Persistent Pain and Well-being
A World Health Organization Study in Primary Care
Oye Gureje, MBBS, PhD, FWACP; Michael Von Korff, ScD;
Gregory E. Simon, MD, MPH; Richard Gater, MRCPsych
Context.— There is little information on the extent of persistent pain across cul-
tures. Even though pain is a common reason for seeking health care, information
on the frequency and impacts of persistent pain among primary care patients is in-
adequate.
Objective.— To assess the prevalence and impact of persistent pain among pri-
mary care patients.
Design and Setting.— Survey data were collected from representative samples
of primary care patients as part of the World Health Organization Collaborative
Study of Psychological Problems in General Health Care, conducted in 15 centers
in Asia, Africa, Europe, and the Americas.
Participants.— Consecutive primary care attendees between the age of major-
ity (typically 18 years) and 65 years were screened (n = 25 916) and stratified ran-
dom samples interviewed (n = 5438).
Main Outcome Measures.— Persistent pain, defined as pain present most of the
time for a period of 6 months or more during the prior year, and psychological ill-
ness were assessed by the Composite International Diagnostic Interview. Disabil-
ity was assessed by the Groningen Social Disability Schedule and by activity-
limitation days in the prior month.
Results.— Across all 15 centers, 22% of primary care patients reported persis-
tent pain, but there was wide variation in prevalence rates across centers (range,
5.5%-33.0%). Relative to patients without persistent pain, pain sufferers were more
likely to have an anxiety or depressive disorder (adjusted odds ratio [OR], 4.14; 95%
confidence interval [CI], 3.52-4.86), to experience significant activity limitations
(adjusted OR, 1.63; 95% CI, 1.41-1.89), and to have unfavorable health perceptions
(adjusted OR, 1.26; 95% CI, 1.07-1.49). The relationship between psychological
disorder and persistent pain was observed in every center, while the relationship
between disability and persistent pain was inconsistent across centers.
Conclusions.— Persistent pain was a commonly reported health problem
among primary care patients and was consistently associated with psychological
illness across centers. Large variation in frequency and the inconsistent relation-
ship between persistent pain and disability across centers suggests caution in
drawing conclusions about the role of culture in shaping responses to persistent
pain when comparisons are based on patient samples drawn from a limited num-
ber of health care settings in each culture.
JAMA. 1998;280:147-151
PAIN is one of the most common1 and
among the most personally compelling
reasons for seeking medical attention.
People seek health care for pain not only
for diagnostic evaluation and symptom
relief, but also because pain interferes
with daily activities, causes worry and
emotional distress, and undermines con-
fidence in one’s health. When .
This document summarizes the results of moderator analyses from a large randomized controlled trial testing the effectiveness of cognitive behavioral therapy (CBT) for chronic pain from osteoarthritis. The trial compared 10 sessions of Pain Coping Skills Training (PCST), a form of CBT, delivered by nurse practitioners to a usual care control group. Several demographic and clinical variables were examined as potential moderators of treatment response. The analyses found that patients' pain coping style, expectations for treatment, disease severity, age, and education level significantly moderated outcomes, with some subgroups showing stronger responses to PCST. Sex, race, BMI, and depression did not impact treatment response. Specifically, patients with interpersonal pain coping problems did not benefit much from
This document summarizes a study examining differences between individuals granted versus denied insurance coverage for chronic pain treatment after being recommended for an interdisciplinary pain management program. The study found no clinically meaningful differences between the groups on various pain-related measures, suggesting insurance denials were not based on patient need. This implies insurance funding decisions are made on non-clinical criteria rather than patient need. The document provides background on chronic pain, the effectiveness of interdisciplinary treatment, and barriers to treatment access when insurance coverage is denied.
An Internet questionnaire to identify Drug seeking behavior in a patient in t...Nelson Hendler
Drug seeking behavior in patients with little or no real pain, has led to the opioid crisis. Until now, there was no reliable method for detecting drug seeking behavior. The Pain Validity Test from www.MarylandClinicalDiagnostics.com can predict with 95% accuracy who will have medical test abnormalities, i.e. who has a valid complaint of pain, and predicts with 85%-100% accuracy who will not have any medical test abnormalities, i.e. who is faking and drug seeking. The Pain Validity Test has been admitted as evidence in over 30 legal cases in 8 states.
Pain Validity Test to detect drug seeking behaviorNelson Hendler
The Pain Validity Test predicts which patient will have medical test abnormalities with 95% accuracy, thereby validating their complaint of pain. The Pain Validity Test also predicts with 85%-100% accuracy who will not have medical test abnormalities, thereby detecting drug seeking behavior, faking and malingering.
Pain Validity Test identifies drug seeking behavior. Stop opioid abuse. Prote...Nelson Hendler
Physician prescribing practices are under constant scrutiny. An Internet questionnaire will predict if a patient will have a medical test abnormality with 95% accuracy, and 100% if the patient will not. This Pain Validity Test can be used to detect drug seeking behavior in patients, at a far high level of accuracy than tests currently in use (34.4%-48.2% accuracy).. The Pain Validity test has been admitted as evidence in 30 cases in 9 states.
This study examined factors that influence relapse in people with mental health disorders in Indonesia, specifically in West Sumatera Province. The study found that stress of caregivers was the strongest predictor of relapse, with caregivers experiencing high stress being over 8 times more likely to experience patient relapse than low-stress caregivers. The study also found that lack of home visits from healthcare workers was associated with a higher likelihood of relapse. Improving home visit programs and supporting caregivers to reduce their stress levels could help lower relapse rates. The study was a cross-sectional analysis of 313 caregivers in West Sumatera that examined how demographic characteristics, stigma, home visits and caregiver stress related to patient relapse.
This study examined patient-determined criteria for treatment success across four domains (pain, fatigue, emotional distress, and interference with daily activities) for fibromyalgia and back pain patients. The study found that both patient groups had high standards for considering treatment successful, requiring large reductions across domains. Specifically, fibromyalgia patients required at least a 54% reduction in pain, 60% reductions in fatigue and distress, and a 63% reduction in interference. Back pain patients required 58% pain reduction, 57% reductions in fatigue and distress, and 68% reductions in interference and distress. Both patient groups did not expect existing treatments would meet their stringent criteria for success. The study highlights the importance of assessing patient perspectives on treatment outcomes.
This study uses 12 years of longitudinal data from the Health and Retirement Study to examine sociodemographic disparities in chronic pain among older American adults. It finds high and increasing prevalence of chronic pain over time. Multivariate analysis reveals large disparities in reported pain levels by sex, education, and wealth. There is no disadvantage in pain for racial/ethnic minorities after accounting for socioeconomic factors. Pain levels are predictive of mortality even a decade later. Reporting heterogeneity, nonresponse bias, and mortality selection do not appear to meaningfully impact estimates of social disparities in pain.
This document summarizes the results of moderator analyses from a large randomized controlled trial testing the effectiveness of cognitive behavioral therapy (CBT) for chronic pain from osteoarthritis. The trial compared 10 sessions of Pain Coping Skills Training (PCST), a form of CBT, delivered by nurse practitioners to a usual care control group. Several demographic and clinical variables were examined as potential moderators of treatment response. The analyses found that patients' pain coping style, expectations for treatment, disease severity, age, and education level significantly moderated outcomes, with some subgroups showing stronger responses to PCST. Sex, race, BMI, and depression did not impact treatment response. Specifically, patients with interpersonal pain coping problems did not benefit much from
This document summarizes a study examining differences between individuals granted versus denied insurance coverage for chronic pain treatment after being recommended for an interdisciplinary pain management program. The study found no clinically meaningful differences between the groups on various pain-related measures, suggesting insurance denials were not based on patient need. This implies insurance funding decisions are made on non-clinical criteria rather than patient need. The document provides background on chronic pain, the effectiveness of interdisciplinary treatment, and barriers to treatment access when insurance coverage is denied.
An Internet questionnaire to identify Drug seeking behavior in a patient in t...Nelson Hendler
Drug seeking behavior in patients with little or no real pain, has led to the opioid crisis. Until now, there was no reliable method for detecting drug seeking behavior. The Pain Validity Test from www.MarylandClinicalDiagnostics.com can predict with 95% accuracy who will have medical test abnormalities, i.e. who has a valid complaint of pain, and predicts with 85%-100% accuracy who will not have any medical test abnormalities, i.e. who is faking and drug seeking. The Pain Validity Test has been admitted as evidence in over 30 legal cases in 8 states.
Pain Validity Test to detect drug seeking behaviorNelson Hendler
The Pain Validity Test predicts which patient will have medical test abnormalities with 95% accuracy, thereby validating their complaint of pain. The Pain Validity Test also predicts with 85%-100% accuracy who will not have medical test abnormalities, thereby detecting drug seeking behavior, faking and malingering.
Pain Validity Test identifies drug seeking behavior. Stop opioid abuse. Prote...Nelson Hendler
Physician prescribing practices are under constant scrutiny. An Internet questionnaire will predict if a patient will have a medical test abnormality with 95% accuracy, and 100% if the patient will not. This Pain Validity Test can be used to detect drug seeking behavior in patients, at a far high level of accuracy than tests currently in use (34.4%-48.2% accuracy).. The Pain Validity test has been admitted as evidence in 30 cases in 9 states.
This study examined factors that influence relapse in people with mental health disorders in Indonesia, specifically in West Sumatera Province. The study found that stress of caregivers was the strongest predictor of relapse, with caregivers experiencing high stress being over 8 times more likely to experience patient relapse than low-stress caregivers. The study also found that lack of home visits from healthcare workers was associated with a higher likelihood of relapse. Improving home visit programs and supporting caregivers to reduce their stress levels could help lower relapse rates. The study was a cross-sectional analysis of 313 caregivers in West Sumatera that examined how demographic characteristics, stigma, home visits and caregiver stress related to patient relapse.
This study examined patient-determined criteria for treatment success across four domains (pain, fatigue, emotional distress, and interference with daily activities) for fibromyalgia and back pain patients. The study found that both patient groups had high standards for considering treatment successful, requiring large reductions across domains. Specifically, fibromyalgia patients required at least a 54% reduction in pain, 60% reductions in fatigue and distress, and a 63% reduction in interference. Back pain patients required 58% pain reduction, 57% reductions in fatigue and distress, and 68% reductions in interference and distress. Both patient groups did not expect existing treatments would meet their stringent criteria for success. The study highlights the importance of assessing patient perspectives on treatment outcomes.
