Hanne Hollnagel

Representativeness in population-based studies: A detailed description of non-response in a Danish cohort study:

Background: Decreasing rates of participation in population-based studies increasingly challenge the interpretation of study results, in both analytic and descriptive epidemiology. Consequently, estimates of possible differences between participants and non-participants are increasingly important for the interpretation of study results and generalization to the background population. Methods: An age-specific, population-based cohort of 1,198 individuals was examined at age 40, 45, 51, and 60. Participants were compared with non-participants and when possible also with the background population using a wide range of detailed information on somatic and mental health collected at each examination, including data from a clinical examination, biochemical measurements, questionnaires, interviews, and public registers. Results: Participation rates were higher than 80% at examinations at age 40, 45, and 51, but decreased to 65% at age 60. At the baseline investigation at age 40, analyses indicated that participants were representative of the cohort as well as the background population. However, the mortality rate was higher among non-participants in the succeeding 20 years. Among living cohort members at the 60-year examination, non-participants had lower socioeconomic status, higher hospitalization rate, and a worse overall health profile than participants. Conclusions: The detailed data presented reinforce the contention that the health profile of non-participants is typically worse than that of participants. The results also indicate that while data from public registers give easily accessible information about non-participants, these crude proxy measures of health may not be enough to document representativeness.

Influence of smoking and alcohol consumption on blood lead levels

SummaryBlood lead levels were determined in 88% of all men and women born in 1936 and residing in four suburbs of Copenhagen, i.e., 504 men and 548 women. Smoking habits and alcohol consumption were assessed by interview and were found to be independent of other indicators of lead exposure. Increased blood lead levels of smokers could, for the most part, be explained by augmented alcohol intake as indicated by the partial correlation coefficient and by the relationship between alcohol consumption and lead levels in nonsmokers. Further, smoking contributed little to the blood lead levels of individuals who did not consume any alcohol. A multivariate analysis indicated that one unit of alcohol (1.35 cl pure ethanol) per day might contribute 0.5-1.0 μg lead/100 ml blood. No significant difference was found between the influence of beer, wine, and hard liquor.

From risk factors to health resources in medical practice

The healing and preventive powers of peoples health resources and self-assessed knowledge have so far been grossly underestimated in medicine. In this article, we call attention to ethical and epistemological dilemmas related to knowledge, values, communication, and autonomy embedded in the prevailing risk-oriented epidemiology, and suggest a patient-centred salutogenetic approach to promote a better balance between resources and risks in medicine. Identification and intervention upon risk factors can provide hypotheses about origins of disease and predict and sometimes prevent disease at a group level. However, there are several pitfalls related to this perspective concerning causal factors, group level based possibilities, adequate end points for intervention, informed consent, and medicalization, especially in the individualized context of the clinical encounter. By introducing a salutogenic perspective, we urge to shift the attention toward resources, agency and strength, which may counteract risk of disease and empower the patient. Talk can mediate oppression as well as empowerment. A communicative key question approach, and self-assessed health resources identified through this strategy, are briefly presented as examples of empowerment through dialogue.

The Doctor Who Cried: A Qualitative Study About the Doctor's Vulnerability

PURPOSE We wanted to explore those clinical events when doctors had exposed their vulnerability toward patients in a potentially beneficial way. METHODS We undertook a qualitative study based on memory work, a structured approach to transform memories into written texts. Study participants were 9 members of a research group who had known each other a couple of years. They were asked in advance to recall a clinical event during which vulnerability was perceived and exposed in a way appreciated positively by the patient. During a group meeting, participants wrote their individual memory stories recalling these events, and the subsequent group discussion was audiotaped, transcribed, and analyzed using a phenomenological approach, applying specific linguistic cues to reveal points of special interest. The main outcome measure was the vulnerability expressed by practitioners. RESULTS Vulnerability had been experienced and exposed by the participants on several occasions during which the patients had confirmed its potentially beneficial effect. All reported events could be interpreted as different ways of personal disclosure toward the patient. We identified two kinds of disclosure: spontaneously appearing emotions and considered sharing of experiences. CONCLUSION A spontaneous exposure of emotions from the doctor may help the patient, and sharing personal experiences may lead to constructive interaction. We need to know more about when and how personal disclosure and other aspects of vulnerability exposed by the doctor are experienced as beneficial by the patient.

