Volume 168 Issue 6

Use of systematic reviews of randomised trials by Australian neonatologists and obstetricians Christopher F C Jordens, Penelope Hawe, Les M Irwig, David J Henderson-Smart, Margaret Ryan, Deborah A Donoghue, Roger G Gabb and Ian S Fraser MJA 1998; 168: 267-270 For editorial comment see Phillips Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - ©MJA1998 Abstract Objective: To determine what proportion of Australian neonatologists and obstetricians report using systematic reviews of randomised trials. Design: Cross-sectional survey using structured telephone interviews. Setting: Australian clinical practice in 1995. Participants: 103 of the 104 neonatologists in Australia (defined as clinicians holding a position in a neonatal intensive care unit); a random sample of 145 members of the Royal Australian College of Obstetricians and Gynaecologists currently practising in Australia. Main outcome measures: Information sources used in clinical practice; reported awareness of, access to and use of systematic reviews, and consequent practice changes. Results: Response rates were 95% (neonatologists) and 87% (obstetricians); 71 neonatologists (72%) and 55 obstetricians (44%) reported using systematic reviews, primarily for individual patient care. Databases of systematic reviews were used with a median frequency of once per month. Among neonatologists, systematic reviews were used more commonly by those who were familiar with computers, attended professional meetings, and had authored research papers. Among obstetricians, they were used more commonly by those who were familiar with computers, had less than 10 years' clinical experience, attended more deliveries, and were full-time staff specialists in public hospitals. Of neonatologists who reported using systematic reviews, 58% attributed some practice change to this use. For obstetricians, the corresponding figure was 80%. Conclusions: There is evidence that Australian neonatologists and obstetricians use systematic reviews and modify their practice accordingly. Dissemination efforts can benefit from knowledge of factors that predict use of systematic reviews. Introduction Randomised controlled trials are widely accepted as the best method of evaluating the effectiveness of medical interventions. However, their findings are slow to change medical opinion and practice.1,2 The communication of clinically important research findings is hampered by the volume and geometric growth of the medical literature.3 Reviews address this problem, but conventional review methodology is unscientific4,5 and open to selection biases inherent in the publication process.5,6 This has led to the development of systematic reviews. A properly conducted systematic review begins with an exhaustive search for published and unpublished randomised trials addressing a well defined research question. The second step is to identify trials of adequate quality to contribute to decision-making. The results of included trials are then pooled, or "meta-analysed", to arrive at a quantitative estimate of the benefits and harms of treatment. Systematic reviews published by the Cochrane Collaboration are also continuously updated by specialist review groups.7 Systematic reviews in pregnancy and childbirth have been available for some years. In 1988 a comprehensive trial register became commercially available in database form as the Oxford database of perinatal trials.8 Effective care in pregnancy and childbirth, 9 a textbook based on this research synthesis, was published the following year, with a guide for non- specialist readers.10 A companion textbook, Effective care of the newborn infant,11 appeared in 1992. From 1993, systematic reviews relating to pregnancy and childbirth were available electronically in the Cochrane pregnancy and childbirth database.12 All these reviews are currently being updated for The Cochrane library.13 These new publications represent prototypes for future publications in other fields of practice. However, their impact on clinical practice remains uncertain, despite several surveys to ascertain the extent of their dissemination and uptake.14-18 To make a practical difference, systematic reviews must be readily available to clinicians who are aware of them, who use them, and who implement their findings. To ascertain whether this is occurring in Australia, we conducted a survey of neonatologists and obstetricians with the aims: To gauge awareness of, access to, and use of the Oxford database, Cochrane database, and Effective care textbooks; To place these resources in the context of other information sources that inform practice in obstetrics and neonatology; and To ascertain how often and why these resources are consulted, predictors of their use, and whether their use has led to reported changes in clinical practice. Methods Participants Clinicians who held a position in one of Australia's 23 neonatal intensive care units were eligible for the survey. The Australian and New Zealand Neonatal Network (ANZNN), which covers all neonatologists, provided a current listing. The Royal Australian College of Obstetricians and Gynaecologists (RACOG) drew a simple random sample of 20% of Fellows from its membership. Those sampled were eligible