This study uses 12 years of longitudinal data from the Health and Retirement Study to examine sociodemographic disparities in chronic pain among older American adults. It finds high and increasing prevalence of chronic pain over time. Multivariate analysis reveals large disparities in reported pain levels by sex, education, and wealth. There is no disadvantage in pain for racial/ethnic minorities after accounting for socioeconomic factors. Pain levels are predictive of mortality even a decade later. Reporting heterogeneity, nonresponse bias, and mortality selection do not appear to meaningfully impact estimates of social disparities in pain.
Sociodemographic disparities in chronic pain...Paul Coelho, MD
This study uses 12 years of longitudinal data from the Health and Retirement Study to examine sociodemographic disparities in chronic pain among older American adults. It finds high and increasing prevalence of chronic pain over time. Multivariate analysis reveals large disparities in reported pain levels by sex, education, and wealth. There is no disadvantage in pain for racial/ethnic minorities after accounting for socioeconomic factors. Pain levels are predictive of mortality even a decade later. Measurement biases like reporting heterogeneity and mortality selection may impact estimates of social disparities in pain.
1) This randomized clinical trial compared opioid vs nonopioid medication therapy over 12 months for patients with chronic back, hip, or knee pain.
2) It found no significant difference in pain-related function between the two groups, but pain intensity was significantly better in the nonopioid group. Adverse effects were significantly more common in the opioid group.
3) The study concludes that opioid therapy was not superior to nonopioid medications for improving pain-related function over 12 months, and the results do not support initiating opioids for moderate to severe chronic musculoskeletal pain.
Homeopathic treatment of elderly patients - a prospective observational study...home
The severity of disease showed marked and sustained improvements under homeopathic treatment,
but this did not lead to an improvement of quality of life. Our findings might indicate that homeopathic medical
therapy may play a beneficial role in the long-term care of older adults with chronic diseases and studies on
comparative effectiveness are needed to evaluate this hypothesis.
The folly of believing positive findings from underpowered intervention studiesJames Coyne
Presented at the European Health Psychology Conference, July 13, 2013, This slideshow shows the folly of accepting positive findings from underpowered studies. Much of the "evidence" in health psychology comes from such unreliable studies.
This randomized clinical trial compared the effectiveness of mindfulness-based stress reduction (MBSR), cognitive behavioral therapy (CBT), and usual care for treating chronic low back pain. 342 adults with chronic low back pain were randomly assigned to receive MBSR, CBT, or usual care. At 26 weeks, participants receiving MBSR or CBT reported significantly greater improvement in back pain and functional limitations compared to usual care. There were no significant differences in outcomes between MBSR and CBT. These findings suggest that MBSR may be an effective treatment option for chronic low back pain.
This document contains summaries of several research papers on topics related to chronic pain, suicide risk, and bipolar disorder:
1) One study found that tapering opioid doses for chronic pain patients was associated with increased risks of overdose and mental health crisis compared to patients who did not taper. Higher tapering speeds were linked to even greater risks.
2) Another study observed chronic pain patients undergoing opioid tapering or transition to buprenorphine treatment. Higher initial opioid doses predicted needing buprenorphine, and benzodiazepine use predicted dropout. Pain levels varied after treatment.
3) Research on combat veterans found that those exposed to combat had higher rates of PTSD, suicide attempts, strokes and chronic pain
This study examined the heritability of pain catastrophizing using a twin study design. 400 twins completed measures of pain catastrophizing and underwent a cold pressor task experiment. Results showed pain catastrophizing was 37% heritable, with the remaining 63% due to unique environmental factors. The association between catastrophizing and increased pain response during the cold pressor task was not attributable to shared genetics or environment, suggesting a direct relationship between catastrophizing and experimental pain outcomes. This was the first study to examine the genetic contributions to catastrophizing and its relationship to experimental pain responses.
Original ArticleDesign and implementation of a randomized.docxgerardkortney
Original Article
Design and implementation of a randomized
trial evaluating systematic care for bipolar
disorder
Abundant evidence demonstrates that treatments
for bipolar disorder can reduce the severity of
mood symptoms and improve daily functioning.
Specific pharmacotherapies have been proven effi-
cacious in the acute management of mania and
depression (1, 2) as well as in the prevention of
recurrence (1). For lithium, more intensive treat-
ment has been shown to improve both long-term
clinical outcomes and psychosocial functioning.
Promising evidence also supports the efficacy of
several disease-specific psychosocial interventions
for bipolar disorder (3, 4).
Unfortunately, treatments provided in everyday
practice fall far short of those proven in clinical
Simon GE, Ludman E, Unützer J, Bauer MS. Design and implementation
of a randomized trial evaluating systematic care for bipolar disorder.
Bipolar Disord 2002: 4: 226–236. ª Blackwell Munksgaard, 2002
Objectives: Everyday care of bipolar disorder typically falls short of
evidence-based practice. This report describes the design and
implementation of a randomized trial evaluating a systematic program to
improve quality and continuity of care for bipolar disorder.
Methods: Computerized records of a large health plan were used to
identify all patients treated for bipolar disorder. Following a baseline
diagnostic assessment, eligible and consenting patients were randomly
assigned to either continued usual care or a multifaceted intervention
program including: development of a collaborative treatment plan,
monthly telephone monitoring by a dedicated nurse care manager,
feedback of monitoring results and algorithm-based medication
recommendations to treating mental health providers, as-needed outreach
and care coordination, and a structured psychoeducational group
program (the Life Goals Program by Bauer and McBride) delivered by the
nurse care manager. Blinded assessments of clinical outcomes, functional
outcomes, and treatment process were conducted every 3 months for
24 months.
Results: A total of 441 patients (64% of those eligible) consented to
participate and 43% of enrolled patients met criteria for current major
depressive episode, manic episode, or hypomanic episode. An additional
39% reported significant subthreshold symptoms, and 18% reported
minimal or no current mood symptoms. Of patients assigned to the
intervention program, 94% participated in telephone monitoring and 70%
attended at least one group session.
Conclusions: In a population-based sample of patients treated for bipolar
disorder, approximately two-thirds agreed to participate in a randomized
trial comparing alternative treatment strategies. Nearly all patients
accepted regular telephone monitoring and over two-thirds joined a
structured group program. Future reports will describe clinical
effectiveness and cost-effectiveness of the intervention program compared
with usual care.
Gregory E Simona, Evette
Lud.
AssignmentRead a selection of your colleagues responses..docxnormanibarber20063
Assignment:
Read
a selection of your colleagues' responses.
Respond
to at least
two
of your colleagues by comparing your assessment tool to theirs. APA Format with at least two references in each responses no more than five years old
Response Post #1
Main Post - Brief Psychiatric Rating Scale
Week 2 Discussion - Assessment and Diagnosis in Psychotherapy
Main Post
Assessment Tools
It is paramount as health care professionals to be skillful in assessing clients to be able to diagnose, plan, and produce optimal care yielding full or partial recovery of the clients. Various assessment and measuring tools are available for mental health providers to help measure illness, diagnose clients, and measure a client’s response to treatment that will help supplement data obtained from the clinical interview. Though assessments usually span the entire treatment cycle, a thoughtfully constructed initial intake meeting can be a great tool to establish and reinforce the required therapeutic alliances between client and therapist, provide reassurance, ease anxiety, and enhance information gathering process required for an accurate diagnosis and suitable treatment plan (Wheeler, 2014).
Brief Psychiatric Rating Scale
The Brief Psychiatric Rating Scale (BPRS) was developed in the sixties. It is still one of the most popular behavioral rating scales/instruments use today by clinicians to quickly gather information about the possible presence and severity of various psychiatric symptoms and to assess changes in symptoms in response to medications (Zanello et al., 2013). Originally, the BPRS was a 16-item scale, it was later extended to the standard 18-item version and currently expanded to a 24-item scale to measure additional aspects of schizophrenia symptoms thereby increasing its sensitivity to psychotic and affective disorders and to be used for patients living in the community (Shafer et al., 2017).
The 18-item BPRS assess the following symptoms: somatic concern, anxiety, emotional withdrawal, conceptual disorganization, guilt feelings, tension, mannerisms and posturing, grandiosity, depressive mood, hostility, suspiciousness, hallucinatory behavior, motor retardation, uncooperativeness, unusual thought content, blunted affect, excitement, and disorientation (Yee et al., 2017). The manual of administration of the 24-item BPRS offers a more detailed semi-structured interview with more probe questions for each symptom, and providing supplementary rules for the rating (e.g., delusions) including a well-defined anchor point (Zanello et al., 2013). The recent analysis of the 24-item BPRS produced a four-factor solution: Negative Symptoms, Positive Symptoms, Manic-hostility, and Anxiety–Depression (Zanello et al., 2013). The current BPRS is rated on a seven-point Likert-type scale. A rating of “1” indicates the absence of symptoms, ratings of “2–3” indicate “very mild” to “mild” symptoms that are considered to have nonpathological inte.
This study compared patient pain scores to those assessed by emergency healthcare providers (doctors and triage nurses) in the emergency department of a large Malaysian hospital. The mean patient pain score on arrival was 6.8 out of 10, significantly higher than scores assessed by doctors (5.6) and triage nurses (4.3). Significant differences were found for 5 specific conditions: soft tissue injury, headache, abdominal pain, fracture, and abscess/cellulitis. Upon discharge or admission, nearly half of patients still reported moderate pain, suggesting undertreatment of pain in the emergency department. Accurately assessing patient-reported pain scores is important for effective pain management in emergency medicine.
1) The study examined the association between spousal or significant other solicitous responses and opioid dose in 466 patients with chronic pain. 2) It found that higher scores on a scale measuring solicitous responses, such as asking about pain symptoms, were associated with higher daily morphine equivalent doses. 3) This association remained even after adjusting for other factors like age, sex, depression and pain severity. The findings suggest solicitous responses may influence opioid dose among chronic pain patients.
