http://hdl.handle.net/1956/938 Search the Channel search http://bora.uib.no/simple-search http://hdl.handle.net/1956/2325 Title: Assessing medical students’ attitudes towards learning communication skills – which components of attitudes do we measure? <br/> <br/>Authors: Anvik, Tor; Gude, Tore; Grimstad, Hilde; Baerheim, Anders; Fasmer, Ole B.; Hjortdahl, Per; Holen, Are; Risberg, Terje; Vaglum, Per <br/> <br/>Abstract: Background. The Communication Skills Attitudes Scale (CSAS) created by Rees, Sheard and Davies and published in 2002 has been a widely used instrument for measuring medical students' attitudes towards learning communication skills. Earlier studies have shown that the CSAS mainly tests two dimensions of attitudes towards communication; positive attitudes (PAS) and negative attitudes (NAS). The objectives of our study are to explore the attitudes of Norwegian medical students towards learning communication skills, and to compare our findings with reports from other countries. Methods. The CSAS questionnaire was mailed simultaneously to all students (n = 3055) of the four medical schools in Norway in the spring of 2003. Response from 1833 students (60.0%) were analysed by use of SPSS ver.12. Results. A Principal component analysis yielded findings that differ in many respects from those of earlier papers. We found the CSAS to measure three factors. The first factor describes students' feelings about the way communication skills are taught, whereas the second factor describes more fundamental attitudes and values connected to the importance of having communication skills for doctors. The third factor explores whether students feel that good communication skills may help them respecting patients and colleagues. Conclusion. Our findings indicate that in this sample the CSAS measures broader aspects of attitudes towards learning communication skills than the formerly described two-factor model with PAS and NAS. This may turn out to be helpful for monitoring the effect of different teaching strategies on students' attitudes during medical school. Thu, 29 Mar 2007 22:58:59 GMT http://hdl.handle.net/1956/2321 Title: Retrospective assessment of exposure to carcinogens in Norway’s offshore petroleum industry <br/> <br/>Authors: Steinsvåg, Kjersti <br/> <br/>Abstract: Objectives: The main research objective of the four articles comprising this dissertation was to provide retrospective exposure information for a planned study on cancer in a cohort within Norway’s offshore petroleum industry. Methods: Background information on possible exposure was obtained through company visits, including interviewing key personnel (n = 83) and collecting monitoring reports (n = 118) and other relevant documents (n = 329). The collected material was used to identify relevant carcinogens. Twenty-seven job categories were defined based on a previous questionnaire administered to present and former offshore employees in 1998. Descriptions of products containing known and suspected carcinogens, exposure sources and processes were extracted from the collected documentation and the interviews of key personnel (Article II). Exposure data on oil mist and oil vapour covered 37 drilling facilities and were analysed by descriptive statistics and by constructing linear mixed-effects models (Article I). A group of three university and five industry experts individually assessed the likelihood (unlikely, possible or probable) of exposure for combinations of 17 carcinogens, 27 job categories and four time periods (1970–1979, 1980–1989, 1990–1999 and 2000–2005). Each rater was to assess 1836 combinations based on summary documents on carcinogenic agents, which included descriptions of sources of exposure and products, descriptions of work processes carried out within the different job categories and monitoring data. Interrater agreement was calculated using Cohen’s kappa index and single and average score intraclass correlation coefficients. Differences in interrater agreement between the different time periods, raters, carcinogen class and amount of information provided were then studied (Article III). In subsequent plenary discussions, the experts agreed on exposed combinations. Agreement between the individual and the panel assessments was calculated using Cohen’s kappa index. Using the panel assessment as reference, sensitivity and specificity were estimated (Article IV). Results: This study indicated possible exposure to the following known and suspected carcinogenic agents, mixtures or exposure circumstances: benzene; mineral oil – inhalation exposure; mineral oil – skin exposure; crystalline silica; asbestos; refractory ceramic fibres; formaldehyde; tetrachloroethylene; trichloroethylene; welding; nickel compounds; chromium [VI]; lead; crude oil – skin exposure; diesel engine exhaust; dichloromethane; ionising radiation; and occupational exposure as a painter (Article II). Monitoring reports were obtained on seven agents: benzene, mineral oil mist and vapour, respirable and total dust, asbestos fibres, refractory