if they were currently practising obstetrics. Any clinicians not currently practising in Australia, not on the telephone network, or who were involved in designing this survey, were ineligible. Eligible clinicians were sent an introductory letter, telephoned, and invited to schedule a confidential, 10-minute telephone interview about information sources used in clinical practice. Systematic reviews were not mentioned until the interview was under way. Interviews An existing interview schedule15,16 was modified in consultation with the ANZNN and the RACOG. Respondents were first asked to name the three main sources of information they used for keeping up with new developments in their field, and for dealing with uncertainty about a specific treatment decision. They were also asked which of the three information sources they considered the most important or useful for each task. Respondents were then asked about their access to and use of computers, and asked directly whether they had heard of, had access to, and used the Cochrane database, Oxford database, and Effective care of the newborn infant (neonatologists) or Effective care in pregnancy and childbirth (obstetricians). Those who reported using any of these resources were asked what a systematic review was, how often they consulted that resource, what they used it for, whether they thought using it had made any difference to their clinical practice and, if so, whether they could name a treatment policy they had altered in response to evidence from a systematic review. To count as users of systematic reviews, respondents had to mention randomised trials or meta-analysis in their description of a systematic review. The final questions sought demographic information on clinical experience, place of education, attendance at professional meetings, research publications, academic appointments, and qualifications. A research degree was defined as a doctorate, relevant master's degree, or bachelor's degree of science in medicine, held in addition to basic medical and specialty qualifications. Reports of authorship were verified by searching MEDLINE and by screening abstracts. For neonatologists it was noted whether they held full- or part-time positions, whether they worked in a hospital with an obstetric unit, whether they headed a neonatal unit, and in which unit they worked. For obstetricians, it was noted whether they held a position as a full-time staff specialist in a public hospital. They were asked how many deliveries they attended each year, and whether they worked at any hospital with an accredited RACOG training post. The interview schedule was modified after a pilot study with seven neonatologists in New Zealand. The main survey was conducted between August and December 1995, with ethics approval from the ANZNN, RACOG and the University of Sydney. All interviews were conducted by the first author (C F C J). Analysis Confidence intervals for the proportion of obstetricians who reported using systematic reviews were calculated with a finite population correction. Confidence intervals were not calculated for the corresponding proportion of neonatologists, as this was ascertained for all Australian neonatologists. Descriptive and c 2 analyses were conducted. Then, using a backwards stepwise modelling procedure, a multivariate logistic regression analysis was used to determine which study factors predicted the reported use of systematic reviews. With the neonatology data, this modelling procedure was repeated using binomial generalised estimating equations to adjust for clustering of respondents within neonatal units.19 Results Of 106 listed neonatologists, three were ineligible (one had retired, one was not practising in Australia, and one was involved in designing this survey). Of the 103 eligible clinicians remaining, 98 completed interviews (95% response). From a sample of 210 obstetricians, 65 were ineligible for the survey (51 no longer practised obstetrics, 13 were not practising in Australia, and one could not be located on the telephone network). Of 145 eligible obstetricians, 126 completed interviews (87% response). Respondent characteristics are shown in Box 1, with comparative data on computer use. For the purpose of keeping up with new clinical developments, respondents favoured journals, conferences and meetings, colleagues and MEDLINE (in that order) over systematic reviews. For the purpose of clinical problem-solving, colleagues, MEDLINE, journals, and other printed medical literature were favoured over systematic reviews as sources of information. Although the percentages favouring each source varied between the two specialties and according to whether the respondent was simply nominating the resource or nominating it as the most important resource, the rank order of the resources remained consistent. In each specialty, 21% of respondents mentioned systematic reviews without prompting from the interviewer when naming the information sources they used, or when describing their computer use. When questioned directly about systematic reviews, 71 neonatologists (72%) and 55 obstetricians (44%; 95% confidence interval, 36%-51%) reported using them in either electronic database or textbook form. The confidence interval