The CATIE schizophrenia trial was a large, multi-phase study that compared the effectiveness of four second-generation antipsychotics (SGAs) and one first-generation antipsychotic (FGA) in the treatment of schizophrenia. In Phase 1, only 26% of subjects completed the 18-month trial on their initially assigned medication. Olanzapine showed a slightly longer time to discontinuation than the other SGAs. Perphenazine unexpectedly showed comparable effectiveness to the SGAs with no more side effects. In Phase 2, clozapine demonstrated better effectiveness for subjects who discontinued their Phase 1 medication due to lack of efficacy. The trial provided important data on outcomes, costs, and side effects of antipsychotic medications.
This study examined the prognosis of 118 patients with chronic low back pain who participated in a private, community-based group exercise program over 12 months. The patients experienced substantial improvements in pain intensity, disability, function and bothersomeness during the study period. Pain intensity and bothersomeness improved most in the first 6 months, while disability and function continued improving throughout the full year. At 12 months, 25% of patients were fully recovered from their back pain. Baseline pain intensity predicted 10% of the variation in pain outcomes at 12 months, while duration of current episode, disability, and education level together predicted 15% of the variation in disability outcomes.
This journal club presentation summarizes a study that used real-world clinical data from two UK health trusts to investigate the effectiveness of cholinesterase inhibitors and memantine for dementia. The study found that these medications were associated with a temporary stabilization of cognitive decline for up to 4-6 months. Effectiveness was greater in those with moderate-to-severe impairment and depended on factors like concomitant antipsychotic use and medication switching. Approximately one-third of patients were considered non-responders based on cognitive changes over 6 months before and after treatment.
The document provides revised recommendations for the management of fibromyalgia based on a review of evidence from systematic reviews and meta-analyses published since the original 2005 guidelines. Key findings include:
- Exercise was the only intervention with a "strong for" recommendation based on meta-analyses showing benefits for pain, fatigue, sleep and functioning.
- A graduated four-stage approach is proposed, beginning with patient education and non-pharmacological therapies. Pharmacological therapies (amitriptyline, pregabalin, cyclobenzaprine, duloxetine, milnacipran) received "weak for" recommendations for severe pain or sleep issues.
- Growth hormone, sodium oxybate, NSAIDs, S
The document provides revised recommendations for the management of fibromyalgia based on a review of evidence from systematic reviews and meta-analyses published since the original 2005 guidelines. Key findings include:
- Exercise is the only therapy strongly recommended based on meta-analyses showing benefit for pain, sleep, and functioning.
- A graduated four-stage approach is proposed, beginning with patient education and non-pharmacological therapies.
- If non-response, further therapies such as psychological therapies, pharmacotherapy, or rehabilitation may be tailored to the individual. However, meta-analyses only found weak evidence for all potential pharmacological therapies.
- Most treatments show relatively modest effects. Future research priorities are identifying who benefits from specific interventions,
Rethinking chronic pain in a primary care settingPaul Coelho, MD
This article discusses rethinking chronic pain management in primary care settings. It highlights that chronic pain is a complex biopsychosocial condition influenced by multiple factors. While guidelines exist, key aspects are often overlooked including understanding the underlying pain mechanism, incorporating psychosocial factors, and systematically tracking patient data. The article recommends clinicians identify the likely nociceptive, neuropathic, or central sensitization mechanisms driving a patient's pain to guide treatment selection. It also stresses the importance of a multidisciplinary approach incorporating psychological support to supplement pharmacological treatments. Tracking comprehensive pain data in electronic records can improve outcomes by monitoring treatment effectiveness over time.
This study assessed outcomes of physical therapy and surgery for 150 patients with neurogenic thoracic outlet syndrome (NTOS) using patient-reported measures. 40 patients (27%) had satisfactory improvement with a 6-week physical therapy trial, while 90 (60%) underwent surgery after physical therapy failed. Patients who underwent surgery had greater reductions in disability scores and better patient-rated outcomes compared to those who received only physical therapy. However, pre-treatment factors did not reliably predict who would benefit from each treatment. This study provides information on contemporary outcomes for physical therapy and surgery for NTOS.
Your initial post should be 2-3 paragraphs in length.Inclu.docxdanhaley45372
Your initial post should be
2-3 paragraphs
in length.
Include one peer reviewed journal article to support your post. You can search for a journal article from Welder Library EResources. (Ex: Risk of social media or social media polices, etc.).
Your
initial post is due by Thursday
. This allows you and your classmates time to read and reply.
Make sure to demonstrate critical thinking and analysis by using research and personal work experiences.
For full credit, you are required to
respond
to a minimum of two classmates
. Please begin your reply by addressing the student by name. Your
responses
must be completed by Sunday at midnight
.
Please refer to the rubric for the grading requirements. You can view the rubric by clicking on the wheel in the upper right corner and selecting "show rubric."
Scott Lefor,
The release of information to the public – including through social media – can impact everything from a company’s image before the public to an individual’s image before a company. Jackson et al. (2020) note that while “strategic HR use of social media can build the employer’s reputation in the labor market and help HR professionals to reach candidates and current employees,” the use of social media can also “lead to the disclosure of trade secrets” or present a negative image of the company (p. 21). While companies place substantial hours and dollars into cultivating a favorable brand image before the public, a careless comment or complaint by an employee or contractor on social media can go viral and counteract such marketing efforts. In such cases, companies may find themselves forced to address such comments or complaints before the public in an attempt to save the brand image they have worked so hard to build.
In addition to impacting the image of a company, careless social media posts can also impact potential and current employees before the company. According to Melton and Miller (2015), while “most students appear to know that the content they post” on social media could be viewed negatively by “potential employers,” many students continue to do so (p. 678). Through social media, what would have been a careless comment if spoken aloud becomes a permanent statement viewable by countless individuals. Furthermore, comments and images referencing illegal activities or poor decision-making and communicating abilities become enshrined for potential and current employers to reference and base hiring and firing decisions upon.
It is worth noting that careless comments via social media can go beyond “negative,” and can sometimes involve trade secrets (as noted). While negative comments can cast a shadow over a company’s brand, comments revealing trade secrets can jeopardize long-term strategies, losing hard-won competitive edges. As referenced above, Melton and Miller (2015) assert that even though individuals know of such risks, many continue to post comments that can be understood to be “careless.”
In short, informa.
Your initial post should be made during Unit 2, January 21st at 4.docxdanhaley45372
Your initial post should be made during
Unit 2, January 21st at 4:00 pm.
Submissions after this time will not be accepted.
Please respond to the following questions:
In 6-7 sentences, compare and contrast one of the dance television shows referenced in this unit (try to choose a show that has not already been referenced by another student) to that of the American Dance Marathons, considering such questions as:
How does the socioeconomic and sociopolitical climate of the time affect how dance is presented and how the participants are treated/portrayed?
Discuss the Issue of exploitation, who was exploited, who did the exploiting, and how?
What aspects were theatre, and what aspects were real? How were these exaggerated?
What are the reinforced stereotypes present in the competitions?
Tell us about the idea that drama sells.
Use specific terminology and concepts discussed in class thus far. Make sure that you are citing all sources, or being clear that your statement is your idea/belief/observation.
.
Your initial post should be at least 450+ words and in APA forma.docxdanhaley45372
Your initial post should be at least
450+ words
and in APA format (including Times New Roman with font size 12 and double spaced). Post the actual body of your paper in the discussion thread then attach a Word version of the paper for APA review
2 Replies each with minimum
100 words
.
.
Your initial post should be made during Unit 2, january 21st at 4.docxdanhaley45372
Your initial post should be made during
Unit 2, january 21st at 4:00 pm.
Submissions after this time will not be accepted.
Please respond to the following questions:
Using the “Tools to Analyze Dance on Screen” document (based off of the video about film analysis), find and provide a link to a music video (not yet shown in class or by another student). Analyze how the video is representing the “brand” for the artist, what the video is representing, and how dance is used to accomplish this. What does this video say about their values and interests and who they are?Analyze by focusing on some of the following: the use of the camera, editing, and art direction, in addition to the dancing/movement and use of the body. Use specific terminology and concepts discussed in class thus far. Make sure that you are citing all sources, or being clear that your statement is your idea/belief/observation.
.
More Related Content
Similar to Persistent Pain and Well-beingA World Health Organization St.docx
Sociodemographic disparities in chronic pain...Paul Coelho, MD
This study uses 12 years of longitudinal data from the Health and Retirement Study to examine sociodemographic disparities in chronic pain among older American adults. It finds high and increasing prevalence of chronic pain over time. Multivariate analysis reveals large disparities in reported pain levels by sex, education, and wealth. There is no disadvantage in pain for racial/ethnic minorities after accounting for socioeconomic factors. Pain levels are predictive of mortality even a decade later. Measurement biases like reporting heterogeneity and mortality selection may impact estimates of social disparities in pain.
1) This randomized clinical trial compared opioid vs nonopioid medication therapy over 12 months for patients with chronic back, hip, or knee pain.
2) It found no significant difference in pain-related function between the two groups, but pain intensity was significantly better in the nonopioid group. Adverse effects were significantly more common in the opioid group.
3) The study concludes that opioid therapy was not superior to nonopioid medications for improving pain-related function over 12 months, and the results do not support initiating opioids for moderate to severe chronic musculoskeletal pain.
Homeopathic treatment of elderly patients - a prospective observational study...home
The severity of disease showed marked and sustained improvements under homeopathic treatment,
but this did not lead to an improvement of quality of life. Our findings might indicate that homeopathic medical
therapy may play a beneficial role in the long-term care of older adults with chronic diseases and studies on
comparative effectiveness are needed to evaluate this hypothesis.
The folly of believing positive findings from underpowered intervention studiesJames Coyne
Presented at the European Health Psychology Conference, July 13, 2013, This slideshow shows the folly of accepting positive findings from underpowered studies. Much of the "evidence" in health psychology comes from such unreliable studies.
This randomized clinical trial compared the effectiveness of mindfulness-based stress reduction (MBSR), cognitive behavioral therapy (CBT), and usual care for treating chronic low back pain. 342 adults with chronic low back pain were randomly assigned to receive MBSR, CBT, or usual care. At 26 weeks, participants receiving MBSR or CBT reported significantly greater improvement in back pain and functional limitations compared to usual care. There were no significant differences in outcomes between MBSR and CBT. These findings suggest that MBSR may be an effective treatment option for chronic low back pain.
