Labelling and patient knowledge of dispensed drugs as quality indicators in primary care in Botswana.

OBJECTIVES: To assess the quality of dispensing and patient knowledge of drugs dispensed in primary care in Botswana. SETTING: Thirty randomly assigned primary healthcare facilities in three districts of Botswana. PARTICIPANTS: Patients visiting clinics and health posts. DESIGN: Analysis of data from prospective participative observations of the drug dispensing process and interview of patients about their knowledge of drugs received immediately after dispensing. The quality of drug labelling was assessed by calculating mean labelling scores composed of five dispensing attributes: name of patient, and name, strength, dosage, and volume of the drug (incorrect or no labelling=0, 1 point for each correct labelling attribute; maximum score=5). Mean knowledge scores were obtained immediately after dispensing from patient recall of name and dosage of drug, duration of treatment, and reason for prescription (incorrect recall=0, 1 point for each correct recall attribute; maximum score=4). RESULTS: 2994 consecutive patient consultations were analysed. The mean labelling score was 2.75. Family welfare educators and pharmacy technicians scored highest (3.15 and 2.98, respectively) and untrained staff lowest (2.60). Factors independently associated with the labelling score were analgesics v other drugs, district, health posts v clinics, education of prescriber (nurse best), and years of experience of prescriber (4-11 years best). The mean patient knowledge score was 2.50. The reason for prescription of the drug(s), dosage, duration of treatment, and name of the drug(s) was recalled by 92%, 83%, 44%, and 31% of patients, respectively. The qualification level of the dispenser was the strongest factor independently associated with the knowledge score. Antibiotics had the second lowest score, both for labelling (2.39) and patient knowledge (2.39). CONCLUSION: Only trained dispensing staff provided satisfactory quality of labelling. Patients had a fair knowledge of the drugs dispensed. The knowledge of drugs dispensed by family welfare educators was less than satisfactory. The labelling score is a useful indicator of the quality of dispensing, and the knowledge score of both the quality of prescribing and of dispensing. These indicators should be added to the WHO list of patient care indicators.

Adherence to treatment guidelines in primary health care facilities in Botswana.

OBJECTIVES: To assess the quality of nurses' prescribing through an assessment of their prescription in relation to diagnosis, and to investigate trends in drug use in Botswana primary health care. METHODS: Key data regarding nurses' adherence to national prescription and treatment guidelines were obtained through participatory observation using a questionnaire, related to each consultation. Adherence was categorized into (i) Full adherence, (ii) acceptable adherence, (iii) acceptable adherence, but one or more useless, but not dangerous, drugs and (iv) insufficient or dangerous treatment. The study comprises data on nurses' prescriptions, diagnoses and quality of dispensing in 2994 consecutive consultations in 30 primary health care facilities in three districts of Botswana: Ngami East, Gaborone and Kgalagadi North. RESULTS: The average number of drugs prescribed per patient was 2.3. Antibiotics were prescribed in 27% of all encounters. Full adherence was found in 44%, acceptable compliance in 20%, 'acceptable, but one or more useless, but not dangerous, drugs' in 33% and 'insufficient or dangerous treatment' in 3% of the consultations. Four factors were found to be independently associated with full adherence: patient age 16-31 years, specified diagnosis, type of health facility and nurses' years of practice (4-11 years best). CONCLUSION: Although Botswana's health workers perform relatively well in terms of drug use indicators, there is a clear potential for improving health workers' adherence to national treatment guidelines.

[Health--people's perspective]. / Helse--slik folk ser det.

In 1997--2000, we conducted a study of people's concept of health. 80 persons aged 16 - 93 years were invited to a qualitative interview taken on five different locations in Norway. Included in the material was a group of former and present top athletes. We identified six essential elements in people's conceptualization of health: well-being, function, nature, a sense of humour, coping, and energy. The lay perspective on health is characterized by three qualities: WHOLENESS: Health is a holistic phenomenon. Health is related to all aspects of life and society. PRAGMATISM: Health is a relative phenomenon. Health is experienced and evaluated according to what people find reasonable to expect, given their age, medical condition and social situation. INDIVIDUALISM: Health is a personal phenomenon. Every human being is unique, and health and strategies for health must be individualized.

[Health and quality of life among long-term unemployed]. / Helse og livskvalitet blant langtidsledige.