indicates the reliability of the sample prevalence as an estimate of the population prevalence. The Figure shows reported levels of awareness of, access to and use of systematic reviews by specialty. Predictors of use of systematic reviews Results of the multivariate analysis are shown in Box 2. Among neonatologists, three factors significantly (P<0.05) and independently predicted use of systematic reviews: attendance at meetings of the Australian Perinatal Society, authorship of at least one research paper, and familiarity with computers (our index of this was use of a computer for word-processing). Results from cluster analysis agreed with those from logistic regression. Among obstetricians, four factors sig nificantly and independently predicted use of systematic reviews: familiarity with computers, mode of practice (full-time staff specialists were more likely to use systematic reviews than others), clinical experience (recent graduates were more likely to use systematic reviews), and number of deliveries per year (likelihood of using systematic reviews increased with this number). Descriptors of use of systematic reviews Both neonatologists and obstetricians reported using databases of systematic reviews with a median frequency of once per month. The main purpose for using systematic reviews (irrespective of their format) reported by respondents from both specialties was individual patient care. Systematic reviews were also said to be used for (in rank order of frequency of reporting) teaching, preparing a pre sentation, reviewing current management or developing evidence-based protocols or guidelines, settling disputes, background information, reviewing a topic, research, as a source of references, and patient information. Of the 71 neonatologists who reported using systematic reviews, 58% said that this had changed their clinical practice in some way, and 44% gave at least one example of a treatment policy they had altered in response to a systematic review. The most common examples were treatment of respiratory disorders, and use of steroids and indomethacin. Corresponding percentages for obstetricians who reported using systematic reviews were 80% (reported a change in practice) and 71% (gave at least one example). The most common example was use of steroids in management of preterm rupture of membranes. Discussion We found that 72% of neonatologists and 44% of obstetricians reported consulting systematic reviews, primarily for the purpose of individual patient care. Databases of systematic reviews were used at a median frequency of once per month. Systematic reviews were used more commonly by those who were familiar with computers in both specialties, by those who attended professional meetings and had authored research papers among neonatologists, and by those who had had less than 10 years' clinical experience, attended more deliveries, and who had a position as a full-time staff specialist among obstetricians. The findings of this survey are based on self-reporting. Although the survey was designed to minimise over-reporting, it was still subject to imprecision in respondents' recall about (for example) the frequency with which they used systematic reviews, and to difficulties in attributing practice changes to their use. Nevertheless, this was the first study of the use of systematic reviews by Australian clinicians, and the findings have immediate and practical relevance for organisations such as universities, government agencies and specialty colleges that are trying to improve access to the best available evidence and to promote its use.20-23 The association between use of systematic reviews and attendance at Australian Perinatal Society meetings among neonatologists could reflect greater receptiveness to innovations among clinicians who attend professional meetings. However, it also supports the perception (reported elsewhere13 ) that professional organisations play an important role in disseminating research findings. Future dissemination efforts could usefully concentrate on these organisations. In both specialties, familiarity with computers predicted use of systematic reviews. Better access to digital information technology and training in its use is therefore likely to enhance uptake of these reviews. This might include improved access to The Cochrane library and the Internet, and training workshops for searching specialist databases. The remaining predictors of use of systematic reviews, as well as the overall contrast between neonatology and obstetrics, suggest that specialists practising primarily in public hospitals are more likely to use systematic reviews than those working primarily in private practice. Special efforts are therefore needed to reach the latter. As systematic reviews do not appear to rank highly among the information sources used in clinical practice, it is important to stress their relative advantages. Uptake of this innovation appears more likely among recent graduates, with senior clinician researchers acting as "product champions".24 Although debate persists as to whether practising clinicians accept the innovations of evidence-based medicine,25 our survey found evidence that Australian neonatologists and obstetricians use systematic