Factors Associated with Healthcare Utilization Among Arab Immigrants and Iraqi Refugees.

Arab migrants-both immigrants and refugees-are exposed to pre- and post- migration stressors increasing their risk for health problems. Little is known, however, about rates of, or factors associated with, healthcare utilization among these two groups. A sample of 590 participants were interviewed approximately 1 year post-migration to the United States. Factors associated with healthcare utilization, including active and passive coping strategies, were examined using logistic regressions. Compared to national healthcare utilization data, immigrants had significantly lower, and refugees had significantly higher rates of healthcare utilization. Being a refugee, being married, and having health insurance were significantly associated with medical service utilization. Among refugees, less use of psychological services was associated with the use of medications and having problem-focused (active) strategies for dealing with stress. Healthcare utilization was significantly higher among refugees, who also reported a greater need for services than did immigrants.

Financial incentives in health care. The impact of performance-based reimbursement.

The key question addressed in this study is whether performance-based reimbursement (PBR) is a useful way to create the right incentive for efficiency improvements in health care. In this 4-year prospective cohort study, physicians in one council with PBR and in ten councils without such a system were studied. The results of this study indicate that PBR, compared to an annual budget system, creates a different incentive, an 'inner incentive' which may be stronger than the external incentive of financial pressures. PBR may result in a greater cost awareness and shorter average length of stay, but it may also lead to negative effects on the quality of care. A strong cost awareness was found to be a negative predictor of quality of care indicating that it is a difficult balancing act to maintain cost considerations at a 'good' level in order to retain the benefits of cost awareness without adversely impacting quality of care. There is a need for further studies of the impact of PBR on financial performance and quality of care issues.

The effect of supplementary antioxidant therapy in patients who report hypersensitivity to electricity: a randomized controlled trial.

CONTEXT: Hypersensitivity to electricity is a proposed environmental illness of unknown etiology. Patients report a variety of symptoms that they relate to electric equipment. The afflicted individuals suffer from ill health. Many interventions have been tried but, to date, there is no one specific treatment that has been proven superior to other remedial actions. In general, there is a lack of controlled prospective studies. OBJECTIVE: To test the hypothesis that antioxidant therapy reduces symptoms and improves health in patients reporting hypersensitivity to electricity. DESIGN: Randomized, double-blind, crossover, placebo-controlled study. SETTING: Patients referred to the Environmental Illness Research Centre, Stockholm County Council. PATIENTS: Sixteen patients reporting hypersensitivity to electricity. INTERVENTION: Antioxidant supplementation (vitamins C and E, selenium). MAIN OUTCOME MEASURES: Self-reported symptoms and reported degree of hypersensitivity to electricity, serum levels of uric acid and diphenylpycrylhydrazyl (DPPH). RESULTS: The results indicated no significant differences in reported symptoms, reported hypersensitivity to electricity, or oxidative status in serum between periods of antioxidant and placebo treatments. Serum levels of DPPH and uric acid showed no correlation with the reported degree of symptoms or hypersensitivity to electricity. CONCLUSIONS: The study did not show any beneficial effect of antioxidant supplementation for patients reporting hypersensitivity to electricity. The results do not support the hypothesis that oxidative stress is a major contributor to ill health in patients who report hypersensitivity to electricity.

Employee effects of an educational program for managers at an insurance company.

BACKGROUND: Possible health effects for employees of efforts to improve the psychosocial competence of managers have not been studied scientifically in the past. OBJECTIVE: To explore how efforts to improve management will change the work environment and health of the employees. METHODS: Managers of the experimental department in a large insurance corporation underwent 2-hour biweekly training sessions for 1 year-altogether, 60 hours. A control group of employees in other departments in the corporation not affected by the modification was followed with the same assessments. Morning blood samples for the assessment of serum cortisol were collected both at baseline and after 1 year in 155 participants in the experimental group and in 147 subjects in the control group. Liver enzymes and lipids were also assessed. In the questionnaire part of the 1-year follow-up study, there were 119 participants in the experimental group and 132 in the control group. RESULTS: When repeated-measures ANOVA was used, a significant interaction effect was found for the level of serum cortisol; serum cortisol levels were decreased in the intervention group and were unchanged in the control group (ANOVA two-way interaction, p =.02; after exclusion of the managers, p =.005). A significant interaction effect was also observed for decision authority, with increased decision authority in the intervention group and, conversely, a decreased level in the control group (p =.001; after exclusion of managers, p =.02). CONCLUSIONS: The study indicates that a moderately intensive psychosocial manager program lasting for 1 year can be beneficial for the employees with regard to both lowered serum cortisol and improved authority over decisions.

