; reception in the general practitioner's office; the doctor's perceived knowledge about HIV and AIDS. RESULTS: 394 of 402 patients consented to interview; 87% were registered with a general practitioner and 91% of those indicated that the doctor was aware of their HIV diagnosis. The overwhelming majority of patients (94%) had a friendly or at least neutral reception in the general practitioner's surgery and only six patients' general practitioner changed his or her behaviour for the worse because of the HIV diagnosis. Two thirds of patients said they would consult first with their primary care doctor for a physical problem, but only 13% would do so for psychological problems. Over a third of the patients did not routinely inform other doctors or medical staff about their HIV status, but there was no significant correlation between this concealment and ever having been rejected by a doctor (7%) or a dentist (12%). CONCLUSION: Most patients expressed a high degree of satisfaction with their general practitioners in terms of confidential issues, attitudes, knowledge, and management.

Attitude of Health Personnel↗
PubMed1992

Mysterious slapped face rash at holiday centre.

OBJECTIVE: To discover the cause of an outbreak of facial rash in a holiday centre. DESIGN: Questionnaire survey of those with rash; analysis of samples of linen. SETTING: Holiday centre in south west England. PATIENTS: 98 holiday-makers presenting to the first aid post with a facial rash. INTERVENTION: Replacement of bed linen with new linen in selected parts of the site. RESULTS: The attack rate was 7.0-14.2/1000 for most accommodation areas in the centre, but in one accommodation area the rate was zero. The pH of rinse water from sheets varied from 7.4 to 9.0. Those parts of the accommodation provided with new linen had zero attack rates. CONCLUSION: The facial rash resulted from irritation from washing powder retained owing to insufficient rinsing during laundering. Modifications to the rinsing process led to a gradual disappearance of the rash.

Adolescent↗
PubMed1992

Storage of vaccines in the community: weak link in the cold chain?

OBJECTIVE: To assess quality of storage of vaccines in the community. DESIGN: Questionnaire survey of general practices and child health clinics, and monitoring of storage temperatures of selected refrigerators. SETTING: Central Manchester and Bradford health districts. SUBJECTS: 45 general practices and five child health clinics, of which 40 (80%) responded. Eight practices were selected for refrigeration monitoring. MAIN OUTCOME MEASURES: Adherence to Department of Health guidelines for vaccine storage, temperature range to which vaccines were exposed over two weeks. RESULTS: Of the 40 respondents, only 16 were aware of the appropriate storage conditions for the vaccines; eight had minimum and maximum thermometers but only one of these was monitored daily. In six of the eight practices selected for monitoring of refrigeration temperatures the vaccines were exposed to either subzero temperatures (three fridges) or temperatures up to 16 degrees C (three). Two of these were specialised drug storage refrigerators with an incorporated thermostat and external temperature gauges. CONCLUSION: Vaccines were exposed to temperatures that may reduce their potency. Safe storage of vaccines in the clinics cannot be ensured without adhering to the recommended guidelines. Provision of adequate equipment and training for staff in maintaining the "cold chain" and the use and care of equipment are important components of a successful immunisation programme.

Child↗
PubMed1992

Health service support of breast feeding--are we practising what we preach?

OBJECTIVE: To ascertain the attitudes of health professionals and breast feeding mothers to breast feeding and their views on current practice. DESIGN: Questionnaire to all midwives and health visitors and to breast feeding mothers in Newcastle upon Tyne. SETTING: Maternity units and community in Newcastle upon Tyne. SUBJECTS: 127 hospital midwives, 23 community midwives, 63 health visitors, and 50 first time breast feeding mothers. RESULTS: Optimum practice guidelines were not followed. 30 (60%) mothers said they were separated from their babies on the first night after birth. 82 (42%) professionals said that breast fed babies were frequently given water to drink. 28 (56%) babies in the mothers survey had received food or water other than breast milk; 19 of these had been given water. Professionals expressed mainly positive attitudes towards breast feeding in general but less positive attitudes to specific issues such as the beneficial effects on child health and the value of voluntary organisations in breast feeding promotion and management. CONCLUSIONS: Although many health workers are in favour of breast feeding there is conflict among the professions working most closely with breast feeding mothers. Good breast feeding support requires closer attention to monitoring hospital practices and continued training on good lactation management.