This document contains summaries of several research papers on topics related to chronic pain, suicide risk, and bipolar disorder:
1) One study found that tapering opioid doses for chronic pain patients was associated with increased risks of overdose and mental health crisis compared to patients who did not taper. Higher tapering speeds were linked to even greater risks.
2) Another study observed chronic pain patients undergoing opioid tapering or transition to buprenorphine treatment. Higher initial opioid doses predicted needing buprenorphine, and benzodiazepine use predicted dropout. Pain levels varied after treatment.
3) Research on combat veterans found that those exposed to combat had higher rates of PTSD, suicide attempts, strokes and chronic pain
This study examined the heritability of pain catastrophizing using a twin study design. 400 twins completed measures of pain catastrophizing and underwent a cold pressor task experiment. Results showed pain catastrophizing was 37% heritable, with the remaining 63% due to unique environmental factors. The association between catastrophizing and increased pain response during the cold pressor task was not attributable to shared genetics or environment, suggesting a direct relationship between catastrophizing and experimental pain outcomes. This was the first study to examine the genetic contributions to catastrophizing and its relationship to experimental pain responses.
Original ArticleDesign and implementation of a randomized.docxgerardkortney
Original Article
Design and implementation of a randomized
trial evaluating systematic care for bipolar
disorder
Abundant evidence demonstrates that treatments
for bipolar disorder can reduce the severity of
mood symptoms and improve daily functioning.
Specific pharmacotherapies have been proven effi-
cacious in the acute management of mania and
depression (1, 2) as well as in the prevention of
recurrence (1). For lithium, more intensive treat-
ment has been shown to improve both long-term
clinical outcomes and psychosocial functioning.
Promising evidence also supports the efficacy of
several disease-specific psychosocial interventions
for bipolar disorder (3, 4).
Unfortunately, treatments provided in everyday
practice fall far short of those proven in clinical
Simon GE, Ludman E, Unützer J, Bauer MS. Design and implementation
of a randomized trial evaluating systematic care for bipolar disorder.
Bipolar Disord 2002: 4: 226–236. ª Blackwell Munksgaard, 2002
Objectives: Everyday care of bipolar disorder typically falls short of
evidence-based practice. This report describes the design and
implementation of a randomized trial evaluating a systematic program to
improve quality and continuity of care for bipolar disorder.
Methods: Computerized records of a large health plan were used to
identify all patients treated for bipolar disorder. Following a baseline
diagnostic assessment, eligible and consenting patients were randomly
assigned to either continued usual care or a multifaceted intervention
program including: development of a collaborative treatment plan,
monthly telephone monitoring by a dedicated nurse care manager,
feedback of monitoring results and algorithm-based medication
recommendations to treating mental health providers, as-needed outreach
and care coordination, and a structured psychoeducational group
program (the Life Goals Program by Bauer and McBride) delivered by the
nurse care manager. Blinded assessments of clinical outcomes, functional
outcomes, and treatment process were conducted every 3 months for
24 months.
Results: A total of 441 patients (64% of those eligible) consented to
participate and 43% of enrolled patients met criteria for current major
depressive episode, manic episode, or hypomanic episode. An additional
39% reported significant subthreshold symptoms, and 18% reported
minimal or no current mood symptoms. Of patients assigned to the
intervention program, 94% participated in telephone monitoring and 70%
attended at least one group session.
Conclusions: In a population-based sample of patients treated for bipolar
disorder, approximately two-thirds agreed to participate in a randomized
trial comparing alternative treatment strategies. Nearly all patients
accepted regular telephone monitoring and over two-thirds joined a
structured group program. Future reports will describe clinical
effectiveness and cost-effectiveness of the intervention program compared
with usual care.
Gregory E Simona, Evette
Lud.
AssignmentRead a selection of your colleagues responses..docxnormanibarber20063
Assignment:
Read
a selection of your colleagues' responses.
Respond
to at least
two
of your colleagues by comparing your assessment tool to theirs. APA Format with at least two references in each responses no more than five years old
Response Post #1
Main Post - Brief Psychiatric Rating Scale
Week 2 Discussion - Assessment and Diagnosis in Psychotherapy
Main Post
Assessment Tools
It is paramount as health care professionals to be skillful in assessing clients to be able to diagnose, plan, and produce optimal care yielding full or partial recovery of the clients. Various assessment and measuring tools are available for mental health providers to help measure illness, diagnose clients, and measure a client’s response to treatment that will help supplement data obtained from the clinical interview. Though assessments usually span the entire treatment cycle, a thoughtfully constructed initial intake meeting can be a great tool to establish and reinforce the required therapeutic alliances between client and therapist, provide reassurance, ease anxiety, and enhance information gathering process required for an accurate diagnosis and suitable treatment plan (Wheeler, 2014).
Brief Psychiatric Rating Scale
The Brief Psychiatric Rating Scale (BPRS) was developed in the sixties. It is still one of the most popular behavioral rating scales/instruments use today by clinicians to quickly gather information about the possible presence and severity of various psychiatric symptoms and to assess changes in symptoms in response to medications (Zanello et al., 2013). Originally, the BPRS was a 16-item scale, it was later extended to the standard 18-item version and currently expanded to a 24-item scale to measure additional aspects of schizophrenia symptoms thereby increasing its sensitivity to psychotic and affective disorders and to be used for patients living in the community (Shafer et al., 2017).
The 18-item BPRS assess the following symptoms: somatic concern, anxiety, emotional withdrawal, conceptual disorganization, guilt feelings, tension, mannerisms and posturing, grandiosity, depressive mood, hostility, suspiciousness, hallucinatory behavior, motor retardation, uncooperativeness, unusual thought content, blunted affect, excitement, and disorientation (Yee et al., 2017). The manual of administration of the 24-item BPRS offers a more detailed semi-structured interview with more probe questions for each symptom, and providing supplementary rules for the rating (e.g., delusions) including a well-defined anchor point (Zanello et al., 2013). The recent analysis of the 24-item BPRS produced a four-factor solution: Negative Symptoms, Positive Symptoms, Manic-hostility, and Anxiety–Depression (Zanello et al., 2013). The current BPRS is rated on a seven-point Likert-type scale. A rating of “1” indicates the absence of symptoms, ratings of “2–3” indicate “very mild” to “mild” symptoms that are considered to have nonpathological inte.
This study compared patient pain scores to those assessed by emergency healthcare providers (doctors and triage nurses) in the emergency department of a large Malaysian hospital. The mean patient pain score on arrival was 6.8 out of 10, significantly higher than scores assessed by doctors (5.6) and triage nurses (4.3). Significant differences were found for 5 specific conditions: soft tissue injury, headache, abdominal pain, fracture, and abscess/cellulitis. Upon discharge or admission, nearly half of patients still reported moderate pain, suggesting undertreatment of pain in the emergency department. Accurately assessing patient-reported pain scores is important for effective pain management in emergency medicine.
1) The study examined the association between spousal or significant other solicitous responses and opioid dose in 466 patients with chronic pain. 2) It found that higher scores on a scale measuring solicitous responses, such as asking about pain symptoms, were associated with higher daily morphine equivalent doses. 3) This association remained even after adjusting for other factors like age, sex, depression and pain severity. The findings suggest solicitous responses may influence opioid dose among chronic pain patients.
The CATIE schizophrenia trial was a large, multi-phase study that compared the effectiveness of four second-generation antipsychotics (SGAs) and one first-generation antipsychotic (FGA) in the treatment of schizophrenia. In Phase 1, only 26% of subjects completed the 18-month trial on their initially assigned medication. Olanzapine showed a slightly longer time to discontinuation than the other SGAs. Perphenazine unexpectedly showed comparable effectiveness to the SGAs with no more side effects. In Phase 2, clozapine demonstrated better effectiveness for subjects who discontinued their Phase 1 medication due to lack of efficacy. The trial provided important data on outcomes, costs, and side effects of antipsychotic medications.
This study examined the prognosis of 118 patients with chronic low back pain who participated in a private, community-based group exercise program over 12 months. The patients experienced substantial improvements in pain intensity, disability, function and bothersomeness during the study period. Pain intensity and bothersomeness improved most in the first 6 months, while disability and function continued improving throughout the full year. At 12 months, 25% of patients were fully recovered from their back pain. Baseline pain intensity predicted 10% of the variation in pain outcomes at 12 months, while duration of current episode, disability, and education level together predicted 15% of the variation in disability outcomes.
This journal club presentation summarizes a study that used real-world clinical data from two UK health trusts to investigate the effectiveness of cholinesterase inhibitors and memantine for dementia. The study found that these medications were associated with a temporary stabilization of cognitive decline for up to 4-6 months. Effectiveness was greater in those with moderate-to-severe impairment and depended on factors like concomitant antipsychotic use and medication switching. Approximately one-third of patients were considered non-responders based on cognitive changes over 6 months before and after treatment.
The document provides revised recommendations for the management of fibromyalgia based on a review of evidence from systematic reviews and meta-analyses published since the original 2005 guidelines. Key findings include:
- Exercise was the only intervention with a "strong for" recommendation based on meta-analyses showing benefits for pain, fatigue, sleep and functioning.
- A graduated four-stage approach is proposed, beginning with patient education and non-pharmacological therapies. Pharmacological therapies (amitriptyline, pregabalin, cyclobenzaprine, duloxetine, milnacipran) received "weak for" recommendations for severe pain or sleep issues.
- Growth hormone, sodium oxybate, NSAIDs, S
The document provides revised recommendations for the management of fibromyalgia based on a review of evidence from systematic reviews and meta-analyses published since the original 2005 guidelines. Key findings include:
- Exercise is the only therapy strongly recommended based on meta-analyses showing benefit for pain, sleep, and functioning.
- A graduated four-stage approach is proposed, beginning with patient education and non-pharmacological therapies.
- If non-response, further therapies such as psychological therapies, pharmacotherapy, or rehabilitation may be tailored to the individual. However, meta-analyses only found weak evidence for all potential pharmacological therapies.