A comparative study of the experiences of violence of English and Swedish mental health nurses.

Recent studies suggest that violence in health care environments, especially mental health care, appears to be increasing. Although there is a lack of cross-cultural studies to prove it, this increase in violence would seem to be an international phenomenon. The present study sought to compare the extent and nature of violence encountered by mental health nurses in Sweden and England. Systematic studies of violence have previously been carried out independently in both countries but this was the first attempt to compare levels of violence. Clearly defined study protocols were put in place, an operational definition of 'violence' adhered to, and random samples recruited. A specially designed questionnaire was sent to every subject (Swedish nurses n=720; English nurses n=296) enquiring about the extent of nurses' exposure to violence, the nature and severity of the violence experienced, and the effect of violence on self-esteem and job satisfaction. Significant differences were found with English nurses experiencing more violence than their Swedish counterparts. Yet support for English nurses appeared to be less good than for Swedish nurses. Reasons for the differences are discussed along with possible measures to minimise the frequency of violence against nurses and the negative effects on their work.

Violence towards health care staff and possible effects on the quality of patient care.

Much of the research on violence in the health care sector has focused on the immediate and long-term effects of patient violence on staff victims. There is a lack of studies, however, examining whether individual reactions to violent episodes, such as anger and increased fear in one's work, have any measurable effect on staff behaviour toward their patients, and ultimately on the quality of patient care. The aim of the present study was to investigate whether an association exists between staff experiences with violence and patient-rated quality of patient care. A theoretical model was presented, suggesting that violence or threats experienced by health care staff have a negative effect on the quality of health care services offered, as measured by patients. In addition, it was theorised that there would be an association between staff work environment and staff reports of violence. Six questionnaire studies, three concerning hospital staff's views of their work environment and three dealing with patients' perceptions of the quality of care, provided the data for evaluating the model. Work environment and quality of care studies were carried out simultaneously at a single hospital in 1994, 1995, and again in 1997. Regression analysis was used to see which combination of work environment and quality of care variables would best predict a positive overall grade for quality of care from the patient perspective. Violence entered consistently as an important predictor into each of the three best regression equations for 1994, 1995, and 1997, respectively. The results of this analysis suggest that the violence experienced by health care staff is associated with lower patient ratings of the quality of care. The study indicates that violence is not merely an occupational health issue, but may have significant implications for the quality of care provided.

Environmental illness: fatigue and cholinesterase activity in patients reporting hypersensitivity to electricity.

The lack of a pathophysiological marker hinders studies on environmental illnesses of unknown origin. Hence, research focused on the identification of such a marker is a priority. This study investigated the nature and a possible etiology of fatigue in hypersensitivity to electricity (the most commonly reported environmental illness in Sweden). The aim was to test the hypothesis that perceived fatigue was due to alterations in cholinesterase activity. The study group consisted of 14 people who reported a hypersensitivity to electricity, including disabling fatigue. We assessed cholinesterase activity three times: twice based on current symptoms reported by the subjects (severe fatigue attributed to electromagnetic fields and absence of this symptom) and once at a randomly selected time. No significant reduction in acetylcholinesterase was identified in any subject. Examined on a group level, no significant reduction in activity was identified at the time of severe fatigue, and no correlation between reported degree of fatigue and cholinesterase activity was observed. Fatigue attributed to electromagnetic fields was nonphysical and showed a significant correlation to difficulties in concentrating. The results do not support the hypothesis that a change in cholinesterase activity mediates fatigue in people reporting hypersensitivity to electricity.

Psychosocial challenges facing physicians of today.