Attitude of Health Personnel↗
PubMed1992

Discomfort and pain during mammography: description, prediction, and prevention.

OBJECTIVE: To identify the nature of pain and discomfort experienced during mammography and how it can be ameliorated. DESIGN: Questionnaire survey before invitation for mammography and immediately after mammography. Responses before screening were related to experience of discomfort. SETTING: Health district in South East Thames region. SUBJECTS: 1160 women aged 50-64 invited routinely for screening; 774 completed first questionnaire, of whom 617 had mammography. 597 completed the second questionnaire. MAIN OUTCOME MEASURES: Reported discomfort and pain, comparisons of discomfort with that experienced during other medical procedures, qualitative description of pain with adjective checklist. RESULTS: 35% (206/597) of the women reported discomfort and 6% (37/595) pain. 10 minutes after mammography these figures were 4% (24/595) and 0.7% (4/595) respectively. More than two thirds of women ranked having a tooth drilled, having a smear test, and giving blood as more uncomfortable than mammography. The most important predictor of discomfort was previous expectation of pain (discomfort was reported by 21/32 (66%) women who expected pain and 186/531 (35%) who did not). Discomfort had little effect on satisfaction or intention to reattend. CONCLUSIONS: The low levels of reported pain and discomfort shortly after mammography and the favourable comparisons with other investigations suggest that current procedures are acceptable. Since two thirds of the women experienced less pain than expected health education and promotion must ensure that accurate information is made available and publicized.

Female↗
PubMed1993

An instrument for assessment of videotapes of general practitioners' performance.

OBJECTIVES: To identify those important characteristics of doctors' and patients' behaviour that distinguish between "good" and "bad" consultations when viewed on videotape; to use these characteristics to develop a reliable instrument for assessing general practitioners' performance in their own consultations. DESIGN: Questionnaires completed by patients, general practitioner trainers, and general practitioner trainees. Reliability of draft instrument tested by general practitioner trainers. SETTING: All vocational training schemes for general practice in the Northern region of England. SUBJECTS: First stage: 76 patients in seven groups, 108 general practice trainers in 12 groups, and 122 general practice trainees in 10 groups. Second stage: 85 general practice trainers in 12 groups. MAIN OUTCOME MEASURES: Trainers' ratings of importance; alpha coefficients of draft instrument by trainee, group, and consultation. RESULTS: 6890 characteristics of good and bad consultations were consolidated into a draft assessment instrument consisting of 46 pairs of definitions separated by six point bipolar scales. Nine statement pairs given low importance ratings by trainers were eliminated, reducing the instrument to 37 statement pairs. To test reliability, general practitioner trainers used the instrument to assess three consultations. With the exception of one group of trainers, all alpha coefficients exceeded the acceptable level of 0.80. CONCLUSION: The instrument produced is reliable for assessing general practitioners' performance in their own consultations.

Adolescent↗
PubMed1993

Epidemiological study of wheeze, doctor diagnosed asthma, and cough in preschool children in Leicestershire.

OBJECTIVE: To determine the cumulative prevalences of wheeze and doctor diagnosed asthma and the point prevalences of recurrent cough and wheeze in children aged 5 years and under. DESIGN: Questionnaire survey of population based random sample of children registered on regional authority's child health index for immunisation; questionnaire completed by parents. SETTING: Leicestershire. SUBJECTS: 1650 white children born in 1985-9 who were surveyed in 1990. MAIN OUTCOME MEASURES: Cumulative prevalences of wheeze and doctor diagnosed asthma and point prevalences of recurrent cough and wheeze by age and sex. RESULTS: There were 1422 replies (86.2%; 726 for boys, 696 for girls). Overall, 11.0% (95% confidence interval 9.4% to 12.6%) of children had formally been diagnosed as having asthma, the cumulative prevalence in boys (12.7%) being somewhat higher than in girls (9.2%) (age adjusted odds ratio 1.47, p = 0.03). As expected, the cumulative prevalence of asthma increased significantly with age (7.5% (13/173) in children under 1 year, 15.9% (61/383) in children of 4 years and over; p < 0.001). The cumulative prevalence of wheeze overall was 15.6% (13.7% to 17.5%), being higher in boys (17.6%) than in girls (13.5%) (odds ratio 1.38, p = 0.03). The overall prevalence of recurrent cough without colds was 21.8% (19.6% to 23.9%), with a non-significant excess in boys (23.1% v 20.4%). The overall prevalence of wheezing attacks during the previous 12 months was 13.0% (11.3% to 14.8%) with a non-significant excess in boys (14.5% v 11.5%). CONCLUSIONS: These findings are baseline results and emphasise the importance of studying the age group of interest rather than relying on the recall of parents of school age children.