- Most treatments show relatively modest effects. Future research priorities are identifying who benefits from specific interventions,
Rethinking chronic pain in a primary care settingPaul Coelho, MD
This article discusses rethinking chronic pain management in primary care settings. It highlights that chronic pain is a complex biopsychosocial condition influenced by multiple factors. While guidelines exist, key aspects are often overlooked including understanding the underlying pain mechanism, incorporating psychosocial factors, and systematically tracking patient data. The article recommends clinicians identify the likely nociceptive, neuropathic, or central sensitization mechanisms driving a patient's pain to guide treatment selection. It also stresses the importance of a multidisciplinary approach incorporating psychological support to supplement pharmacological treatments. Tracking comprehensive pain data in electronic records can improve outcomes by monitoring treatment effectiveness over time.
This study assessed outcomes of physical therapy and surgery for 150 patients with neurogenic thoracic outlet syndrome (NTOS) using patient-reported measures. 40 patients (27%) had satisfactory improvement with a 6-week physical therapy trial, while 90 (60%) underwent surgery after physical therapy failed. Patients who underwent surgery had greater reductions in disability scores and better patient-rated outcomes compared to those who received only physical therapy. However, pre-treatment factors did not reliably predict who would benefit from each treatment. This study provides information on contemporary outcomes for physical therapy and surgery for NTOS.
Similar to Persistent Pain and Well-beingA World Health Organization St.docx (18)
Your initial post should be 2-3 paragraphs in length.Inclu.docxdanhaley45372
Your initial post should be
2-3 paragraphs
in length.
Include one peer reviewed journal article to support your post. You can search for a journal article from Welder Library EResources. (Ex: Risk of social media or social media polices, etc.).
Your
initial post is due by Thursday
. This allows you and your classmates time to read and reply.
Make sure to demonstrate critical thinking and analysis by using research and personal work experiences.
For full credit, you are required to
respond
to a minimum of two classmates
. Please begin your reply by addressing the student by name. Your
responses
must be completed by Sunday at midnight
.
Please refer to the rubric for the grading requirements. You can view the rubric by clicking on the wheel in the upper right corner and selecting "show rubric."
Scott Lefor,
The release of information to the public – including through social media – can impact everything from a company’s image before the public to an individual’s image before a company. Jackson et al. (2020) note that while “strategic HR use of social media can build the employer’s reputation in the labor market and help HR professionals to reach candidates and current employees,” the use of social media can also “lead to the disclosure of trade secrets” or present a negative image of the company (p. 21). While companies place substantial hours and dollars into cultivating a favorable brand image before the public, a careless comment or complaint by an employee or contractor on social media can go viral and counteract such marketing efforts. In such cases, companies may find themselves forced to address such comments or complaints before the public in an attempt to save the brand image they have worked so hard to build.
In addition to impacting the image of a company, careless social media posts can also impact potential and current employees before the company. According to Melton and Miller (2015), while “most students appear to know that the content they post” on social media could be viewed negatively by “potential employers,” many students continue to do so (p. 678). Through social media, what would have been a careless comment if spoken aloud becomes a permanent statement viewable by countless individuals. Furthermore, comments and images referencing illegal activities or poor decision-making and communicating abilities become enshrined for potential and current employers to reference and base hiring and firing decisions upon.
It is worth noting that careless comments via social media can go beyond “negative,” and can sometimes involve trade secrets (as noted). While negative comments can cast a shadow over a company’s brand, comments revealing trade secrets can jeopardize long-term strategies, losing hard-won competitive edges. As referenced above, Melton and Miller (2015) assert that even though individuals know of such risks, many continue to post comments that can be understood to be “careless.”
In short, informa.
Your initial post should be made during Unit 2, January 21st at 4.docxdanhaley45372
Your initial post should be made during
Unit 2, January 21st at 4:00 pm.
Submissions after this time will not be accepted.
Please respond to the following questions:
In 6-7 sentences, compare and contrast one of the dance television shows referenced in this unit (try to choose a show that has not already been referenced by another student) to that of the American Dance Marathons, considering such questions as:
How does the socioeconomic and sociopolitical climate of the time affect how dance is presented and how the participants are treated/portrayed?
Discuss the Issue of exploitation, who was exploited, who did the exploiting, and how?
What aspects were theatre, and what aspects were real? How were these exaggerated?
What are the reinforced stereotypes present in the competitions?
Tell us about the idea that drama sells.
Use specific terminology and concepts discussed in class thus far. Make sure that you are citing all sources, or being clear that your statement is your idea/belief/observation.
.
Your initial post should be at least 450+ words and in APA forma.docxdanhaley45372
Your initial post should be at least
450+ words
and in APA format (including Times New Roman with font size 12 and double spaced). Post the actual body of your paper in the discussion thread then attach a Word version of the paper for APA review
2 Replies each with minimum
100 words
.
.
Your initial post should be made during Unit 2, january 21st at 4.docxdanhaley45372
Your initial post should be made during
Unit 2, january 21st at 4:00 pm.
Submissions after this time will not be accepted.
Please respond to the following questions:
Using the “Tools to Analyze Dance on Screen” document (based off of the video about film analysis), find and provide a link to a music video (not yet shown in class or by another student). Analyze how the video is representing the “brand” for the artist, what the video is representing, and how dance is used to accomplish this. What does this video say about their values and interests and who they are?Analyze by focusing on some of the following: the use of the camera, editing, and art direction, in addition to the dancing/movement and use of the body. Use specific terminology and concepts discussed in class thus far. Make sure that you are citing all sources, or being clear that your statement is your idea/belief/observation.
.
Your initial post should be made during, Submissions after this time.docxdanhaley45372
Your initial post should be made during, Submissions after this time will not be accepted.
Please respond to the following questions:
Consider the movie caricature assigned to your last name, provide a brief description/definition of the caricatures and provide a movie/television/cartoon/internet character that fits this caricature, and one that counters it. Provide a brief explanation of how both do/do not fit. Make sure that you are citing all sources, or being clear that your statement is your idea/belief/observation.
Last names starting with A-E:
The Tom Caricature
Last names starting with F-J:
The Mammy Caricature
Last names starting with K-O:
The Brute/Buck Caricature
Last names starting with P-S:
The Coon Caricature
Last names starting with T-Z:
The Jezebel
.
Your essay should address the following.(a) How is the biologic.docxdanhaley45372
Your essay should address the following.
(a) How is the biological and social elements distinguished in Language?
(b) Explain briefly the phonology, syntax and semantics of language.
(c) The common features of language and pre linguistic mentality.
(d) What has language got that prelinguistic mentality lacks?
(e) What are the features of consciousness tat language lacks?
(f) What are the functions of language and explain the difference between representation and expression.
(g) Show the features of language that is active in creating society.
(h) Sho how commitments are part and parcel of using langue.
(i) How does language enable us to construct social institutions?
The essay should be written in nontechnical, straightforward, ordinary language. The essay should be a approximately a 1000 words, without errors that might impede their understanding as a reader. If you use a technical term please immediately say how the term is to be understood.
.
Your initial post is due by midnight (1159 PM) on Thursday. You mus.docxdanhaley45372
Your initial post is due by midnight (11:59 PM) on Thursday. You must write at least 400 words on Olive Senior's "The Pain Tree" and Ana Menéndez's "Her Mother's House" (in other words, at least 200 words for each story).
Instead of relying on plot summary you will support your interpretation by using and analyzing textual evidence. When you quote the story make sure you cite the page number: for instance, after the quotation put the page number in parenthesis (60). Avoid writing out "on page 60". When you quote a passage from the story make sure you introduce the context and that you are analyzing the meaning of what you quoted.
I encourage your own formulations, but address the following prompts (you can address them in any order and be sure to write at least three or more paragraphs):
In the short stories, you are going to encounter protagonists attempting to reconnect and remember (as in "putting together again") their Caribbean "home" spaces. How have their perceptions of their Caribbean homelands been shaped by their parents? What new perceptions do they gain and how does this transform their view of themselves and their history?
Victor Shklovsky argues that
ostranenie
("making strange" in Russian, and also translated as estrangement/defamiliarization) is the essence of literature. Where in the two stories do we encounter descriptions of estranged perception? Analyze the significance of these moments in the stories. Be sure to consult and cite Shkovsky's essay (especially his definition of
ostranenie
on page 80) to support your analysis.
For our annotation assignment, we learned how to notice patterns and overlooked meanings that helped us understand "Sonny's Blues" more fully. In "The Pain Tree" and "Her Mother's House" what patterns, connections or implied meanings did you notice structuring the stories?
.
Your individual sub-topic written (MIN of 1, MAX 3 pages)You.docxdanhaley45372
Your individual sub-topic written (MIN of 1, MAX 3 pages)
Your portion of the White Paper must include one of the following:
1. Introduction/Summary
2. History/Background and Context
3. Problem (Defined)
4. Discussion to relate point of view from sources used
5. Writer takes a position
6.
Solution
/s
7. Conclusion.
.
Your HR project to develop a centralized model of deliveri.docxdanhaley45372
Your HR project to develop a centralized model of delivering HR services has progressed through very critical stages of the project thus far. It is now time to present actionable, decision-making information to project leaders. This can be best accomplished when projects have been successfully managed, devoid of any major risks, and have been properly closed out and finalized.
Write a five to six (5-6) page paper in which you:
1. Explain what it means to successfully direct and manage project work and identify and discuss 3-4 strategies you might use to manage and sustain progress in your HR project. Be specific.
2. Identify and discuss a minimum of 3 strategies that could be used to address and resolve any risks within the control of the project. HINT: See Exhibit 14.5 in the textbook. Is any one of the strategies you selected more important than the others? Why?
Exhibit 14.5
RISK EVENT RESOLUTION STRATEGIES RISKS WITHIN PROJECT CONTROL
Understand and control WBS
Closely monitor and control activity progress
Closely manage all project changes
Document all change requests
Increase overtime to stay on schedule
Isolate problems and reschedule other activities
Research challenging issues early
RISKS PARTIALLY WITHIN PROJECT CONTROL
Establish limits to customer expectations
Build relationships by understanding project from client’s perspective
Use honesty in managing client expectations
Work with client to reprioritize cost, schedule, scope, and/or quality
Carefully escalate problems
Build team commitment and enthusiasm
RISKS OUTSIDE PROJECT CONTROL
Understand project context and environment
Actively monitor project environment
Understand willingness or reluctance of stakeholders to agree to changes
3. Describe 2-3 actions a project manager may take as they begin to close out the project. Be sure to justify using the actions you discuss.