Fundamental changes in the organization, financing, and delivery of health care have added new stressors or opportunities to the medical profession. These new potential stressors are in addition to previously recognized external and internal ones. The work environment of physicians poses both psychosocial, ergonomic, and physico-chemical threats. The psychosocial work environment has, if anything, worsened. Demands at work increase at the same time as influence over one's work and intellectual stimulation from work decrease. In addition, violence and the threat of violence is another major occupational health problem physicians increasingly face. Financial constraint, managed care and consumerism in health care are other factors that fundamentally change the role of physicians. The rapid deployment of new information technologies will also change the role of the physician towards being more of an advisor and information provider. Many of the minor health problems will increasingly be managed by patients themselves and by non-physician professionals and practitioners of complementary medicine. Finally, the economic and social status of physicians are challenged which is reflected in a slower salary increase compared to many other professional groups. The picture painted above may be seen as uniformly gloomy. In reality, that is not the case. There is growing interest in and awareness of the importance of the psychosocial work environment for the delivery of high quality care. Physicians under stress are more likely to treat patients poorly, both medically and psychologically. They are also more prone to make errors of judgment. Studies where physicians' work environment in entire hospitals has been assessed, results fed-back, and physicians and management have worked with focused improvement processes, have demonstrated measurable improvements in the ratings of the psychosocial work environment. However, it becomes clear from such studies that quality of the leadership and the physician team impact on the overall work atmosphere. Physicians unaware of the goals of the department as well as the hospital, that do not receive management performance feedback, and who do not get annual performance appraisals and career guidance, rate their psychosocial environment as more adverse than their colleagues. There is also a great need to offer personally targeted competence development plans. Heads of department and senior physicians rate their work environment as of higher quality than more junior and mid-career physicians. More specifically, less senior physicians perceive similar work demands as their senior colleagues but rate influence over work, skills utilization, and intellectual stimulation at work as significantly worse. In order to combat negative stressors in the physicians' work environment, enhancement initiatives should be considered both at the individual, group, and structural level. Successful resources used by physicians to manage the stress of everyday medicine should be identified. Physicians are a key group to ensure a well-functioning health care system. In order to be able to change and adapt to the ongoing evolution of the Western health care system, more focus needs to be put on the psychosocial aspects of physicians' work.

Effects of performance-based reimbursement on the professional autonomy and power of physicians and the quality of care.

The key question addressed in this study is whether performance-based reimbursement in health care affects the professional power and autonomy of physicians, and if so, whether this has any consequences for the quality of care. This cohort study examines the period 1994-98 in 11 Swedish county councils. Four hundred and eighteen physicians were studied in Stockholm County Council, which has a performance-based reimbursement system, and in ten councils without such a system. The results show that professional power and autonomy are considered to be very limited in all councils, and that they have decreased during the period studied. Professional autonomy is, however, more limited in Stockholm. The limitations in Stockholm are more related to financial considerations, whereas the limitations in the other councils are more due to guidelines and lists of recommended drugs. Professional autonomy and power were found to be important determinants for quality of care, and the physicians in Stockholm estimated the quality of care lower than their colleagues in the ten other councils. Thus, our study suggests that the performance-based reimbursement system might fail to reach the desired results due to its negative impact on professional power and autonomy.

Effects of performance-based reimbursement in healthcare.

The aim of this study was to assess changes in attitudes and behaviour related to efficiency and quality of care after introduction of performance-based reimbursement. The study consisted of two parts. Part One was performed in 1992-94 as a repeated cross-sectional study of physicians in Stockholm County Council working with a newly introduced performance-based reimbursement system. Part Two was a similar study conducted in 1994 in 11 Swedish councils without performance-based reimbursement. The results show a significant difference between the two groups of physicians in attitudes concerning changes in quality of care and premature discharge from hospital. Despite concern about quality and premature discharge, physicians in Stockholm were found to have changed their behaviour in that the average length of stay in 1994 was about one day shorter in Stockholm than in the other 11 county councils. This indicates that the performance-based reimbursement system may strengthen the incentive to increase efficiency.

Provocation with stress and electricity of patients with "sensitivity to electricity".

Twenty-four patients with self-reported "sensitivity to electricity" were divided into two groups and tested in a double-blind provocation study. These patients, who reported increased skin symptoms when exposed to electromagnetic fields, were compared with 12 age- and sex-matched controls. Both groups were exposed to 30-minute periods of high or low stress situations, with and without simultaneous exposure to electromagnetic fields from a visual display unit. The matched controls were tested twice and given the same exposure as the patients but had the fields turned on every time. Stress was induced by requiring the participants to act in accordance with a random sequence of flashing lights while simultaneously solving complicated mathematical problems. Blood samples were analyzed for levels of the stress-related hormones melatonin, prolactin, adrenocorticotrophic hormone, neuropeptide Y, and growth hormone, and the expression of different peptides, cellular markers, and cytokines (somatostatin, CD1, factor XIIIa, and tumor necrosis factor-alpha). Skin biopsies were also analyzed for the occurrence of mast cells. Stress provocation resulted in feelings of more intense mental stress and elevated heart rate. The patients reported increased skin symptoms when they knew or believed that the electromagnetic field was turned on. With the blind conditions there were no differences between "on" or "off." Inflammatory mediators and mast cells in the skin were not affected by the stress exposure or by exposure to electromagnetic fields. The main conclusion was that the patients did not react to the fields.