ceramic fibres, formaldehyde and tetrachloroethylene (Article II). The arithmetic mean of 367 personal samples of benzene was 0.037 ppm (range: less than the limit of detection – 2.6 ppm). Asbestos fibres were detected (0.03 fibres/cm3) when asbestos-containing brake bands were used in drilling draw work in 1988. The personal exposure to formaldehyde in the process area ranged from 0.06 to 0.29 mg/m3. Samples of oil mist and oil vapour had been taken during the use of three generations of hydrocarbon base oils: diesel oils (1979–1984), low-aromatic mineral oils (1985–1997) and nonaromatic mineral oils (1998–2004). Sampling done before 1984 showed high exposure to diesel vapour (arithmetic mean = 1217 mg/m3). Downward time trends were indicated for both oil mist (6% per year) and oil vapour (8% per year) when the year of monitoring was introduced as a fixed effect in a linear mixed-effects model analysis. Rig type, technical control measures and mud temperature significantly determined exposure to oil mist. Rig type, type of base oil, viscosity of the base oil, work area, mud temperature and season significantly determined exposure to oil vapour. In these models major decreases in variability were found for the between-rig components (Article I). In the individual expert assessment overall, 336 (18%) of the 1836 combinations were denoted possible exposure, and 253 (14%) scored probable exposure. Stratified on the 17 carcinogenic agents, the prevalence of probable exposure ranged from 3.8% for refractory ceramic fibres to 30% for crude oil. The overall mean kappa (κ) was 0.42; single score intraclass correlation coefficient was 0.62, and the average intraclass correlation coefficient was 0.93. Providing limited quantitative measurement data was associated with less agreement than for equally well-described carcinogens without sampling data. The eight experts assessed 1157 (63%) of the 1836 combinations in plenary, resulting in 265 (14%) agreed exposed combinations. The agreement between the experts’ individual assessments and the panel assessment was κ = 0.53–0.74. The sensitivity was 0.55–0.86 and specificity 0.91–0.97. For these parameters, there were no apparent differences between the university experts and the industry experts. Conclusions For defined job categories in Norway’s offshore petroleum industry this study describes possible exposure to known and suspected carcinogenic agents, mixtures or exposure circumstances. An expert panel agreed on probable exposure for 265 of 1836 possible combinations of 17 agents, 27 job categories and four time periods. Measurement data on seven agents are presented. Benzene and mineral oil mist and vapour were considered to have the best potential for development of quantitative estimates of exposure. Exposure to oil mist and oil vapour declined over time in the mud-handling areas of offshore drilling facilities. Exposure was associated with rig type, mud temperature, technical control measures, base oil, viscosity of the base oil, work area and season. The eight raters in the expert group seemed to have enough documentation on which to base their individual estimates. However, providing limited monitoring data leads to more incongruence among raters. The group was large enough to give reliable estimates. The experts’ individual ratings highly agreed with the succeeding panel assessment. The university experts and the industry experts’ assessments did not apparently differ. Thu, 14 Jun 2007 22:58:59 GMT http://hdl.handle.net/1956/2211 Title: Cost-effectiveness of medical interventions to prevent cardiovascular disease in a sub-Saharan African country – the case of Tanzania <br/> <br/>Authors: Robberstad, Bjarne; Hemed, Yusuf; Norheim, Ole F. <br/> <br/>Abstract: Background: There is a high and rising prevalence of cardiovascular risk in sub-Saharan Africa, a development typical for countries in epidemiological transition. Contrary to recommendations in treatment guidelines, medical interventions to prevent cardiovascular disease are implemented only on a limited scale in these settings. There is a widespread concern that such treatment is not cost-effective compared to alternative health interventions. The main objectives of this article are therefore to calculate costs-, effects and cost-effectiveness of fourteen medical interventions of primary prevention of cardiovascular disease in Tanzania, including Acetylsalicylic acid, a diuretic drug (Hydrochlorothiazide), a β-blocker (Atenolol), a calcium channel blocker (Nifedepine), a statin (Lovastatin) and various combinations of these. Methods: Effect sizes were derived from systematic reviews or meta-analyses, and calculated as Disability Adjusted Life Years (DALYs). Data on drug costs were calibrated to a Tanzanian setting. Other recurrent and capital costs were derived from previous studies and reviewed by local experts. Expected lifetime costs and health outcomes were calculated using a life-cycle model. Probabilistic cost-effectiveness analysis was performed using Monte Carlo