4. Review Project Management in Action: The Power of Lessons Learned (pages 518-520 in the textbook) and provide an overview to the project team on the significance of the information. Be specific.
Pg 518-520 from book
PROJECT MANAGEMENT IN ACTION The Power of Lessons Learned Projects are discrete. They have a beginning and an end, at which time the project team disbands and moves on to other things. Despite the fact there has inevitably been significant tacit learning during the project, there is often only a limited capture of this into a sharable form for future reuse. Too often, as the project team dissolves, the learning fades into the memories of individuals minds. This makes it extremely difficult for others to benefit in the future from the insights learned. The usual excuses for this loss echoing through the corridors include just too hard, not enough time, team disbanded before we had the chance, and many more. The key error here is the incorrect assumption that learning during or from projects is an added bonus or a nice- to-have luxury. This is not the case in best.
Your Immersion Project for this course is essentially ethnographic r.docxdanhaley45372
Your Immersion Project for this course is essentially ethnographic research. When you hear the words
ethnography
or
ethnographic research
, you may think of Margaret Mead or Franz Boas performing their research on cultures outside their own countries and living among their research subjects. Contemporary ethnographic research includes many other types of research scenarios, such as urban ethnography, neighborhood studies, and even microstudies of groups as small as families and individuals.
Ethnography
is any systematic study of people and cultures, usually conducted through observation, interviews, dialogues, participation, and historical research. Ethnography is used across disciplines as varied as anthropology, linguistics, sociology, advertising, and of course, human services and social work.
Your Immersion Project is just that—a study of a population group with the goal of better understanding the culture of the group. As you complete this project over the course of the semester, keep in mind one of the classical hallmarks of ethnographic research, pioneered by Boas: The beliefs and activities of humans have to be interpreted within their own cultural terms and not evaluated or judged through the cultural lens or terms of the observer or researcher. That is, human beliefs and behavior are culturally relative.
This week, you submit your Immersion Project Paper, one of two culminating parts of your Final Project for this course (along with your narrated PowerPoint, which is due in Week 10).
This 7- to 10-page paper will be a culmination of what you have experienced and explored throughout your work on this project. Since everyone’s experience will be different, the content of the paper will vary for each student; however, there are two sections that everyone should include:
Reflection on your Immersion Project:
Observation: What observational activity did you attend and what insight did it give you into your selected population?
Dialogue: How did you carry out your dialogue? Reflect on your experience and what insight it gave you into your selected population.
Reaction and Critical Analysis of your experience: This section should incorporate your reflections on your experiences, what you learned about the group, what you learned about yourself, and how your perceptions of this group have changed over time.
Several areas to address in this section:
Description of the group
Values/belief orientation
Social interactions (relationships within and between group members)
Religious/spiritual beliefs
Roles and expectations
Language and communication
.
Your country just overthrew its dictator, and you are the newly .docxdanhaley45372
Your country just overthrew its dictator, and you are the newly elected President. Unfortunately, due to the divisions in the country and the years of war, economic, military, and political structures are non-existent. A group of loyalists to the old dictator have been detonating bombs, murdering civilians, assassinating leaders, and terrorizing towns with help from a neighboring country's dictator.
Create a comprehensive plan for your new government. While creating this government identify 1) the governing style of your government and the principles that govern your leaders (see rubric); 2) the functions of various branches of government; 3) how to maintain public good in domestic areas through at least two programs; 4) an economic structure that is most beneficial to your citizens; 5) ways to create national unity; 6) ways to combat terrorism and violence; and, 6) international organizations to join
.
Your have been contracted by HealthFirst Hospital Foundation (HHF),.docxdanhaley45372
Your have been contracted by HealthFirst Hospital Foundation (HHF),?
Your have been contracted by HealthFirst Hospital Foundation (HHF), a charitable organization that provides services to community clinics in Atlanta, Georgia. Due to the organization's tremendous growth, it will need to computerize its operations. By doing so, HHF will be able to continue to meet the needs of both its benefactors and their employees. To this end, it has decided to move its operation to a more modern facility, where it will install a Local Area Network (LAN), and you will be managing the network implementation.
Department # of Employees
Administration 18
Human Resources 9
Accounting 13
Hospital Relations 12
Media Relations 4
Board Room 0
MIS 6
Total 62
Feasibility of the proposed change
HHF has examined its resources and budgetary constraints and determined that the installation of the LAN is feasible. There is a need to maintain as low a budget as possible.
Project Goals
The goals for the LAN project are as follows:
Fully functional networked system
Design a boardroom in which any department's information can be accessed and expressed
Illustrate the complete network and boardroom design
Maintain as low a price as possible
Current state
The new facility consists of 5 six-cubicle work areas and a separate MIS Department and a boardroom. (See the schematic below) Each work area also includes a closed office for the department head.
Deliverables
The deliverables are outlined below:
Begin compiling your project plan by choosing network servers, routers, and hubs. Describe your network model, topology, and selections with an explanation of your choices in a memo to Roger Chen, the chief information officer at HHF. Be sure to use terms and concepts that you have learned in this course.
.
Your group presentationWhat you need to do.docxdanhaley45372
Your group presentation
What you need to do
Your presentation
groups
You can self-select groups (no more than 6)
Or I will put you into groups
Each group will present for a maximum of 20 minutes
You can self-select your topic
Everyone gets the same mark
Do not complain to me about the social loafers
Your presentation
Follow the rubric
Follow the format as presented in the applied cultural proficiency lectures
Let’s review..
How to get the most marks: (part a)
How to get the most marks in part b
During your tutorials, you will be required to peer review the other presentations. You need to demonstrate an understanding of the determinants of health in the presentation (0/10) and to demonstrate an understanding of the APIE system (0/10). See the rubric to get the best points:
Putting it all together
For your group assignments…
Choosing your topic:
Go to Australian Indigenous HealthInfoNet (http://www.healthinfonet.ecu.edu.au/)
Choose a topic that interests you
Choose a program that interests you
Your presentation might look like this:
6
Pick one of these
https://healthinfonet.ecu.edu.au/
Aunty Kerrie & Papa Ron
Aunty Kerrie & Papa Ron
Then you work your way
through the APIE
Check it out to see if you want to do it…
Your presentation MIGHT look like this…
Using the tools from the lectures…
assessment
How did the programmers decide it was a problem?
Eg, did they measure anything with the ABS? use any of the other assessment tools?
if the programmers did not demonstrate it, how do you think they should/might have assessed this problem?
Examples from the lectures:
Y
feel
hear
see
e.g. did the programmers ask the community?
Should they have?
How did they know it was a problem?
Did they do a holistic assessment?
Why was there a need in this community?
Why was there .
Your contribution(s) must add significant information to the dis.docxdanhaley45372
Your contribution(s) must add significant information to the discussion. Your reply should be a very minimum of 250 words.
Research, read, and then write in your own words. Explain examples and incorporate evidence. Cite your sources within your sentences.
Provide complete citations at the end of your posts. A complete citation includes both the website’s title and
Do not copy and paste stuff….that will cause you to lose points and far more importantly, you will have lost the richness of understanding this information.
ADD COMMENT AND INFORMATION TO THE TEXT BELOW
Many people are skeptical that climate change is even occurring on our beautiful planet. Some places worldwide feel its effects through increased temperatures, which is desirable to some. However, many other places, like the lovely island Fiji, are suffering from the effects of climate change. A Youtube video, “Climate Change Fiji,” posted by the user
UN Climate Change
describes the terrible circumstances faced by civilians who are forced to flee their homes due to rising sea levels (www#1). The loss of beach shores has resulted in a drastic decrease in marine life and land species who rely on coastal areas to survive. According to an article posted by author Sarah Taylor, to the site
EuroNews,
titled “Fiji prepares for ‘Climate Refugees’,” since the 19th century, sea levels have risen by around 25 centimeters worldwide (www#2). This rise in sea levels is attributed to the seemingly neverending rise of greenhouse gas emissions into our atmosphere. Another Youtube video, “Climate Change and Fiji,” posted by the user
COP23fj
emphasizes that Fiji is only one of many other Pacific Islands to be battling climate change (www#3). However, Fijians have taken the lead as the spokespeople for all Pacific Islanders to feel protected and not neglected.
These negative biological implications seem to occur in other places around the world, right? Wrong. Our very own city, San Diego, has been facing and will continue to tackle the negative effects of climate change. A typed interview conducted by the Environmental Health Coalition with Kayla Race exemplifies the many ways climate change appears in our communities, including prolonged heat waves, more intense wildfires, increased water costs, and disruptions on electricity (www#4). My family and I have personally been affected by the increased water (and energy) costs and the interruptions on our electricity. We don’t use our AC system and rely on fans for a cool down from our heatwave, yet are charged more than during the year and face blackouts quite often. A video posted in 2017 by the San Diego Union-Tribune, explains the differences between catastrophic and existential climate change (www#5). Catastrophic damage is survivable by humans, while existential climate change threatens the immediate safety of humans. Many still do not believe that these repercussions are created by car emissions into the air, affecting our atmospher.
Your good friends have just adopted a four-year-old child. At th.docxdanhaley45372
Your good friends have just adopted a four-year-old child. At this point, the only socialization decision they have made is that the child is going to preschool. Imagine that you are an expert in your chosen field. Your friends have come to you for advice and to devise a plan to raise their child. They ask you to be frank with them and give them specific examples to support your opinions. They are determined to raise this child to the best of their ability. Since they are new parents, they need advice on everything!
The summative assignment is to develop a user-friendly PowerPoint handbook of suggestions. The handbook will demonstrate your understanding of the material by applying the major topics discussed in the course to a real situation.
The PowerPoint presentation for the Final Project must include:
Title slide (one slide)
Introduction of the material for the new adoptive parents (one to two slides)
At least 15 slides summarizing each of the items listed below (one to two slides for each item). Please note that the content of each slide should appear in the notes section, while the slide itself should contain the information that would be presented to the parents.