Age Factors↗
PubMed1993

"Whistleblowing": a health issue.

OBJECTIVE: To examine the response of organizations to "whistleblowing" and the effects on individual whistleblowers. DESIGN: Questionnaire survey of whistleblowers who contacted Whistleblowers Australia after its publicity campaign. SETTING: Australia. SUBJECTS: 25 men and 10 women from various occupations who had exposed corruption or danger to the public, or both, from a few months to over 20 years before. RESULTS: All subjects in this non-random sample had suffered adverse consequences. For 29 victimization had started immediately after their first, internal, complaint. Only 17 approached the media. Victimization at work was extensive: dismissal (eight subjects), demotion (10), and resignation or early retirement because of ill health related to victimization (10) were common. Only 10 had a full time job. Long term relationships broke up in seven cases, and 60 of the 77 children of 30 subjects were adversely affected. Twenty nine subjects had a mean of 5.3 stress related symptoms initially, with a mean of 3.6 still present. Fifteen were prescribed long term treatment with drugs which they had not been prescribed before. Seventeen had considered suicide. Income had been reduced by three quarters or more for 14 subjects. Total financial loss was estimated in hundreds of thousands of Australian dollars in 17. Whistleblowers received little or no help from statutory authorities and only a modest amount from workmates. In most cases the corruption and malpractice continued unchanged. CONCLUSION: Although whistleblowing is important in protecting society, the typical organisational response causes severe and longlasting health, financial, and personal problems for whistleblowers and their families.

Adult↗
PubMed1994

Purchasing for all: an alternative to fundholding.

OBJECTIVE: To evaluate general practitioner participation in a district health authority's purchasing work. DESIGN: Questionnaire study of 131 Hackney general practitioners and 33 senior health service managers; review of the minutes of 28 meetings of the Hackney General Practitioners' Forum and the contract between City and Hackney Health Authority and the St Bartholomew's NHS Trust. SETTING: Hackney General Practitioners' Forum. MAIN OUTCOME MEASURES: General practitioners' and managers' perceptions of how representative and effective the general practitioners' forum is; proportion of new quality targets and service developments contributed by general practitioners; main issues discussed by the forum and impact on district health authority policy. RESULTS: 99 (76%) general practitioners and 27 (82%) managers responded. Both groups perceived the forum as representative. 92% (24/26) of the managers thought the forum was effective but only 74% (70/95) of general practitioners did so, largely because some doubted that the forum was listened to 75% (103/138) of quality targets and 55% (16/29) of service developments planned in the 1993-4 contract were contributed by general practitioners. They also lobbied successfully for more resources for urology and community mental health services. CONCLUSIONS: Input into commissioning via a general practitioners' forum can be both representative and effective. General practitioners need to work closely to achieve a consensus and those involved need administrative support. The relation between general practice and public health medicine needs to be strengthened.

Attitude of Health Personnel↗
PubMed1994

Drug and alcohol referrals: are elderly substance abuse diagnoses and referrals being missed?