reviews, and appear to modify their practice accordingly. Efforts are needed to enhance the use of these reviews, and to conduct further evaluations of their influence on clinical practice. In attempting to improve practice standards, it is important to pursue methods which have been shown to be effective.26 Acknowledgements We would like to thank the many clinicians who gave up their time to participate in this survey. Infrastructure support for this project was provided by the Department of Public Health and Community Medicine at the University of Sydney. Special thanks are due to Petra Macaskill, who conducted the cluster analysis, and Jeanette Ward and Mary Osborne, from the Central Sydney Area Health Service Needs Assessment and Health Outcomes Unit, who provided helpful advice on survey procedures. References Antman EM, Lao J, Kupelnick B, et al. A comparison of results of meta-analyses of randomized control trials and recommendations of clinical experts: treatments for myocardial infarction. JAMA 1992; 268: 240-248. Stross JK, Harlan WR. The dissemination of new medical information. JAMA 1979; 241: 2622-2624. Warren KS. From papyrus to parchment to paper to pixels: information technology and the future of biomedical publishing. In: Lock S, editor. The future of medical journals. London: BMJ, 1991: 127-146. Mulrow CD. The medical review article: state of the science. Ann Intern Med 1987; 106: 485-488. Light RJ, Pillemer DB. Summing up: the science of reviewing research. Cambridge: Harvard University Press, 1984. Dickersin K, Berlin JA. Meta-analysis: state-of-the-science. Epidemiol Rev 1992; 14: 154-176. Sackett DL. The Cochrane Collaboration. ACP J Club 1994; 120 Suppl 3: A-11. Chalmers I, editor. Oxford database of perinatal trials. Version 1.2, disk issue 7 (Spring). Oxford: Oxford University Press, 1992. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989. Enkin M, Keirse MJNC, Chalmers I. A guide to effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989. Sinclair JC, Bracken MB. Effective care of the newborn infant. Oxford: Oxford University Press, 1992. Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP, editors. Cochrane pregnancy and childbirth database. Oxford: Update Software, 1993. The Cochrane Library [database on disk and CD-ROM]. The Cochrane Collaboration. Oxford: Update Software; 1996. Updated quarterly. Lomas J. Retailing research: increasing the role of evidence in clinical services for childbirth. Milbank Q 1993; 71: 439-475. Stocking B. Implementing the findings of effective care in pregnancy and childbirth in the United Kingdom. Milbank Q 1993; 71: 497-523. Paterson-Brown S, Fisk NM, Wyatt JC. Uptake of meta-analytical overviews of effective care in English obstetric units. Br J Obstet Gynaecol 1995; 102: 297-301. Paterson-Brown S, Wyatt JC, Fisk NM. Are clinicians interested in up to date reviews of effective care? BMJ 1993; 307: 1464. Hyde C. Who uses the Cochrane pregnancy and childbirth database? BMJ 1995; 310: 1140-1141. Zeger SL, Liang K-Y. Longtitudinal data analysis for discrete and continuous outcomes. Biometrics 1986; 42: 121-130. Rychetnik L. Evidence-based medicine in the GMP (Graduate Medical Program). Focus: graduate medical degree news and events. Sydney: 1995: 1-2. Liddle J, Williamson M, Irwig L. Method for evaluating research and guideline evidence. Sydney: NSW Department of Health, 1996. National Health and Medical Research Council. Clinical practice guidelines: the management of early breast cancer. Canberra: NHMRC, 1995. Commonwealth Department of Human Services and Health. Guidelines for the development and implementation of clinical practice guidelines. Canberra: the Department, 1995. Rogers EM. Diffusion of innovations. New York: MacMillan, 1983. Miles A, Bentley P, Polychronis A, Grey J. Evidence-based medicine: why all the fuss? J Evaluation Clin Pract 1997; 2: 83-85. Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993; 342: 1317-1322. (Received 11 Jun, accepted 11 Sep, 1997) Authors' details University of Sydney, Sydney, NSW. Christopher F C Jordens, MPH, Postgraduate Student, Department of Public Health and Community Medicine; now Researcher, Centre for Values, Ethics and the Law in Medicine, Department of Surgery, University of Sydney; Penelope Hawe, MPH, Senior Lecturer, Department of Public Health and Community Medicine; Les M Irwig, FFPHM, PhD, Associate Professor, Department of Public Health and Community Medicine; David J Henderson-Smart, PhD, FRACP, Professor, and Director, NSW Centre for Perinatal Health Services Research, and Department of Neonatal Medicine, Royal Prince Alfred Hospital, Sydney, NSW; Deborah A Donoghue, RN, BSocSc, Senior Research Assistant, Australian Institute of Health and Welfare National Perinatal Statistics Unit; Ian S Fraser, MD, FRACOG, Professor in Reproductive Medicine, Department of Obstetrics and Gynaecology, Queen Elizabeth II Research Institute for Mothers and Infants. Royal Australian College of Obstetricians and Gynaecologists, Melbourne, VIC. Margaret Ryan, MSW, PhD, Research Officer. Centre for Professional Development, Victoria University of Technology, Melbourne, VIC. Roger G Gabb, PhD, Professor, and Director. Reprints: Mr C F C Jordens, Department of Surgery, Blackburn Building D06, University of Sydney, NSW 2006. E-mail: cjordens AT surgery.usyd.edu.au Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Penelope Hawe · Les M Irwig · David J Henderson-Smart · Margaret Ryan · Deborah A Donoghue