An image that represents each item
Conclusion slide that clearly explains why the parents should review this material (one to two slides)
Reference slide with at least three scholarly sources and the course text properly cited (one slide)
Writing the PowerPoint Presentation of the Final Project
Summarize Bronfenbrenner's ecological model and describe why it is important for them to be aware of this theory (one to two slides).
Suggest and explain a parenting style/philosophy (authoritarian, authoritative, or permissive) that you believe will be most beneficial for the child and the family (one to two slides).
Explain which childcare (nanny, center-based, or family-based care) option (before/during/after preschool) you think is best for the child and why (one to two slides). Be sure to include discussion of the social factors that influence the likelihood of the family selecting a particular form of childcare.
Share specific suggestions, including at least two to implement safe technology use in the home. Explain how the media can (both positively and negatively) influence the child (one to two slides).
Discuss the importance of culture and ethnicity in the development of the self-concept. Share your ideas of ways that the new parents can create opportunities for the child to learn about his or her culture (one to two slides).
Describe at least two researched methods to increase the child's self-esteem and positive attitude (one to two slides).
Differentiate between the importance of socialization that occurs in the home and at school. Explain the importance of each venue as a positive haven for the child (one to two slides).
Explain the importance of the teacher’s role in the child's life. Give examples of how the school and the teacher will affect the child's soci.
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The summative assignment is to develop a user-friendly PowerPoint handbook of suggestions. The handbook will demonstrate your understanding of the material by applying the major topics discussed in the course to a real situation.
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Title slide (one slide)
Introduction of the material for the new adoptive parents (one to two slides)
At least 15 slides summarizing each of the items listed below (one to two slides for each item). Please note that the content of each slide should appear in the notes section, while the slide itself should contain the information that would be presented to the parents.
An image that represents each item
Conclusion slide that clearly explains why the parents should review this material (one to two slides)
Reference slide with at least three scholarly sources and the course text properly cited (one slide)
Writing the PowerPoint Presentation of the Final Project
Summarize Bronfenbrenner's ecological model and describe why it is important for them to be aware of this theory (one to two slides).
Suggest and explain a parenting style/philosophy (authoritarian, authoritative, or permissive) that you believe will be most beneficial for the child and the family (one to two slides).
Explain which childcare (nanny, center-based, or family-based care) option (before/during/after preschool) you think is best for the child and why (one to two slides). Be sure to include discussion of the social factors that influence the likelihood of the family selecting a particular form of childcare.
Share specific suggestions, including at least two to implement safe technology use in the home. Explain how the media can (both positively and negatively) influence the child (one to two slides).
Discuss the importance of culture and ethnicity in the development of the self-concept. Share your ideas of ways that the new parents can create opportunities for the child to learn about his or her culture (one to two slides).
Describe at least two researched methods to increase the child's self-esteem and positive attitude (one to two slides).
Differentiate between the importance of socialization that occurs in the home and at school. Explain the importance of each venue as a positive haven for the child (one to two slides).
Explain the importance of the teacher’s role in the child's life. Give examples of how the school and the teacher will affect the child's socializa.
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Your essay should address the following problem.(a) What is .docxdanhaley45372
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Assignment Information
Using the
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Computer hardware and software
Continuing education
Certification and Recertification
Field or Lab Equipment
Any other needs to maintain professional credibility and marketability
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Monthly Expenses
Amount
Mortgage or rent
Taxes: property
Money to Savings Account
Food
Insurance
Health bills (not covered by insurance)
Car loan
Car expenses
Credit card bills
School loans
Other loans
Professional equipment expenses
Other professional development expenses
Child care
Clothing
Children's Education
Entertainment
Vacations
Charity
Miscellaneous
Total Monthly Expenses:
Yearly Income:
Monthly Income from Job:
Any other monthly income (child support, dividends, and interest):
Total Monthly Income*:
Total Monthly Income:
Total Monthly Expenses:
Difference:
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Your friend Lydia is having difficulty taking in the informati.docxdanhaley45372
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Discuss how attention, deep processing, elaboration, and the use of mental imagery can affect the encoding process. Utilize your readings, lecture, and powerpoints and examples that you might have to help with your post.
Please submit a minimum of 250 words and cite your resources. Turnitin will be utilized. Please make sure, you write your post in your own words.
.
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Persistent Pain and Well-beingA World Health Organization St.docx
1. Persistent Pain and Well-being
A World Health Organization Study in Primary Care
Oye Gureje, MBBS, PhD, FWACP; Michael Von Korff, ScD;
Gregory E. Simon, MD, MPH; Richard Gater, MRCPsych
Context.— There is little information on the extent of persistent
pain across cul-
tures. Even though pain is a common reason for seeking health
care, information
on the frequency and impacts of persistent pain among primary
care patients is in-
adequate.
Objective.— To assess the prevalence and impact of persistent
pain among pri-
mary care patients.
Design and Setting.— Survey data were collected from
representative samples
of primary care patients as part of the World Health
Organization Collaborative
Study of Psychological Problems in General Health Care,
conducted in 15 centers
in Asia, Africa, Europe, and the Americas.
Participants.— Consecutive primary care attendees between the
age of major-
ity (typically 18 years) and 65 years were screened (n = 25 916)
and stratified ran-
dom samples interviewed (n = 5438).
2. Main Outcome Measures.— Persistent pain, defined as pain
present most of the
time for a period of 6 months or more during the prior year, and
psychological ill-
ness were assessed by the Composite International Diagnostic
Interview. Disabil-
ity was assessed by the Groningen Social Disability Schedule
and by activity-
limitation days in the prior month.
Results.— Across all 15 centers, 22% of primary care patients
reported persis-
tent pain, but there was wide variation in prevalence rates
across centers (range,
5.5%-33.0%). Relative to patients without persistent pain, pain
sufferers were more
likely to have an anxiety or depressive disorder (adjusted odds
ratio [OR], 4.14; 95%
confidence interval [CI], 3.52-4.86), to experience significant
activity limitations
(adjusted OR, 1.63; 95% CI, 1.41-1.89), and to have
unfavorable health perceptions
(adjusted OR, 1.26; 95% CI, 1.07-1.49). The relationship
between psychological
disorder and persistent pain was observed in every center, while
the relationship
between disability and persistent pain was inconsistent across
centers.
Conclusions.— Persistent pain was a commonly reported health
problem
among primary care patients and was consistently associated
with psychological
illness across centers. Large variation in frequency and the
inconsistent relation-
ship between persistent pain and disability across centers
3. suggests caution in
drawing conclusions about the role of culture in shaping
responses to persistent
pain when comparisons are based on patient samples drawn
from a limited num-
ber of health care settings in each culture.
JAMA. 1998;280:147-151
PAIN is one of the most common1 and
among the most personally compelling
reasons for seeking medical attention.
People seek health care for pain not only
for diagnostic evaluation and symptom
relief, but also because pain interferes
with daily activities, causes worry and
emotional distress, and undermines con-
fidence in one’s health. When pain per-
sists for weeks or months, its broader
effects on well-being can be profound.
Psychological health and performance of
social responsibilities in work and family
life can be significantly impaired.2
Despite evidence that pain affects
well-being, little is known about how
common persistent pain is among pri-
mary care patients. There is evidence
that the effects of persistent pain on psy-
chological health and functional status
are similar for pain problems at different
anatomical sites.3 However, it is not
known whether impaired emotional
well-being and increased disability are
4. consistent correlates of persistent pain,
or whether the impacts of persistent
pain on well-being are consistent across
cultures. Several recent studies have
compared pain perceptions and coping
across cultures,4-6 but cross-cultural re-
search on pain has typically studied rela-
tively small numbers of patients in con-
venience samples. Comparison groups
of pain-free controls have often been
lacking.
This article reports data from a World
Health Organization (WHO) survey of
primary care patients, the WHO Col-
laborative Study of Psychological Prob-
lems in General Health Care.7 As part of
a broader assessment of health and men-
tal health status, this cross-national sur-
vey collected information on persistent
pain. This report estimates the preva-
lence of persistent pain among primary
care patients in different countries, and
determines the association of persistent
pain with health perceptions, psycho-
logical distress, and activity limitations.
(Persistent pain was defined as pain
present most of the time for a period of 6
months or more during the prior year.)
This article provides the first cross-
national data on the prevalence of per-
sistent pain among primary care pa-
tients, and is also the first large-scale
cross-national study to assess whether
persistent pain shows consistent rela-
tionships to impaired well-being and
6. The WHO Collaborative Study of Psy-
chological Problems in General Health
Care was conducted at 15 centers in 14
countries.7,8 A detailed account of the
methods of this study is provided else-
where9; results from this study concern-
ing the relationship between psychologi-
cal illness and disability were previously
reported in this journal.10 The 15 partici-
pating centers in 14 different countries
were selected to represent broad diver-
sity of culture and socioeconomic devel-
opment. Centers were selected on the
basis of previous successful collabora-
tion with WHO, experience with re-
search in primary care settings, access
to primary care patient populations,
availability of appropriately skilled per-
sonnel to ensure full adherence to the
study protocol, and approval for the
study by local ethics committees. Each
center was required to identify health
care facilities that could be regarded as
prototypical of primary health care ser-
vices in that country.
The study population was consecutive
patients attending the participating pri-
mary care facilities, including both new
and returning patients. Patients were in-
cluded if they were between the age of
majority (typically 18 years) and 65
years. Eligible subjects were not too ill
to participate, had a fixed address, were
attending the clinic for a medical consul-
7. tation, and gave informed consent. In-
formation on the presenting problems of
patients enrolled in the study is present-
ed for each center elsewhere.7 The 12-
item General Health Questionnaire
(GHQ)11 was administered as a screen-
ing instrument to obtain a stratified
random sample in which patients who
were psychologically distressed were
sampled with higher probability than pa-
tients who were not distressed.
