全科醫(yī)學教學課件：第3講 Illness in the Community

1、Illness in the Community（P29-36）Illness in the Community Studies (of illness in the community) have revealed that physicians see only a small fraction of the health problems experienced by the population at large. Retrospective surveys Interview survey simple correlations Regression analysis Prospec

2、tive studyPrevalence of illness and utilization of medical resources 1,000 at risk 750 reporting illness or injury 250 consulting a physician 9 admitted to a hospital 5 referred to another physician 1 referred to a UMCRetrospective surveys 90 percent of adults report a symptom during the previous (p

3、ast,earlier?)two weeks. Only one in every four or five of these have consulted a physician in that period.Interview survey 86 % of adults and children reported at least one physical symptom. The most common symptoms were respiratory, with tiredness second and headaches third in order of frequency. T

4、he predominance of respiratory symptoms was similar to that in surveys in Aus.and the U.S. Respiratory illness is also the most common diagnosis. 51% adults had mental symptoms (e.g. obsessional thoughts, paranoid ideas). 24% of the children reported to have behavioral problems (e.g., enuresis, disc

5、ipline problems). a quarter of the adults had at least one social problem.社區(qū)衛(wèi)生服務(wù)中心就診者的疾病譜（1001班2013年赴四川成都暑期社會實踐數(shù)據(jù)）居民病種居民病種人數(shù)人數(shù)%感冒咳嗽等呼吸道疾病6820.4三高6419.2保健體檢4714.1運動系統(tǒng)疾病339.9心腦血管疾病329.6婦科疾?。?64.8腸胃不適144.2口腔疾病113.3Analysis of simple correlations A high prevalence of symptoms was associated with increas

6、ing age, female sex, unemployment due to illness, marital separation or divorce, passive as opposed to active religious affiliation, living on or above the fifth floor in highrise flats, and a high number of moves of domicile (mobility). The neuroticism score increased with all the adult symptom fre

7、quencies. Subjects with low extroversion scores had significantly more mental and social symptoms. Regression analysis The neuroticism score, age and sex, living in highrise flats, passive religious affiliation, and mobility all remained significant variables.Prospective study Using the health diary

8、 method Adults recorded at least one complaint on 21.8 percent of days only on 6 percent of these days was a doctor consulted. Women: symptoms were recorded on ten days out of twentyeight on the average. The yearly average of symptom episodes was eightyone. A doctor was consulted for only one out of

9、 every thirtyseven symptom episodes.Conclusion It is clear that the occurrence of symptoms is the norm rather than the exception. The important questions, therefore, are not whether symptoms are present, but how serious or frequent they are, and how they are acted upon.Two important concept The Sick

10、 Role Illness BehaviorSick Role When a person has consulted a physician and been defined as sick, he or she occupies a special role in society. Entering the sick role has certain obligations and privileges. The individual is exempted from normal social obligations and is not held responsible for his

11、 or her incapacity. The sick person is expected to seek professional help and to make every effort toward recovery. Whether or not a person decides to enter the sick role when he or she becomes ill is dependent on many individual and group factors that are independent of the severity of the illness.

12、Illness Behavior The ways in which given symptoms may be differentially perceived, evaluated, and acted (or not acted) upon by different kinds of persons. The illness behavior exhibited by an individual determines whether or not he or she will enter the sick role and consult a physician. Problem beh

13、avior : the actions of a patient with a problem of living as distinct from an illness.Distinguishing between illness and illness behavior Illustrated by the irritable colon syndrome. If this syndrome is defined only by the characteristics of patients attending physicians, there is a significant corr

14、elation between the abdominal symptoms and neurotic traits. This has led to the inference that these personality traits are causal in the syndrome. Studies show that people with irritable bowel syndrome who do not attend physicians are psychologically no different from normal subjects without irrita

15、ble bowel syndrome.Understanding of illness behavior Change the perspective of the physician. The key question may be “why did the patient come?” The aim of therapy may be not to remove the symptoms but to help the patient to live with them, as many others in the population have learned to do.Underr

16、eporting of Serious Symptoms and Consultation for Minor Symptoms Variations in illness behavior are responsible for two phenomena of interest to family physicians Failure to consult with serious symptoms Attendance with minor symptoms.Incongruous Referral Defined as Failure to consult with symptoms

17、assessed by the patient himself as serious Consulting for symptoms assessed by the patient as minor. Physical, mental, and behavioral symptoms were graded for pain, disability, seriousness and duration, using the patients own assessment. A mean severity score was then calculated for each subject. So

18、cial symptoms were graded separately for worry or inconvenience. The extent of incongruous referral of both kinds is shown in Figure 3.2. 26% of people with physical, mental, or behavioral symptoms did not seek professional help for serious symptoms. 11% sought professional help for minor symptoms.