Avoiding humiliations in the clinical encounter

Objectives. To explore potentials for avoiding humiliations in clinical encounters, especially those that are unintended and unrecognized by the doctor. Furthermore, to examine theoretical foundations of degrading behaviour and identify some concepts that can be used to understand such behaviour in the cultural context of medicine. Finally, these concepts are used to build a model for the clinician in order to prevent humiliation of the patient. Theoretical frame of reference. Empirical studies document experiences of humiliation among patients when they see their doctor. Philosophical and sociological analysis can be used to explain the dynamics of unintended degrading behaviour between human beings. Skjervheim, Vetlesen, and Bauman have identified the role of objectivism, distantiation, and indifference in the dynamics of evil acts, pointing to the rules of the cultural system, rather than accusing the individual of bad behaviour. Examining the professional role of the doctor, parallel traits embedded in the medical culture are demonstrated. According to Vetlesen, emotional awareness is necessary for moral perception, which again is necessary for moral performance. Conclusion. A better balance between emotions and rationality is needed to avoid humiliations in the clinical encounter. The Awareness Model is presented as a strategy for clinical practice and education, emphasizing the role of the doctors own emotions. Potentials and pitfalls are discussed.

Encouraging the strengths of women patients A case study from general practice on empowering dialogues

This case study illustrates how the use of empowering dialogues in general practice can contribute to alternative images of women, by identifying and emphasizing their strong points. It is a single case study, sampled theoretically from a series of 37 consultations during which key questions about self-assessed health resources were put to women patients. Two women GPs and their consultations were studied. An 18-min dialogue between a 52-year-old woman GP and a 69-year-old woman patient with asthma and back pain was audiotaped and transcribed according to Nessas principles, supported by pragmatic linguistic theory. The womans answers changed the doctors perception of the patient, from that of a passive and resigned sufferer, to that of a strong woman who was active in spite of her pain. Acknowledging this, alternative paths of management could be chosen. In conclusion, disempowering medicalization of women patients can be opposed by resource oriented dialogues in clinical work. However, to change cultural images requires more than individual action.

Talking with women about personal health resources in general practice: Key questions about salutogenesis

We want to share experiences from an approach for clinical communication and research, intended to identify and mobilize personal health resources in female patients, and promote strategies for resource oriented talk in general practice. We used an action research design with qualitative evaluation to summarize the process where we developed a key question about self-assessed health resources in women, based on The Health Resource/Risk Balance Model, including salutogenesis, patient-centredness and gender perspectives. From consultations with 49 female patients in our own practices, we have drawn a narrative description of the development process, a summary of issues that facilitated resource talk, and our final version of the key question. We suggest that resource talk is based on 1) an explicit shift of language from disease to health, but nevertheless recognizing the fact that illness occurs, 2) options for answers given by the female patient and not by the doctor, 3) signification of the womans assessment of her own situation (in contrast to the doctors assessment), and 4) taking for granted that womens personal health resources exist as numerous strategies which are utilized, and may be identified. We have learnt that communicative action can provide tools for shifting the attention of doctor and patients from risks and diseases to resources and strengths. This is an example of one way to change your practice through systematic reflection in dialogue with a colleague.