BACKGROUND: Many studies have shown an association between unemployment and poor health. MATERIAL AND METHODS: This cross-sectional survey from 1993-94 using structured interviews and questionnaires describes health and quality of life among 148 long-term unemployed in Lillesand, Norway. RESULTS: Compared with the general population, somatoform conditions and anxiety symptoms were twice as common among the unemployed, and depression three times as common. There was a higher frequency of depression among unemployed men than among unemployed women. The unemployed had a lower quality of life score than the general population; the difference was more than twice as large among men as among women. Unemployed aged 30-39 reported the strongest symptoms of anxiety and depression. INTERPRETATION: The reason why unemployed men are more often stricken by depression and report lower quality of life than women, may be that men experience the job-loss more existentially threatening than do women.

[Courage--the mother of all virtues]. / Mot--alle dyders mor.

To be a physician requires courage. To engage in the patient as a person calls for social courage. Courage is needed to act rapidly and firmly in unclear clinical situations. The noble art of saying no to patients, bureaucrats and politicians calls upon courageous doctors. To resist follies and fallacies in medicine requires courage. The same virtue is necessary for the brave colleagues who try to diagnose and heal the perils within the medical fraternity. The autonomy, renewal and sustainability of medicine depend on courageous physicians. This article highlights the concept of courage, how this virtue may be promoted in the making of doctors and how courage should be facilitated in our professional culture.

[Physicians and other practitioners of acupuncture in Norway--education, theoretical orientation and practice]. / Leger og andre utøvere av akupunktur i Norge-utdanning, teoriforankring og praksis.

We conducted a survey for the purpose of obtaining information on training, theoretical orientation and practice among various categories of practitioners of acupuncture in Norway. Particular attention was paid to physicians, compared with other groups of practitioners. A questionnaire was sent to 161 persons who had attended Norwegian Medical Acupuncture Seminars (Norske legers akupunkturkurs) and to 274 persons found under "Acupuncture" in the Yellow Pages of the telephone directory. The response rate was 80%, questionnaires being returned by 298 practitioners. A significantly higher percentage of physicians, as opposed to other practitioners, had less than 120 hours of acupuncture training. 30% of the physicians, compared to 60% in other groups, had more than 10 acupuncture consultations a week. Physicians performed only a relatively small number of different acupuncture methods. There was a relatively high number of men among the acupuncturists. Hence, acupuncture seems to be a practice with masculine appeal. 67% of the physicians used one or more Chinese medical concepts associated with acupuncture. 45% stated that they found non-scientific explanations for how acupuncture works reliable. We therefore argue that one can identify parallel processes in the development of acupuncture. Some elements of acupuncture have been integrated in a scientifically defined reality. At the same time, this survey indicates another process: it shows that many practitioners use traditional Chinese medical concepts. This may indicate that some practitioners have changed their view on what constitutes a reliable picture of reality.

Work disability and health-affecting psychosocial problems among patients in general practice.

Psychosocial problems are often ignored among patients in general practice. By identifying high risk groups this situation could possibly be altered. This study aimed to explore if patients in general practice perceiving themselves as work-disabled by at least 50% more often have health-affecting psychosocial problems than those not work-disabled. In a geographically defined population, 1,058 consecutive adult patients consulting 89 general practitioners were approached during one regular working day in March 1995. They completed a questionnaire at home, returning it directly to the department of general practice. Male patients considered themselves work-disabled more often than female patients. All psychosocial problems except having a demanding caregiving task were more common among the work-disabled. The doctors should bear in mind that work-disabled patients more often than other patients have concomitant health-affecting psychosocial problems. Granting long-term sick leave or a disability pension may not be the only management needed.

Influence of social problems on management in general practice: multipractice questionnaire survey.

OBJECTIVES: To find how often social problems influence clinical management in general practice, how management is changed, and how the characteristics of patients, doctors, and the doctor-patient relationship influence this management. DESIGN: Multipractice survey of patients consulting general practitioners. Doctors completed a questionnaire for each patient. SETTING: General practices in Buskerud county, Norway. SUBJECTS: 1401 consecutive adult patients attending 89 general practitioners. MAIN OUTCOME MEASURES: How often management of patients was influenced by different types of social problem and main reasons for consultation; frequency and intercorrelation of different types of management applied; odds ratios for social problems' influence on management, controlled for by characteristics of doctors, patients, and their relationship. RESULTS: In 17% of all consultations the doctors' knowledge of patients' social problems influenced their management, stressful working conditions being the most frequent influencing type of problem. Knowledge of social problems influenced management more often when the doctor knew a patient well, but less often the longer a doctor had worked in a practice. When social problems influenced management, the commonest types of management offered were extra time for consultation (51%), advice (42%), authorisation of sick leave (28%), and prescription of a psychotropic drug (20%), while referral to community services was used in 2.6% of these consultations. Prescription of a psychotropic drug was positively correlated with use of extra time, and was made more often by female doctors. CONCLUSIONS: Patients' social problems influenced choice of management in at least a sixth of consultations. Prior knowledge of the patient, the doctor's time in present practice, age and sex of the patient, and sex of the doctor significantly influenced management of patients.