Implementation and evaluation of a practical intervention programme for dealing with violence towards health care workers.

Implementation and evaluation of a practical intervention programme for dealing with violence towards health care workers The aim of this study was to implement and evaluate a practical intervention programme designed to help staff in health care work-places to deal with patient violence towards staff. The programme was part of a controlled, prospective study that ran for 1 year. The study population was comprised of staff at 47 health care work-places, randomly assigned to either the intervention or control group. The Violent Incident Form (VIF), a checklist designed to simplify the registration of violent events, was introduced at all 47 work sites, where staff were instructed to register all types of violent and threatening incidents directed towards them during the 1-year study period. The intervention work-places also followed a structured feedback programme, where the circumstances concerning registered incidents were discussed on a regular basis with work-place staff. Baseline examination of the study groups revealed no statistically significant difference with regard to self-reported violence in the past year. At the conclusion of the 1-year period, the difference between groups was statistically significant (P < 0.05). Staff at the intervention work sites reported 50% more violent incidents than the control work sites during the year. Compared to the control group, intervention group staff reported better awareness: of risk situations for violence (P < 0.05); of how potentially dangerous situations could be avoided (P < 0.05); and of how to deal with aggressive patients (P < 0.05). Logistic regression analysis confirmed an increased risk for self-reported violence in the intervention group post-intervention (odds ratio 1.49; 95% confidence interval 1.07-2.06; P < 0.05). The structured feedback programme seems to have improved staff knowledge of risks for violence in the intervention group.

Impact of management change and an intervention program on health care personnel.

BACKGROUND: There has been a major shift in the organization and responsibility for the provision of geriatric care in Sweden. This was believed to be stressful. We therefore decided to launch a controlled intervention program on health care personnel aimed at enhancing their adaptation and ability to cope. The purpose of this study was to assess the impact of management change on psychosocial parameters of health care personnel and the effects, if any, of a structured intervention program. METHODS: Two separate wards were randomly allocated to be either intervention (I) or control (C) ward. The I-ward personnel were subjected to a psychologist's structured 10-session intervention program for 20 weeks. The program consisted of an initial educational part followed by a practical problem-solving discussion part. A structured questionnaire on psychosocial issues was answered by the participants before (0 weeks), immediately after (20 weeks), and 10 weeks after the intervention (30 weeks). RESULTS: There were no significant changes in the psychosocial parameters of the C-ward personnel. In the I-ward, however, there was a significant increase in work demand as well as in positive feelings about work, as compared to the C-ward at the 30-week follow-up. There was also significantly better work comfort in the I-ward. CONCLUSIONS: We did not find any anticipated negative psychosocial effects on health care personnel undergoing an organizational change. However, by offering a structured intervention program to one group of health care personnel, we found some positive psychosocial effects. Future research is needed to pinpoint which factor or factors in the intervention program were the most crucial for the effects to occur.

Predictors of good general health, well-being, and musculoskeletal disorders in Swedish dental hygienists.

The aim of the present study was to examine how different personal, physical, and psychosocial work-associated factors are related to good general health, well-being, and musculoskeletal disorders in dental hygienists. A questionnaire was mailed to 575 dental hygienists who were randomly sampled from the Swedish Dental Hygienists' Association (86% responded). Data were analyzed with multiple-logistic regression models. The results showed that high clinical-practice fraction, active leisure, and high management support increased the odds for good general health, while work and family overload decreased the odds. Management support and mastery of work increased the odds for well-being, while work and family overload and high work efficiency decreased them. Scaling work increased the odds for general and work-related musculoskeletal disorders in all parts of the upper body and arms but not in the lower back. In the upper body, active leisure decreased the odds for general musculoskeletal disorders, while the odds for work-related musculoskeletal disorders increased from work and family overload and decreased from many weekly working hours. Many years in the profession increased the odds for general finger disorders. In conclusion, the results suggest that active leisure and several psychosocial work factors strongly influence good general health and well-being. Physical tasks influence musculoskeletal disorders more than active leisure and psychosocial work factors.

Violence in mental health care: the experiences of mental health nurses and psychiatrists.