Unemployment and health: the healthcare system's role Elizabeth Harris, Ian W Webster, Mark F Harris and Penelope J Lee Experts from the South Western Sydney Area Health Service and the University of New South Wales say there are few r eports of healthcare interventions to address the impact of unemployment on health. They outline possible strategies, which include providing accessible and appropriate healthcare; developing the health care system's capacity to deal with the health problems of unemployed people; collaborating with other agencies and sectors working on this issue; acting as an advocate for unemployed people; undertaking research; and providing training, work experience and employment opportunities within the healthcare system. Long term solutions lie in increasing employment and training opportunities. Nevertheless, there is a clear role for the healthcare system in reducing the health impacts of unemployment and ensuring that poor health does not act as a barrier to returning to work. (MJA 1998; 168: 291-296) Introduction - GPs' experience of the health impact of unemployment - Opportunities for action - Conclusion - References - Authors' details - - ©MJA1998 Introduction The health problems of unemployed people1,2 find their way daily into general practitioners' (GPs') consulting rooms and hospitals, and so are a legitimate concern to all health workers and policymakers. The challenge in addressing this issue is to define an effective role for the healthcare system which both promotes employment and reduces its health impacts. Experience gained in addressing other health-related problems with their roots in our social and economic environments (eg, road injury or the health of indigenous people) suggests that action will be needed at many levels both within and outside the healthcare system. Healthcare provided for unemployed people should: Adequately address their existing health problems; Focus on prevention and anticipatory care; and Ensure that health problems do not act as barriers to a return to work. It will also involve work with other sectors and community groups to meet the needs of unemployed people in the local community and to bring the high social and economic costs of the detrimental effects of unemployment on health to the attention of government and the community. Here we examine possible practical action that can be taken by mainstream health services to reduce the impact of unemployment on health. GPs' experience of the health impact of unemployment Differences in the presenting health problems of unemployed and employed people are not subtle. In a GP waiting room survey in outer Sydney, unemployed people were significantly more likely than employed people to report poorer health, depression, anxiety, insomnia and limitations to their social activities due to physical and mental health problems, after adjusting for age, sex and English-speaking or non-English-speaking background3 (Figure, below). There is also evidence that people who are unemployed have, or develop, chronic health problems that act as barriers to a return to work.1,4,5 Differences in management by GPs have been found between employed and unemployed people; people who are unemployed are more likely to be prescribed medication for depression and anxiety by GPs, and to be less frequently referred to self-help groups.6 Opportunities for action Despite all the evidence of an association between unemployment and health, review of the health research literature revealed few examples of health service interventions to reduce the impact of unemployment on health: one described an employment initiative for mental health service users in Wales, and a second documented health service providers' views of unemployment and their response to unemployment issues.7,8 Some studies describe the impact of training programs on health and employment outcomes.9,10 Thus, up to now, the focus has been on defining the association between unemployment and health and little attention has been paid to developing or evaluating interventions within the healthcare system to prevent or reduce the health impacts of unemployment. We currently have little understanding of what are the most appropriate responses. We need more thorough evaluation of current strategies within the healthcare system for addressing this issue, and opportunities to study successful interventions in similar health-related areas.11,12 Possible strategies are listed in Box 1 and described below. Providing accessible preventive care and management of health problems In the South Western Sydney Area Health Service, we have developed standards for GP management of the health problems of unemployed people. In the process, a high level of agreement was found between unemployed people, community groups and GPs on the possible role for primary care workers. GPs were seen as having a central role in providing comprehensive management of existing health problems and anticipatory care, building the capacity of their patients to