OBJECTIVE: To examine the diagnosis of problem substance use in hospital inpatients aged 65 years and over and their referral to drug and alcohol services by medical staff. DESIGN: Questionnaire to registrars or house officers caring for patients 65 years of age and over with problem substance use. SETTING: 3 hospitals in New South Wales, Australia. SUBJECTS: Medical staff caring for 263 inpatients. RESULTS: Medical staff did not recognise substance misuse in older hospital patients and did not seem to be aware of current recommendations of the National Health and Medical Research Council recommendations for safe use of alcohol and benzodiazepines. Three out of 88 problem users of benzodiazepines, 29 out of 76 smokers, and 33 out of 99 problem drinkers were identified by medical staff. Of those identified with problems, 2 benzodiazepine users, 6 smokers, and 19 drinkers were considered for referral to drug and alcohol services. CONCLUSIONS: Greater awareness of recommendations for dealing with problem use of benzodiazepines and alcohol needs to be promoted among medical staff, along with an increased emphasis in medical education on substance use as a potentially important problem for older people. Drug and alcohol services also need to promote a broader role, particularly in regard to early intervention in a hospital setting for older patients.

Aged↗
PubMed1994

Visiting bags: a labile thermal environment.

OBJECTIVE: To define usual colour and site of storage of visiting bags in general practitioners' cars and to investigate effect of these variables on temperature inside bag. DESIGN: Questionnaire to general practitioners; serial temperature measurements from paired black visiting bags at different storage sites and from bags of different colour. SETTING: South Devon coastal town during May and June. SUBJECTS: 200 general practitioners, of whom 145 returned legible questionnaires. MAIN OUTCOME MEASURES: Bag colour, duration and site of storage, temperature inside black bags at defined storage sites, and effects of bag colour on internal temperature. RESULTS: 111 (77%) of the general practitioners carried a black visiting bag, and 76 kept their bag in their car all day. The bag was coolest in the car boot, but irrespective of storage site, maximum internal temperature of the bag was always over 25 degrees C and reached up to 80 degrees C. Spraying a black bag silver significantly reduced the bag's internal temperature (mean difference 8.37 degrees C (95% confidence interval 6.68 to 9.86 degrees C) df = 59, t = 10.29, P < 0.001). CONCLUSIONS: General practitioners should use a silver coloured visiting bag; when visiting, they should store it in their car boot; at other times they should remove it to a cooler site.

Automobiles↗
PubMed1994

Evaluating care of patients reporting pain in fundholding practices.

OBJECTIVE: To compare quality of care between 1990 and 1992 in patients with self diagnosed joint pain. DESIGN: Questionnaire and record based study. SUBJECTS: Patients identified at consecutive consultations during two weeks in 1990, 1991, and 1992. SETTING: Six practice groups in pilot fundholding scheme in Scotland. MAIN OUTCOME MEASURES: Length of consultation; numbers referred or investigated or prescribed drugs; responses to questions about enablement and satisfaction. RESULTS: About 15% of patients consulted with joint pain each year. 25% (316) of them had social problems in 1990 and 37% (370) in 1992; about a fifth wanted to discuss their social problems. Social problems were associated with a raised general health questionnaire score. The mean length of consultation for patients with pain was 7.6 min in 1990 and 7.7 min in 1992. Patients wishing to discuss social problems received longer consultations (8.5 min 1990; 10.4 min 1992); but other patients with social problems received shorter consultations (7.4 min; 7.2 min). The level of prescribing was stable but the proportion of patients having investigations or attending hospital fell significantly from 1990 to 1992 (31% to 24%; 31% to 13% respectively). Fewer patients responded "much better" to six questions about enablement in 1992 than in 1990. Enablement was better after longer than shorter consultations for patients with social problems. CONCLUSIONS: Quality of care for patients with pain has been broadly maintained in terms of consultation times. The effects of lower rates of investigation and referral need to be investigated further.

Drug Prescriptions↗
PubMedDate not supplied

Sartorial eloquence: does it exist in the paediatrician-patient relationship?