Violence against mental health service personnel is a serious workplace problem and one that appears to be increasing. This study aimed to ascertain the extent and nature of violence against mental health nurses and psychiatrists, and to identify what support, if any, they received following exposure to violence. Mental health staff working within five West Midlands Trusts in the United Kingdom were surveyed using a postal questionnaire to investigate the extent and nature of violence they encountered in their daily work. There was an overall response rate of 47%, which included a response rate for psychiatrists of 60% (n=74) and for mental health nurses of 45% (n=301). Though both groups experienced violence at work, nurses were found: to have been exposed to violence significantly more during their career; to have been a victim of violence within the previous 12 months of the survey; and to have suffered a violent incident involving physical contact. Whilst a higher proportion of nurses than psychiatrists received some support following a violent incident, a large proportion of both groups did not receive any, although most felt in need of it. The implications of this study for training and management are discussed.

Staff perception of the impact of health care transformation on quality of care.

OBJECTIVES: To study how medical professionals perceived recent organizational changes and financial cut-backs in terms of organizational and health care quality. DESIGN: A cross-sectional questionnaire survey. SETTING: County council of Stockholm. PARTICIPANTS: A random sample (n=936; 70% response rate) of physicians and nurses employed by the county council of Stockholm. MAIN OUTCOME MEASURES: Staff perception of how recent changes impacted on staff-perceived quality of care, staffs' skills development, management, and perceived organizational efficacy. RESULTS: Over 60% of the respondents rated that patients' access to health care had diminished as a result of ongoing changes. A similar percentage also perceived a decline in the quality of health care delivered in general. However, fewer staff rated a decline during the last year in the quality of care provided by their own department (44%). Staff rating that quality of care in their own department had worsened during the last year also scored substantially lower on all counts of organizational well-being. The most important determinants of staff-perceived quality of care were staff access to pertinent information concerning their daily work and organizational changes, participatory management, performance management, and job commitment. Job satisfaction was more strongly associated with organizational well-being than staff-perceived quality of care. CONCLUSION: Staff perception should be used as an additional indicator of quality of care. To improve quality of care further, management should encourage staff involvement in everyday management issues, including up-to-date information about organizational goals and mission.

Individual and organizational well-being in psychiatric nursing: a cross-cultural study.

Although health care systems around the world are undergoing rapid changes, there is an absence of comparative studies of how these changes affect nurses' well-being and work life. The purpose of this study was (i) to identify and describe possible differences between the psycho-social work environments of English and Swedish mental health nurses, and (ii) to attempt to explain these differences. 1016 psychiatric nurses from Stockholm (Sweden) and Birmingham (England) responded to a postal questionnaire on their psycho-social work environment and feelings of professional fulfillment, mental energy and work-related exhaustion. The study was given ethical clearance in Stockholm and Birmingham. Results indicated that while the English nurses rated their organizational well-being more favourably, Swedish psychiatric nurses reported greater individual well-being than their counterparts. Multiple regression analyses indicated that self-esteem was important for explaining mental energy and work-related exhaustion, but less so for explaining professional fulfillment, which was predicted primarily by organizational factors. When controlling for self-esteem, which was higher amongst the Swedish nurses, the differences in professional fulfillment and mental health were no longer significant. Reasons for the differences in self-esteem and experiences of the workplace are discussed. Low response rate may have contributed to a selection bias.

Feelings of professional fulfilment and exhaustion in mental health personnel: the importance of organisational and individual factors.

BACKGROUND: Mental health personnel are at high risk for mental illness, burnout and suicide. Previous studies of this group of professionals have indicated the importance of organisational factors in explaining burnout, or exhaustion, and work satisfaction. This study looks more systematically at the contribution of organisational and individual factors to work-related exhaustion and to professional fulfillment, an expanded version of job satisfaction. METHODS: A cross-sectional study of 1, 051 psychiatrists and mental health nurses in the city of Stockholm was carried out by postal questionnaire with a previously validated instrument. Multiple and logistic regressions were used to identify predictors of exhaustion and professional fulfillment. RESULTS: Organisational characteristics were found to be more important than individual characteristics in predicting exhaustion and professional fulfillment in mental health professionals. CONCLUSIONS: The results indicate that the psychosocial work environment and well-being of mental health professionals can be improved by concentrating on organisational factors such as efficiency, personal development and goal quality.

A 50-Hz electromagnetic field impairs sleep.

In view of reports of health problems induced by low frequency (50-60 Hz) electromagnetic fields (EMF), we carried out a study in 18 healthy subjects, comparing sleep with and without exposure to a 50 Hz/1 mu Tesla electrical field. We found that the EMF condition was associated with reduced: total sleep time (TST), sleep efficiency, stages 3 + 4 slow wave sleep (SWS), and slow wave activity (SWA). Circulating melatonin, growth hormone, prolactin, testosterone or cortisol were not affected. The results suggest that commonly occurring low frequency electromagnetic fields may interfere with sleep.