solve health-related problems and ensuring referral to relevant services (Box 2). GPs trained in these standards have gained confidence in managing the problems of their unemployed patients, and increased their knowledge of local services.13 Further work on assessing the impact of use of the standards on patient health outcomes is required. Patients with chronic health problems require particular attention, as these problems may lead to unemployment or act as significant barriers to re-employment. The job security of people who are limited by mental or physical conditions is increasingly at risk as the labour force contracts, and stressful working conditions may exacerbate existing disabilities, especially mental disability. Building the capacity of the healthcare system to address unemployment Healthcare services must be accessible and affordable. Medicare has improved access to general practice, but access of unemployed people to healthcare may be limited by the costs of private medical treatment, imaging and prescriptions. For example, people who are unemployed are more likely to experience mental health problems.14,15 The cost of private psychiatric services is high and publicly funded mental health services may give low priority to problems such as anxiety, depression, emotional instability and social isolation, to which unemployed people are more prone. Furthermore, more unemployed people live in geographic areas where public health services are in limited supply (such as the western suburbs of Sydney and Melbourne, and in rural areas). An ever-present problem is that even healthcare workers are not immune to prejudices against unemployed people. This can result in a lack of sensitivity to the range of problems faced by unemployed people and how they can be addressed, different medical treatment being given to unemployed people, and unjust assumptions being made ("all they want is a quick fix"). One way to deal with these prejudices is by providing pre-service educational programs that require medical, nursing and allied health students to undertake case studies of the health and social problems faced by unemployed people. Working with other agencies and departments to reduce the impact of unemployment on health and increase the chances of finding work Many healthcare workers already informally collaborate with other services to address the needs of particular individuals or families. A more formal and systematic collaboration is needed to prevent job loss whenever possible, to reduce the impact of unemployment on health, and to ensure that existing health problems do not become a barrier to returning to work. Establishing better relationships between service providers can prevent the different ways organisations do business from compounding the problems (eg, making arrangements for managing drug or alcohol dependence can improve unemployed people's ability to concentrate on training programs). Action can also be directed at providing skills and resources to other organisations, and supporting them in addressing the needs of their unemployed clients. Skillshares (community-based training providers for unemployed people) provide an important venue for health service providers to make contact with unemployed people. The Division of General Practice Southern Tasmania has developed an innovative program in which GPs regularly provide health education for Skillshare participants.16 At evaluation of this program, both the confidence of participants in dealing with the health system and their knowledge of factors that improve health were increased. Several recent studies have found that introduction of short courses to improve problem-solving skills and reduce negative feelings and beliefs had positive and long-lasting impacts on psychological health, and also increased the number of people who found work.10,17 With experience gained from these projects, the South Western Sydney Area Health Service is working with Skillshares to promote early detection and referral of health problems, to increase the skills and knowledge of participants in making healthy life choices, and to build psychological resilience and coping strategies. Acting as advocates for unemployed people to government and the wider community Health workers have an important role in advocating on behalf of their patients. For people who are unemployed, this may involve intervening in decisions that have been made by government departments (eg, loss of benefits), dealing with other institutions (eg, negotiating for a priority housing listing), or asking for special support and assistance (eg, requesting assistance with paying electricity bills). More generally, the healthcare system can highlight the impact of unemployment on health and challenge stereotyping of unemployed people as lazy or "dole bludgers". It is in this area that the role of the health sector in preventing health problems can be most effective. Because appreciable changes in employment opportunities in Australia require political action, it is important that the contribution is not only in defining the problem but also in providing leadership in directing change. Continuing to research the impact of unemployment on health and to evaluate interventions There