Explaining risk factors to patients during a general practice consultation: Conveying group-based epidemiological knowledge to individual patients

For the last 20 years I have been conducting an epidemiological study into the health status of a cohort of just over 1000 men and women. The cohort consisted of all individuals from four municipal areas in Glostrup, Copenhagen who were born in 1936. Health status was first recorded in 1976, when the participants were 40 years old. The most recent assessment was conducted in 1996, when all participants were aged 60. Group-based knowledge, particularly in relation to risk factors, was compiled through these observations (1,2). When conducting research as part of my own consultations, I apply a qualitative research approach. The great challenge facing the general practitioner (GP) is to combine the group-based knowledge with the knowledge about individual patients and to consider this combination in the context of patients’ lives and their wider social and cultural milieu. The current paper will focus on this challenge. I will illustrate the problems that I have encountered as an epidemiologist, a clinician and a qualitative researcher when explaining group-based knowledge to individuals during patient consultations. In dealing with the patient, the task of the GP is to ensure that both the perspective of the patient and the perspective of the doctor are identified and incorporated into any course of action. In order to gain an understanding of the patients’ experiences of illness, their reason for seeking medical advice, and their expectations and feelings, the doctor must listen to the patient. However, the doctor also needs to pass on his or her knowledge; that is, the medical information that is relevant for a particular patient at a particular point in time. So, the doctor’s task is to inform, enlighten and educate while ensuring that appropriate information is provided in a form which can be easily understood. I regard the dissemination of information on risk factors to be particularly problematic. I conclude that the information on risk factors pro6ided by the health ser6ices is inaccurate. Consequently, it is often misleading – not only for patients and the general population but e6en for clinicians. I will now present my premises for this conclusion.

The impact of changes in self-rated general health on 28-year mortality among middle-aged Danes

Objective. Self-rated general health (SRH) predicts future mortality. SRH may change, and these changes may alter the mortality risk. All-cause mortality until the age of 68 and its association with changes in SRH from the age of 40–45, 45–51, and 51–60 years was examined in a cohort of Danes. Design. Prospective population study started in 1976 with follow-up in 1981, 1987, and 1996. Setting. Suburban area of Copenhagen. Subjects. A total of 1198 individuals born in 1936. Main outcome measure. All-cause mortality. Results. Among participants with two consecutive SRH ratings the mortality rate per 1000 observation years was 7.6 (95% CI 6.4; 8.9), 8.5 (95% CI 7.1; 10.2), and 8.9 (95% CI 6.4; 10.3) after the 45-, 51-, and 60-year examination. Decline in SRH between two time-points was in bivariate Cox regression analyses associated with an increased mortality risk, the association increasing as participants grew older. Multivariate analysis of the effect of changes of SRH on mortality gave similar results: hazard ratios for declined SRH were (reference: “unchanged good”) 1.55 (95% CI 0.93–2.58), 1.96 (95% CI 1.09–3.53), and 2.22 (95% CI 0.97–5.09) at the 40–45, 45–51, and 51–60-year intervals. However, unchanged poor and improved SRH (at the 40–45-year interval) were also associated with an increase, and additional analyses showed that just rating SRH as poor at one rating was associated with increased risk. Conclusion. Changes in SRH are associated with higher mortality risks than unchanged good SRH.

Prevalence, severity and determinants of asthma in Danish five-year-olds.

Background: The prevalence of asthma and wheeze is increasing. Aim: To study the annual and cumulative prevalence of asthma and wheeze in 5‐y‐old Danish children. Methods: We obtained data on 3052 (82.0% of eligible) Danish children by a postal parental questionnaire including ISAAC questions regarding respiratory symptoms and our own questions on sociodemography and tobacco exposure. Results: “Wheeze ever” was reported in 38.3%, “doctor‐diagnosed asthma ever” in 10.5%, “childhood bronchitis ever” in 30.0%, “current wheeze” (<12 mo) in 19.7%, and being “severe” (>3 episodes) in 3.9% of the children. Current wheeze was associated with male gender (OR 1.63, 95% CI 1.35–1.96), low parental post‐primary education (OR 1.29, 95% CI 1.02–1.63 for <3 y vs ≥3 y) and current maternal smoking (OR 1.69, 95% CI 1.39–2.04). “Severe current wheeze” was recognized as asthma in six and childhood bronchitis in three of 10 cases. Nearly all diagnosed asthmatics had suffered wheeze, two‐thirds recently.