simulation, and results presented as cost-effectiveness acceptability curves and frontiers. The potential impacts of uncertainty in value laden single parameters were explored in one-way sensitivity analyses. Results: The incremental cost-effectiveness ratios for the fourteen interventions and four different levels of risk (totally 56 alternative interventions) ranged from about USD 85 per DALY to about USD 4589 per DALY saved. Hydrochlorothiazide as monotherapy is the drug yielding the most favorable cost-effectiveness ratio, although not significantly lower than when it is combined in duo-therapy with Aspirin or a β-blocker, in triple-therapy with Aspirin and a β-blocker, or than Aspirin given as mono-therapy. Conclusion: Preventive cardiology is not cost-effective for any patient group in this setting until willingness to pay exceeds USD 85 per DALY. At this level of willingness to pay, the optimal intervention is Hydrochlorothiazide to patients with very high cardiovascular risk. As willingness to pay for health increase further, it becomes optimal to provide this treatment also to patients with lower cardiovascular risk, and to substitute to more sophisticated interventions. Wed, 21 Feb 2007 22:58:59 GMT http://hdl.handle.net/1956/2209 Title: High prevalence of respiratory symptoms among workers in the development section of a manually operated coal mine in a developing country : a cross sectional study <br/> <br/>Authors: Mamuya, Simon H. D.; Bråtveit, Magne; Mashalla, Yohana; Moen, Bente E. <br/> <br/>Abstract: Background: Few studies of miners have been carried out in African countries; most are from South Africa, where the working conditions are assumed to be better than in the rest of Africa. Several studies have focused on respiratory disorders among miners, but development workers responsible for creating underground road ways have not been studied explicitly. This is the first study assessing the associations between exposure to dust and quartz and respiratory symptoms among coal mine workers in a manually operated coal mine in Tanzania, focusing on development workers, as they have the highest exposure to coal dust. Methods: A cross-sectional study was carried out among 250 production workers from a coal mine. Interviews were performed using modified standardized questionnaires to elicit information on occupational history, demographics, smoking habits and acute and chronic respiratory symptoms. The relationships between current dust exposure as well as cumulative respirable dust and quartz and symptoms were studied by group comparisons as well as logistic regression. Results: Workers from the development group had the highest dust exposure, with arithmetic mean of 10.3 mg/m3 for current respirable dust and 1.268 mg/m3 for quartz. Analogous exposure results for mine workers were 0.66 mg/m3 and 0.03 mg/m3, respectively; and for other development workers were 0.88 mg/m3 and 0.10 mg/m3, respectively. The workers from the development section had significantly higher prevalence of the acute symptoms of dry cough (45.7%), breathlessness (34.8%) and blocked nose (23.9%). In addition, development workers had significantly more chronic symptoms of breathlessness (17.0%) than the mine workers (6.4%) and the other production workers (2.4%). The highest decile of cumulative exposure to respirable dust was significantly associated with cough (OR = 2.91, 95% CI 1.06, 7.97) as were cumulative exposure to quartz and cough (OR = 2.87, CI 1.05, 7.88), compared with the reference consisting of the group of workers with the lowest quartile of the respective cumulative exposure. Conclusion: The development workers in a coal mine had more acute and chronic respiratory symptoms than the mine and the other production workers. In addition, there was an association between high cumulative coal dust and respiratory symptoms. Wed, 31 Jan 2007 22:58:59 GMT http://hdl.handle.net/1956/2207 Title: Effect of an antepartum Pap smear on the coverage of a cervical cancer screening programme: a population-based prospective study <br/> <br/>Authors: Nygård, Mari; Daltveit, Anne-Kjersti; Thoresen, Steinar Ø.; Nygård, Jan F. <br/> <br/>Abstract: Background: Almost one-third of Norwegian women aged 25–69 years invited to have a Pap smear do not attend during the recommended period, and thus constitute a population with high-risk of cervical cancer (CC). Since the incidence of precancerous lesions of the cervix peak with occurrence of pregnancies within the same decade in women aged 25 to 35 years of age, antepartum care presents an opportunity to offer a Pap smear thereby increasing the coverage of the programme. The study objective was to describe the effect of the antepartum Pap smear on the coverage of a cytological CC screening programme. Methods: Among 2 175 762 women resident in Norway in 31.12.1996, all women who gave birth in 1996–7 were identified from the Medical Birth Registry of Norway. Attendance to the cervical cancer screening was assessed by linkage to the Cytology Registry separately for the pregnant and non-pregnant women cohorts. The results were stratified by age, history of previous Pap smear and history of invitation to the CC screening programme. Logistic regression was used to estimate the relative probabilities of having a Pap smear adjusted for age, screening history, and time since invitation, for pregnant and non-pregnant women, respectively. Results: 69% of the pregnant women had a Pap smear during one year of follow-up since beginning of the pregnancy with the majority taken during the antepartum period. Irrespectively of age or history of having a Pap smear, pregnant women were 4.3 times more likely to have a Pap smear during follow-up compared to non-pregnant women. 