is a need for further research to explain the nature of the link between unemployment and ill-health -- the complex interplay of poverty, stress, social support, lifestyle risk factors, pre-existing disease and access to or use of healthcare services. There also needs to be a substantial shift away from defining the problem to developing and evaluating interventions that may reduce the health impact of unemployment. At a policy level the health costs associated with unemployment need to be better documented; in part to justify the reorienting of healthcare services to address the needs of unemployed people, but also to ensure that these costs are added into any evaluation of unemployment costs to the community. Providing training, work experience and employment for unemployed people The healthcare system is one of Australia's largest employers. Many NSW health services have made significant contributions to providing training, work experience and ultimately employment for local unemployed people. The second-largest employer in south-west Sydney, the South Western Sydney Area Health Service (SWSAHS), in collaboration with the federal Department of Employment, Education, Training and Youth Affairs, has established both training programs for long term unemployed, and a routine referral system to the Commonwealth Employment Service for SWSAHS job vacancies in certain areas (eg, clerical and catering, as well as laboratory technicians and ward orderlies). This has resulted in over 100 unemployed people being placed in the Area Health Service. The benefits of such programs lie not only in the employment and training opportunities that they provide, but also in building up organisational commitment to addressing the health problems of unemployed people.18 Conclusion The healthcare system can and should be expected to play a significant role in reducing the impact of unemployment on health and ensuring that health problems do not act as barriers to people returning to work. Unemployment is not a disease and should not be medicalised. However, its impact on health needs to be more formally recognised by the healthcare system in the way we deliver and plan services for individuals and populations. It also needs to be made clear to governments and the community that the long-term solution to these health problems will not be found in hospitals or GP surgeries, but in the creation of employment and training opportunities for all Australians who want to work. The medical profession in this country has provided real leadership on this issue in the past: the AMA organised conferences and seminars in 1995; and both the AMA and the Public Health Association have made submissions to parliamentary committees and attempted to raise community awareness through media publicity. The need to provide leadership has not diminished. References Mathers CD, Schofield DJ. Health consequences of unemployment: the evidence. Med J Aust 1998; 168: 178-182. Morrell SL, Taylor RJ, Kerr CB. Unemployment and young people's health. Med J Aust 1998; 168: 236-240. Harris E, Lee P, Fisher R, et al. Unemployment and health in general practice. Sydney: School of Community Medicine, UNSW, 1995. Smith R. Unemployment and health: a disaster and a challenge. Oxford: Oxford University Press; 1987. Jinn RL, Chandrakant PS, Tomislav JS. The impact of unemployment on health: a review of the evidence. Can Med Assoc J 1995; 153: 529-540. Harris MF, Silove D, Kehag E, et al. Anxiety and depression in general practice patients: prevalence and management. Med J Aust 1996; 164: 526-529. Hutchings J, Gower K. Unemployment and mental health. J Mental Health 1993; 2: 606-607. Mason RA, Boutilier MA. Unemployment as an issue for public health: preliminary findings from North York. Can J Public Health 1995; 86: 152-154. Vinokur AD, Van Ryn M, Gramlich EM, et al. Long-term follow-up and benefit-cost analysis of the Tabs program: a preventive intervention for the unemployed. J Appl Psychol 1991; 76: 213-219. Proudfoot J, Guest D, Cars J, et al. Effect of cognitive-behavioural training on job-finding among long-term unemployed people. Lancet 1997: 350: 86-100. National Health and Medical Research Council. Health Advancement Standing Committee. Promoting the health of Aboriginal and Torres Strait Islander communities -- case studies and principles of good practice. Canberra: NHMRC, 1997. National Health and Medical Research Council. Health Advancement Standing Committee. Promoting the health of Australians: case studies of achievements in improving the health of the population. Canberra: NHMRC, 1997. Harris E, Harris M, Fisher R. Unemployment and health. A guide for general practitioners. Sydney: Fairfield Division of General Practice and School of Community Medicine, UNSW, 1995. Warr P. Work, unemployment and mental health. Oxford UK: Oxford University Press, 1987. Fryer D. The experience of unemployment in the social context. In: Fischer S, Reason J, editors. Handbook of life stress, cognition and health. New York: John Wiley and Sons, 1988: 211-237. The Division of General Practice Tasmania Southern Region, and Glenorchy Skillshare Inc. GP health education to Skillshare jobseekers. New Town (TAS): The Division of General Practice Tasmania Southern