Psychosocial problems presented by patients with somatic reasons for encounter: tip of the iceberg?

BACKGROUND: Health-affecting psychosocial problems are inherent in general practice, present among one-third of the patients and constituting between 3 and 13% of reasons for encounter. Such problems are not always presented, and often overlooked by the doctors. OBJECTIVES: We aimed to describe the frequency of psychosocial problems presented to the doctor by patients with somatic reasons for encounter, as a proportion of the patients' existing health-affecting problems, and to explore whether characteristics of the doctor, the patient, their relationship or reason for encounter influence the presentation of problems. METHODS: A questionnaire survey of 1401 consecutive patients visiting 89 Norwegian GPs mapped the prevalence of nine commonly occurring psychosocial problems and the frequency by which they were disclosed during the consultation. RESULTS: From 21% (loneliness) to 59% (occupational stress) of problems were disclosed to the doctors. Reason for encounter was the only factor to influence the disclosure from male patients, while reason for encounter, educational level and income source of the patient, gender of the doctor, and the doctor's previous general knowledge of the patient influenced the disclosure from female patients. CONCLUSIONS: Less than half of health-affecting psychosocial problems are disclosed to GPs by patients with somatic reasons for encounter. Occupational stress is disclosed more often than other psychosocial problems. Female patients disclose non-occupational problems more often than male patients, especially if they know the doctor or if the doctor is a woman. Symptoms from the musculoskeletal system are the reasons for encounter most often preceding the disclosure of psychosocial problems.

Clinical practice: between Aristotle and Cochrane.

Health and disease consist of amino acids and self image, cell membranes and human ideals, muscles and politics. Only to a limited extent can clinical practice be based on science. It can never be carried on in isolation from political, and cultural forces that influence patients' health behaviour. Evidence-based medicine is essential but not sufficient. A continuous relationship with patients is a conditio sine qua non for general practice. The general practitioner must be a master of pragmatic medicine. Rationality, the dominant modern trend, may be dangerous for patients and doctors: (1) advances in technology can give patients and doctors the illusion of mastering the universe; (2) patients complain of being treated like biomachines, without human touch. Another symptom of modernity is the decline of religion. But patients and doctors are by no means rational beings. God, destiny and hope are replaced by modern medico-scientific megalomania. Modern medicine is also strongly influenced by commercialization and invasion by bureaucrats. Instead of becoming a biomedical robot, the general practitioner must learn to value the Aristotelian concept of phronesis. It means practical wisdom and can only be gained by personal experience; a form of learning by doing. Good clinical practice cannot come from science alone, or from personal experience alone. It is an amalgam of scientia and phronesis.

General practitioners' knowledge of their patients' socioeconomic data and their ability to identify vulnerable groups.

OBJECTIVE: To explore general practitioners' knowledge of their patients' socioeconomic data and their ability to identify vulnerable groups. DESIGN: A multipractice survey of consecutive adult patients consulting general practitioners during one regular workday. Doctors and patients independently completed mirrored questionnaires. SETTING: A geographically defined population of patients and doctors in Buskerud county, Norway. SUBJECTS: 1401 patients attending 89 general practitioners during the last two weeks of March 1995. MAIN OUTCOME MEASURES: The doctors' ability to state the patients' socioeconomic situation correctly using sensitivity and specificity. Results for patients scarcely and well known to the doctors are compared. RESULTS: Sensitivity ranged from 0.93 for work as main income source to 0.04 for not having WC/bathroom inside the dwelling. Specificity ranged from 1.00 for several factors to 0.73 for low educational level. Information on household composition and income source was correct for more than half of patients scarcely known to the doctors. CONCLUSIONS: General practitioners' knowledge of various socioeconomic data of their patients differs substantially and are collected at different stages in the relationship. Among socioeconomic data defining vulnerable groups, the patients' self-perceived work disability is the variable general practitioners are best at evaluating.