63.2% of the pregnant women had a smear as response to the invitation letter compared to 28.7% of the non-pregnant women, OR = 2.1 (95% CI 1.9 to 2.4). As an indication of "over-screening", 5397 pregnant women (57.8%) with a smear shortly before the start of follow-up also had a new Papsmear, compared to 83 023 (32.3%) in non-pregnant. Conclusion: Pap smear screening during pregnancy increases the coverage of the CC screening programme. The contribution of the antepartum Pap smear to "over-screening" exists but its effect is modest in countries where women on average become pregnant after the start of recommended age of screening. Mon, 22 Jan 2007 22:58:59 GMT http://hdl.handle.net/1956/2203 Title: Epidemiological studies of multiple sclerosis in a Sardinian population, insular Italy : cluster studies and health status <br/> <br/>Authors: Pugliatti, Maura <br/> <br/>Abstract: MS is a disorder of the central nervous system, manifesting as acute focal inflammatory demyelination and axonal loss, and culminating with chronic multifocal sclerotic plaques. MS involves several nervous functional systems resulting in disability, has a rather unpredictable course, and thus leads to poorer quality of life. It is a disorder of young adults, and the most common cause of non post-traumatic neurological disability. It is believed to be caused by interplay between genes and the environment. Potentially any environmental agent can have a role in determining MS in susceptible populations and yet be neither a necessary nor a sufficient cause. Potential risk factors have been investigated, such as infectious agents, vaccines, stress, occupation, climate and nutrition. At what age in a genetically predisposed individual’s life, exogenous factors can interact to initiate MS is rather controversial, although this probably occurs within the first 15 years of life. The present work involves two broad areas in MS research: (i) epidemiological descriptive studies aimed at disclosing clues to disease etiology and mechanisms of disease induction, and (ii) the study of determinants of health-related quality of life in the MS population at large. The specific objectives to this work were: to disclose MS variation at a microgeographic level, as a possible expression of the spatial distribution of disease risk factor(s) (Paper I); to update and characterise MS incidence patterns, as a possible expression of temporal distribution of disease risk factor(s) (Paper II); to assess whether individuals that later develop MS have shared the same environment at the same age indicating common exposure to disease factor(s), and if so at what age has this occurred (Paper III); and to compare the self-perceived health status to the general population, with special regards to physical functioning, in MS patients with no or mild disability as objectively measured (Paper IV). All these studies have been conducted on the province of Sassari, northern Sardinia, insular Italy (450,000 pop. circa) based on a registry system of MS cases. Epidemiological studies conducted over the past two decades using repeated assessments have shown that Sardinia is at high risk for MS with a prevalence of 150 per 100,000 and an annual mean incidence of 6 per 100,000. To investigate the distribution of MS in Sardinia at microgeographic level a spatial analysis of the disease prevalence in the study area for year 1997 was conducted (Paper I). To overcome random variability due to small numbers of cases per geographic unit, a hierarchical Bayesian approach was adopted. Spatial clustering patterns in the province south-west and a west-to-east gradient were observed. An incidence study was performed on 689 MS patients with disease onset between 1965 and 1999 in the study area (Paper II). The mean annual incidence rate increased significantly from 1 per 100,000 pop in 1965–69 to 6 in 1995–99, with no differences for gender and province sub-areas. The mean age at onset increased significantly during the same period from 25.7 to 30.6 years, while the proportion of patients with progressive initial course declined over time. Space-time cluster analysis was performed in the study area to indicate a possible shared exposure to MS risk(s) factors during the disease latent period, and the individuals’ age for this susceptibility period (Paper III). Residence changes from birth