Region, 1994. Creed PA, Machin MA, Hicks R. Neuroticism and mental health outcomes for long-term unemployed youth attending occupational skills training programs. Person Individ Diff 1996; 21: 537-544. South Western Sydney Area Health Service. Nomination for the NSW Premier's Award for excellence in public policy. Sydney: South West Sydney Area Health Service, 1997 . This is the final article in a series on unemployment and health (see also MJA 1998; 168: 177, 178 and 236) Authors' details South Western Sydney Area Health Service (SWSAHS), Sydney, NSW. Elizabeth Harris, BA, DipSocWk, MPH, Deputy Director, Centre for Health Equity Training Research and Evaluation; Penelope J Lee, BA, BCA(Hons), Research Officer, Unemployment and Health Project. School of Community Medicine, University of New South Wales, NSW. Ian W Webster, MD, FRACP, FAFPHM, Professor of Public Health; and Director, Division of Population Health, SWSAHS; Mark F Harris, MD, FRACGP, Professor of General Practice; and Director, General Practice Unit, SWSAHS. Reprints will not be available from the authors. Correspondence: Professor M F Harris, General Practice Unit, Fairfield Hospital, Fairfield, NSW 2165. E-mail: m.f.harris AT unsw.edu.au - Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Elizabeth Harris · Ian W Webster · Mark F Harris · Penelope J Lee

Letter A study of 100 anabolic-androgenic steroid users MJA 1998; 168: 311-312 To the Editor: We report the findings of a study of 100 current anabolic-androgenic steroid (AAS) users in New South Wales which aimed to explore the patterns and correlates of AAS use (motivations for use, ways of identifying harms, and knowledge, attitudes and behaviours concerning harm reduction strategies, as well as appropriate public health strategies). We recruited the sample through media and gymnasia advertising and conducted interviews in 1996-1997. Thirty-eight subjects were from inner-city areas, 50 from suburban metropolitan areas and 12 from non-metropolitan areas. Our AAS users were different from other Australian samples of injecting drug users.1 They were more likely to be men (94), homosexual (27), in a stable relationship (37 were married or in a de-facto relationship; of the 85 non-married subjects, 55 were in a relationship that had lasted a mean of 22.5 months), well educated (68 post-secondary school), and employed (86). Their median age was 27 years (range, 18-50) and they had been using AASs for a median of four years (range, 1 month - 21 years). General practitioners (GPs) were the reported source of AASs for 42 subjects and, for 21, their usual supply source. Fifty-four were being monitored (32 by a GP, 2 by a medical student, and the rest by a friend, trainer or partner). The most common source of education on injection technique was a GP (30). In common with other illicit drug users, AAS users experienced negative health and psychological effects; those most commonly self-reported included fluid retention (64), painful injection sites (57), acne (54), and hypertension (18). Men reported testicular atrophy (52/94) and gynaecomastia (32/94), and all of the women reported clitoral hypertrophy and voice changes (which are irreversible2), and four of the six women reported menstrual irregularities. Nearly half of the sample (42) reported more aggressive behaviour when using AASs. Thirteen met DSM-IV3 criteria for dependence on AASs, including symptoms of tolerance and withdrawal, and a further 24 met criteria for AAS abuse. Subjects reported that health concerns were the most likely deterrent to AAS use. Several potentially harmful activities engaged in included self-taught injection procedures, injecting specific muscle groups for localised growth (calves, biceps), concurrent use of several AASs ("stacking"), use of high doses and/or long cycles, and use of other drugs such as clenbuterol, diuretics, thyroxine, insulin, and human growth hormone. AAS users actively seek out information relevant to their AAS use. Friends (63), non-medical handbooks (60) and fitness magazines (53) are the most common sources, making the quality of the information highly questionable. Almost three-quarters (73) of the sample claimed that their preferred AAS information source would be their family medical practitioner (provided she or he were well informed and approachable), giving scope for improving the harm reduction information available to this eager group by educating medical practitioners. Medical education could highlight the legal and ethical obligations of medical practitioners as well as provide harm reduction information to pass on to their patients. Jan Copeland Lecturer Richard Peters Research Assistant Paul Dillon Information Officer National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052 Darke S, Ross J, Hall W. Overdose among heroin users in Sydney, Australia. 1. Prevalence and correlates of non-fatal overdose. Addict 1994; 91: 405-411. Bierly JR. Use of anabolic steroids by athletes: do the risks outweigh the benefits? Postgrad Med 1987; 82: 67-74. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edition. Washington, DC: American Psychiatric Association, 1994. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Jan Copeland · Richard Peters · Paul Dillon