19、For social symptoms the figures were 16 percent and 12 percent, respectively. Incidence of incongruous referral (F 3.2). Of the medical symptoms Behavioral symptoms in children were most likely to be referred for professional help Physical symptoms in all subjects next Mental symptoms in adults leas

20、t likely to be referred.Failure to consult for serious symptoms Was associated with unemployment due to illness, passive religious allegiance, lower social class, living alone, and higher neuroticism scores. On regression analysis, neuroticism, poor past and present health, increasing age, female se

21、x, and mobility were significant associated variables.Consultation for minor symptoms Was associated on regression analysis with greater number of present illnesses, separation or divorce, increasing age, female sex, few years in present residence, poor experience of doctors or hospitals, difficulty

22、 in contacting doctor, and number of hospital stays.Factors affecting illness behaviour Upperclass persons more often reported themselves ill than lowerclass persons, and were more likely to seek treatment when ill. Lowerclass persons had more symptoms, but reported themselves to be less often ill a

23、nd were less likely to visit a physician. Some of these differences in relation to specific symptoms are illustrated in Table 3.1.Percentage of respondents in each social class recognizing specified symptoms as needing medical attention(T 3.1)SymptomClass I (N=51) II(N=335) III(N=128)Loss of appetit

24、e575020Persistent backache534419Continued coughing (8w)777823Persistent joint and muscle pains804719Blood in stool988960Blood in urine1009369Excessive vaginal bleeding928354Swelling of ankles777623Loss of weight805121Bleeding gums795120Chronic fatigue805319Shortness of breath775521Persistent headach

25、es805622Fainting spells805133Pain in chest805131Lump in breast947144Lump in abdomen926534Women (aged twenty to fortyfour) Those with a high level of freefloating anxiety were more likely to consult their general practitioners about their symptoms. The nature of the symptoms had a strong correlation

26、with the decision to seek care. Table 3.2 illustrates the wide variation in response to different symptoms.The likelihood of symptom episodes leading to consultation with a physician( T 3.2 )SymptomRatio of Symptom Episodes to ConsultationsChanges in energy456:1Headache184:1Disturbance of gastric fu

27、nction109:1Backache52:1Pain in lower limb49:1Emotional/psychological46:1Abdominal pain29:1Disturbance of menstruation20:1Sore throat18:1Pain in chest14:1Several Researchs Mechanic found that persons reporting high stress levels, especially interpersonal difficulties, showed a high inclination to use

28、 medical services. Zola interviewed ItalianAmerican and IrishAmerican patients before they saw the physician on new visits to hospital clinics. Information on the primary diagnosis, secondary diagnosis, potential seriousness, and degree of urgency was obtained from the physician. Besides comparisons

29、 between the two groups, comparisons were also made between matched pairs of one Irish and one Italian patient of the same sex who had the same primary diagnosis, the same duration of illness, and the same degree of seriousness.Major differences emerged The Irish more often than the Italians denied

30、that pain was a feature of their illness. More Irish described their chief problem in terms of specific dysfunction; more Italians described it in terms of a diffuse difficulty. The Irish tended to limit and understate their difficulties, whereas the Italians tended to spread and generalize theirs.

31、The Italians complained of more symptoms, more bodily areas affected, and more kinds of dysfunction than did the Irish, and more often felt that their symptoms affected their interpersonal behavior.Reactions to pain in patients of Jewish, Italian, and “Old American” stock. Data was collected from in

32、terviews with patients, from observation of their behavior when in pain, and from discussion with doctors and nurses involved in the care of the individual. Jews and Italians were described as being very emotional in their responses to pain. Italians, however, were mainly concerned with the immediac

33、y of the pain, whereas Jews focused their concern on the meaning of the pain and its longterm implications. The Italians called for pain relief and soon forgot their sufferings when this occurred. The Jews were reluctant to accept drugs, were concerned about their side effects, and regarded them as

34、giving only temporary relief. The “Old American” patients tended to have a detached and unemotional attitude to their pain. Like the Jewish patients, “Old Americans” were concerned about the meaning and future implications of their pain; but, whereas the anxieties of Jews were tinged with pessimism

35、about the outcome, “Old Americans” tended to retain an attitude of optimism born of their confidence in the skill of the expert.Summary for studies Illness behavior is related to ethnic origin, social class, age, sex, nature of illness, religious affiliation, personality, and environmental factors.

36、Hannays findings challenge the widely held belief that neuroticism is strongly related to high utilization of services and to consultation about trivia. In the Glasgow study, it was the less neurotic who were more likely to seek professional advice both in general and for “trivia.” It was the more n

37、eurotic who were most likely to be part of the symptom “iceberg.”Self-Care and Other Alternatives to Medical Care It will be clear from the above studies that the majority of symptom episodes are managed by the sufferers themselves without recourse to medical advice. Selfcare refers to all the actio

38、ns taken by a sufferer on his or her own behalf. These actions may replace medical advice or they may precede consultation with a physician. Forms of Selfcare Selfmedication Other remedial actions Consultation with others Use folk alternative medicineSelfmedication High rates of selfmedication (5080

39、% of adults reported taking an overthecounter medication in a two to fourweek period). The great majority of these are analgesics, cold remedies, and antacids. The pharmacist is often a source of advice on overthecounter medication. In neighborhood pharmacies, for every 100 prescriptions issued, abo

40、ut nineteen other people asked for advice on health problems. The most common of these were upper respiratory infections, stomach and bowel complaints, pain, and inquiries about vitamins.Other remedial actions A large number of nonmedical actions were reported. Social actions, like taking to friends

41、 or relatives, attending a club, or going out for a meal Individual actions, like doing housework, going out shopping, or gardening. All these actions were recorded because they were viewed as being therapeutic.Consultation with others There may be lay referral, or consultation with family members,

42、friends, neighbors, and other nonprofessional people whose advice may be sought. Certain individuals in a neighborhood may have a reputation for being knowledgeable in health matters.Others may be valued for their advice on personal problems. All societies have resources of this kind, quite independent of the health care system. In highly mobile societies there is less opportunity for such informal aid systems to develop. This may help to explain the large number of personal problems that are p