OBJECTIVE: To evaluate children's and parents' perceptions of hospital doctors' attire. DESIGN: Questionnaire study asking children and parents to assign positive and negative attributes to five photographs of a male or female doctor dressed formally and informally. SETTING: Outpatient department, Children's Hospital, Birmingham. SUBJECTS: 203 consecutive child-parent pairs attending outpatient clinics over three months. MAIN OUTCOME MEASURES: Children's and parents' preferences, assessed by comparing proportions. RESULTS: 70% (286/406) of children and parents rated doctors' dress as important; more children rated it "very important" (27% (54/203) v 14% (29/203), P < 0.01, 95% confidence interval for difference 5% to 21%). Of the 99 children responding, 44 regarded the man in white coat as most competent (44% v 20% expected by chance, P < 0.01, 34% to 54%) and most concerned (32% v 20%, P < 0.01, 23% to 41%). Children also regarded the woman in white coat as most competent; however, male and female doctors in white coats rated lower for friendliness. Asians and regular surgical attenders preferred doctors in white coats. The man in polo shirt and trousers was rated as most friendly (40% v 20% expected by chance, P < 0.01, 30% to 50%) and most gentle (37% v 20%, P < 0.01, 27% to 46%). The woman in tee shirt and slacks also rated most friendly and gentle; however, both casually dressed doctors rated lower for competence. Parents preferred more casual dress but expressed preferences less strongly, and they poorly predicted which outfits their children preferred. CONCLUSIONS: Children regard formally dressed doctors as competent but not friendly; they regard casual dress as friendly but not competent.

Ambulatory Care↗
PubMed1995

Do doctors accurately assess coronary risk in their patients? Preliminary results of the coronary health assessment study.

OBJECTIVE: To evaluate the ability of doctors in primary care to assess risk patients' risk of coronary heart disease. DESIGN: Questionnaire survey. SETTING: Continuing medical education meetings, Ontario and Quebec, Canada. SUBJECTS: Community based doctors who agreed to enroll in the coronary health assessment study. MAIN OUTCOME MEASURE: Ratings of coronary risk factors and estimates by doctors of relative and absolute coronary risk of two hypothetical patients and the "average" 40 year old Canadian man and 70 year old Canadian woman. RESULTS: 253 doctors answered the questionnaire. For 30 year olds the doctors rated cigarette smoking as the most important risk factor and raised serum triglyceride concentrations as the least important; for 70 year old patients they rated diabetes as the most important risk factor and raised serum triglyceride concentrations as the least important. They rated each individual risk factor as significantly less important for 70 year olds than for 30 year olds (all risk factors, P < 0.001). They showed a strong understanding of the relative importance of specific risk factors, and most were confident in their ability to estimate coronary risk. While doctors accurately estimated the relative risk of a specific patient (compared with the average adult) they systematically overestimated the absolute baseline risk of developing coronary disease and the risk reductions associated with specific interventions. CONCLUSIONS: Despite guidelines on targeting patients at high risk of coronary disease accurate assessment of coronary risk remains difficult for many doctors. Additional strategies must be developed to help doctors to assess better their patients' coronary risk.

Clinical Competence↗
PubMed1995

Health and cancer prevention: knowledge and beliefs of children and young people.

OBJECTIVE: To collect information from children and young people about their knowledge of and attitudes towards cancer and their understanding of health and health related behaviours to inform future health promotion work. DESIGN: Questionnaire survey of 15-16 year olds, and interviews with play materials with 9-10 year old children. SETTING: Six inner city, suburban, and rural schools. SUBJECTS: 226 children aged 15-16 years and 100 aged 9-10 years. MAIN OUTCOME MEASURES: Knowledge about different types of cancer; beliefs about health; sources of information; quality of research data obtainable from young children about cancer and health. RESULTS: Both samples knew most about lung cancer, but there was also some knowledge of breast and skin cancer and leukaemia. Smoking, together with pollution and other environmental factors, were seen as the dominant causes of cancer. Environmental factors were mentioned more often by the inner city samples. Television and the media were the most important sources of information. Young people were more worried about unemployment than about ill health. More than half the young people did not describe their health as good, and most said they did not have a healthy lifestyle. Children were able to provide detailed information about their knowledge and understanding by using drawings as well as interviews. CONCLUSIONS: Children and young people possess considerable knowledge about cancer, especially about lung cancer and smoking, and show considerable awareness of predominant health education messages. Despite this knowledge, many lead less than healthy lifestyles. Health is not seen as the most important goal in life by many young people; the circumstances in which many children and young people live are not experienced as health promoting.

Adolescent↗