to clinical onset were recorded for all MS patients with clinical onset between 1965 and 1999 in the study area. Closeness in space and time was defined as living in the same commune, at the same time and at the same age differing only by 1, 2 or 5 years. The analysis was performed from birth until age 25 years or disease clinical onset, and by demographic and clinical subgroups. Clustering was substantial in early childhood. It was most marked in the most recent cases, among women and in patients with relapsing-remitting course. No clustering was found when closeness in time was defined as a fixed number of years before onset, arguing against a fixed latency period of the disease. MS heterogeneous spatial distribution at microgeographic level, its increased incidence and change of clinico-demographic phenotypes over a relatively short period of time, and evidences of clustering in space and time in early childhood especially occurring recently, are suggestive for the action of an exogenous factor(s) in determining MS. Ecological and case-control studies need to be designed and implemented to validate and characterise these observations. The self-perceived health status among MS patients with no or mild disability according to EDSS and the impact of self-rated physical functioning have been compared between a sample of fully ambulatory (EDSS ≤3.5) MS patients and the general population (Paper IV). SF-36 was used to self-rate health status. The 197 MS patients analysed (150 women and 47 men) had significantly lower mean SF-36 scores than the general population, except for bodily pain. Similar results were found for a sub sample of 107 patients (81 women and 26 men) with even lower disability (EDSS ≤2.0). EDSS correlated weakly with the physical functioning subscale, explaining only 2% of the variance in such SF-36 subscale. The regression of the physical functioning subscale on the other seven SF-36 subscales was significantly lower among MS patients than in the general population for all subscales, except for role limitation due to physical health problems and social functioning. Therefore factors other than physical functioning contribute to the low scores for the other dimensions compared with the general population. Neither disease course nor duration correlated significantly with SF-36 subscales. Strategies targeting a broad spectrum of health related issues for MS patients should be implemented starting already in the disease early stage. For cost-of-illness studies these findings provide clues to indicators to the disease socio-economic burden in the early stages, and elements for disease-specific interventions. Thu, 29 Mar 2007 22:58:59 GMT http://hdl.handle.net/1956/1965 Title: Antihypertensive and lipid lowering treatment in 70–74 year old individuals – predictors for treatment and blood-pressure control : a population based survey. The Hordaland Health Study (HUSK) <br/> <br/>Authors: Brekke, Mette; Hunskaar, Steinar; Straand, Jørund <br/> <br/>Abstract: Background: In an elderly, community based population we aimed at investigating antihypertensive and lipid lowering medication use in relation to own and familiar cardiovascular morbidity and diabetes mellitus, as well as to lifestyle factors and general health. We also examined levels of blood pressure in untreated and treated residents, to investigate factors correlating with blood pressure control. Methods: A health survey carried out in 1997-9 in the county of Hordaland, Norway included a self-administered questionnaire mailed to 4 338 persons born in 1925-7. Drug use the day prior to filling in the questionnaire was reported. A health check-up was carried out, where their systolic and diastolic blood pressure (SBP and DBP), body mass index (BMI), and serum-cholesterol level were recorded. Results: One third of respondents used one or more antihypertensive drugs, while 13% of men and women were treated with a statin. Diabetes mellitus, own or relatives'cardiovascular disease, having quit smoking, physical inactivity, and overweight correlated with antihypertensive treatment. Mean blood pressure was lower in respondents not on treatment. Among those on treatment, 38% of men and 29% of women had reached a target BP-level of lower than 140/90 mm Hg. Own cardiovascular disease and a low BMI correlated with good BP-control. Conclusion: One third of 70–74 year old individuals living in the community used one or more antihypertensive drugs. Only around one third of those treated had reached a target BP-level of less than 140/90 mm Hg. Own cardiovascular disease and a low BMI correlated with good BP-control. Wed, 18 Oct 2006 22:58:59 GMT http://hdl.handle.net/1956/1936 Title: Children with developmental problems and disorders : selected aspects of motor and multidisciplinary assessment and intervention <br/> <br/>Authors: Iversen, Synnøve <br/> <br/>Abstract: The general aim of this thesis was to apply a multidisciplinary approach to selected clinical aspects of children with developmental problems and disorders, in order to contribute to the development of assessment and intervention strategies. Motor coordination difficulties were particularly focused. The following aspects were investigated in the separate studies: - Behaviour, cognitive, linguistic and motor skills were assessed in 6-year old children considered at risk with regard to inclusion in ordinary schooling due to behavioural and emotional difficulties. - Incidence, severity and types of motor coordination difficulties in 6-year-old children with behavioural and emotional difficulties were compared to age and gender matched controls. - Incidence, severity and types of motor coordination difficulties in a group of 10-12 year old children with dyslexia and a group consisting of teacher referred poor readers, were compared to a control group, which comprised teacher referred good readers. - A participatory multidisciplinary team approach was developed and implemented at school start at 27 schools in two regions in Norway in order to promote health and improve services for all children, but with a particular focus on children with developmental problems and disorders. - Mid-childhood effects of a high-intensity, task specific school-based intervention approach were compared with traditional municipal physiotherapy intervention for 6-year old children with motor coordination difficulties. The results from the evaluation of the 6-year-old children considered at risk with respect to ordinary school inclusion highlighted the importance of multidisciplinary assessment of young children with behavioural and emotional problems. While the most severe problems were found in social interaction and attention, the children also scored below average on cognitive and linguistic measures. Severe motor problems were found in more than half of the group. The following in-depth investigation of motor coordination difficulties revealed that 62.1 % in the high-risk group and 20.7 % in the control group showed borderline or definite motor coordination difficulties at or below the 15th centile when assessed with the Movement Assessment Battery for Children (M-ABC) (Henderson and Sugden, 1992). In the high-risk group 55.2 % fulfilled the criteria for developmental coordination disorder (DCD), compared to 3.4 % of the controls. The high-risk group showed a mixed profile, with significant difficulties within all sub-areas of the M-ABC. Investigation of motor profiles for children in the high-risk group with specific types of behavioural and emotional problems showed a significant relationship between attention problems and manual dexterity difficulties, and continuous, precise fine motor movements were particularly difficult. More than 50 % of the children with dyslexia as well as the group comprising teacher referred poor readers showed definite motor coordination difficulties at or below the 5th centile, compared to 13.6 % of the controls. Children in both groups performed significantly worse than controls within the sub-area of manual dexterity and balance, but not in ball-skills. Continuous precise fine motor movements stood out as particularly difficult for both groups of poor readers. The participatory multidisciplinary team approach implemented at school start was reported to improve multidisciplinary teamwork and professional relations. An increased focus on general developmental and health care issues was also reported, as well as improved health and educational services to vulnerable children, including children with developmental problems and disorders. Local creativity and ownership within supportive administrative structures were evaluated as promoting factors, while available time and professional resources from the supportive municipal services stood out as main constraints. The construction of learning partnerships based on face-to-face interaction appeared to be a particular strength of the approach. The evaluation of possible mid-childhood effects of two different types of intervention approaches applied at the age of six for children with motor coordination difficulties (DCD), revealed no significant differences with respect to total impairment and subscale scores at the MABC. At the levels of activity and participation the parents representing the high-intensity, task specific approach reported an overall more favourable situation. Their children were physically active, with frequent use of targeted motor skills learned during intervention. The majority of children from both groups displayed comorbid learning difficulties and attention deficits at follow-up, and the parents considered their children vulnerable and worried about future social functioning. The studies demonstrated that children with developmental problems and disorders represent a complex, variable and vulnerable group. Although some pure cases of developmental disorders were identified, the majority of children evaluated presented with concomitant difficulties, highlighting a need for coordinated municipal multidisciplinary health and educational services. Wed, 23 Aug 2006 22:58:59 GMT