A total of 25 916 patients were suc-
cessfully screened. This represented a
response rate of 96%. Patients were se-
lected for the second-stage assessment
using stratified random sampling based
on their GHQ score. Using center-spe-
cific GHQ score norms determined from
a large pilot test in each center,9 patients
were placed in a low GHQ score stratum
(approximately 60% of consecutive pa-
tients in a particular center), a medium
GHQ score stratum (20% of patients), or
a high GHQ score stratum (20% of pa-
tients). The high GHQ score stratum cor-
responds to a moderate to severe level of
psychological distress, the medium GHQ
stratum to a mild level of distress, and
the low GHQ score stratum to a low level
of psychological distress. All high GHQ
scorers, 35% of medium GHQ scorers,
and 10% of low GHQ scorers were ran-
domly sampled for the second-stage as-
sessments. The analysis of data from this
8. stratified random sampling scheme was
weighted taking the sample selection
probabilities in each stratum into ac-
count (as explained below), so that un-
biased estimates were obtained for the
population of consecutive primary care
attendees in each center. Sampled pa-
tients were interviewed at a place of
their choice, commonly their home. Of
8729 eligible patients, 5447 completed
the second-stage assessments (average
response rate, 62%).
Assessment
Patients sampled for the second-stage
evaluation were assessed by highly
trained interviewers using the WHO
primary care version of the Composite
International Diagnostic Interview
(CIDI).12 This version assessed persis-
tent pain in addition to identifying psy-
chological disorders (eg, anxiety and de-
pressive disorders) defined according to
International Statistical Classification
of Diseases, 10th Revision (ICD-10)13 di-
agnostic criteria. Using this question-
naire, a pain problem was defined as cur-
rent and persistent if pain was present
most of the time for a period of 6 months
or more during the prior year. To elimi-
nate insignificant aches and pains, pa-
tients needed to report that at some time
during their lifetime they talked to ei-
ther a physician or other health profes-
sional about the pain, had taken medica-
9. tion for the pain more than once, or had
reported that the pain had interfered
with life or activities a lot. Although the
CIDI obtained ratings of whether per-
sistent pain was “medically explained”
or not, these ratings were ignored for
the purposes of this report. Review of
these ratings indicated that the ratings
of what conditions were medically ex-
plained were inconsistent across cen-
ters. Moreover, understanding the fre-
quency of persistent pain is clinically
important whether the pain is medically
explained or not.
Disability was assessed using the “Oc-
cupational Role” section of the Social
Disability Schedule (SDS).14 The SDS is
a semistructured interview that rates
disability on the basis of work role per-
formance relative to cultural expecta-
tions. Daily work activities (including
gainful employment, volunteer work, or
housekeeping), activities directed at se-
curing a job for individuals not employed
(study and job searching), and the struc-
turing of daily activities for retired indi-
viduals were assessed. Interviewer rat-
ings were made on a 4-point scale: 0 (no
disability), 1 (mild disability), 2 (moder-
ate disability), and 3 (severe disability).
Interviewer-observer reliability of the
SDS occupational role was assessed with
19 videotaped interviews circulated
across the centers. An overall k of 0.85
10. was obtained, with a range of 0.72 and
0.93 on items.9 In addition, each subject
was asked the number of days in the pre-
vious month they had been unable to
carry out their usual activities.15 Pa-
tients rated their overall health status
as excellent, very good, good, fair, or
poor.
The physician seeing each patient in
the sample completed an encounter form
that included a rating of the patient’s
physical health status at the time of the
visit. Patients were rated by their phy-
sicians as completely healthy, having
some symptoms but subclinical physical
illness, mild physical illness, moderate
physical illness, or severe physical ill-
ness. All participating physicians were
instructed in the use of the encounter
form in practice sessions with the local
investigators. These ratings were used
to control for severity of physical illness
in multivariate analyses.
At non–English-speaking centers,
questionnaires were translated by a
panel of local bilingual experts. Back-
translations to English were checked
centrally at WHO. At least 1 English-
speaking investigator from every center
participated in a 5-day joint training ses-
sion in the use of the instruments. In gen-
eral, the interviewers who assessed
study subjects had mental health train-
ing and experience.
11. Data Analysis
Because this study used a stratified
random sampling plan, the estimates we
report are based on weighted data.
Weighted data from the second-stage as-
sessment provide unbiased estimates for
the base population of consecutive pri-
mary care attendees. The weighting ac-
counts for the stratified sampling
scheme and differentials in response
rate by GHQ stratum, sex, and center to
control nonresponse bias associated with
these variables.9
Whether there was greater variation
in the prevalence rate of persistent pain
across centers than expected by chance
was evaluated by a Wald statistic esti-
mated for the center indicator variables
from a logistic regression model that
controlled for age and sex. Odds ratios
(ORs) estimating the effect of sex (wom-
en vs men) and their confidence inter-
vals (CIs) were estimated for each cen-
ter and for all centers combined.
Whether ORs differed from unity more
than expected by chance was evaluated
by the Wald statistic. Using logistic re-
gression, we contrasted the rates of hav-
ing the impairments of interest (eg, work
disability) for persons with persistent
148 JAMA, July 8, 1998—Vol 280, No. 2 Persistent Pain and
Well-being—Gureje et al
13. The prevalence of persistent pain for all
centers combined was 21.5%, with
prevalence rates varying from 5% to
33%. Sex-specific prevalence rates are
shown in Table 1, with the centers or-
dered from the highest overall preva-
lence rate to the lowest. The difference
in prevalence rates across centers was
highly significant after adjusting for age
and sex (Wald statistic = 217.7, df = 14,
P,.001).
Among the European centers, Ath-
ens, Greece (12%), and Verona, Italy
(13%), had relatively low prevalence
rates, while the remaining centers in
Germany, France, the Netherlands, and
England were found to have persistent
pain prevalence rates in excess of 20%.
The 2 Asian centers (Nagasaki, Japan,
and Shanghai, China) had relatively low
prevalence rates of persistent pain (12%
and 13%, respectively), while the 2 South
American centers (Rio de Janeiro, Bra-
zil, and Santiago, Chile) had relatively
high prevalence rates (31% and 33%, re-
spectively). The center in Ibadan, Nige-
ria, had the lowest prevalence rates of
persistent pain of any center for both
men and women.
As shown in Table 1, persistent pain
was significantly more common among
women than men based on a pooled es-
timate for the 15 participating centers,
14. with 25% of women compared with 16%
of men reporting persistent pain. After
adjusting for age, the prevalence of per-
sistent pain was significantly higher
among women than men in 9 of the 15
centers.
Anatomical Site
As shown in Table 2, among patients
with persistent pain, the 3 most com-
monly reported anatomical pain sites (in
order of frequency) were back pain,
headache, and joint pain. The large ma-
jority (68%) of primary care patients
with persistent pain reported pain in at
least 2 anatomical sites (Table 2). Be-
cause pain was typically reported at mul-
tiple sites, the remaining analyses con-
cern persistent pain without differentia-
tion by anatomical site.
Persistent Pain and Well-being
Persons with persistent pain were
substantially more likely to have an anxi-
ety or depressive disorder meeting ICD-
10 diagnostic criteria than persons not
experiencing persistent pain (Table 3).
After adjusting for center, age, sex, and
physician-rated severity of physical dis-
ease, the odds of having a psychological
disorder meeting diagnostic criteria
among persons with persistent pain
showed a 4-fold increase over those not
15. affected by persistent pain. The associa-
tion of persistent pain was not specific to
depression, as both anxiety and depres-
sive disorders showed a comparable as-
sociation with persistent pain.16
For all 15 centers combined, the pres-
ence of persistent pain was associated
with a modest increase in the likelihood of
patients rating their overall health as fair
or poor (Table 3). Unfavorable health per-
ceptions were reported by 33% of those
with persistent pain compared with 21%
of those without persistent pain.
Work role disability was assessed by a
semistructured interview protocol tak-
ing cultural norms into account in deter-
mining the extent of disability.14 Across
the participating centers, 31% of those
with persistent pain were rated as having
moderate to severe work role interfer-
ence, compared with 13% among those
without persistent pain. After adjusting
for center, age, sex, psychological disor-
der status, and physician-rated severity
of physical disease, the odds of work dis-
ability showed a 2-fold increase among
those with persistent pain (Table 3). Simi-
Table 1.—Subjects With Persistent Pain by Sex, World Health
Organization Psychological Problems in General Health Care
Survey, 1991-1992 (Weighted Data)
Participating Center
(No. of Cases/No. of Subjects)
16. Men, %
(n = 1919)
Women, %
(n = 3519)
All Patients, %
(n = 5438)
Adjusted OR
(95% CI)* P
Santiago, Chile (130/274) 13.5 40.8 33.0 3.87 (1.87-8.02) ,.001
Berlin, Germany (140/400) 27.1 36.8 32.8 1.44 (0.92-2.26) .11
Rio de Janeiro, Brazil (149/393) 17.6 35.8 30.8 2.38 (1.36-4.18)
.002
Ankara, Turkey (154/400) 21.1 32.9 28.9 1.77 (1.08-2.93) .02
Paris, France (124/405) 16.9 37.3 26.5 3.15 (1.96-5.06) ,.001
Mainz, Germany (130/400) 28.5 24.7 26.3 0.86 (0.55-1.35) .51
Groningen, the Netherlands (127/340) 19.7 29.3 25.5 1.84
(1.06-3.20) .03
Manchester, England (149/428) 26.4 18.1 20.7 0.68 (0.41-1.11)
.12
Bangalore, India (109/398) 14.1 23.8 19.0 1.53 (0.89-2.62) .13
Seattle, Wash (88/373) 9.4 21.2 17.3 2.80 (1.40-5.61) .004
17. Verona, Italy (49/250) 3.9 18.6 13.3 5.81 (1.90-17.82) .002
Shanghai, China (106/576) 8.7 14.9 12.6 1.97 (1.11-3.50) .02
Athens, Greece (34/196) 5.4 15.5 12.0 3.47 (1.06-11.33) .04
Nagasaki, Japan (53/336) 9.2 14.2 11.8 1.68 (0.84-3.37) .14
Ibadan, Nigeria (27/269) 6.2 5.3 5.5 0.92 (0.28-2.95) .88
All centers (1569/5438) 16.2 24.8 21.5 1.69 (1.47-1.95) ,.001
*The adjusted odds ratio (OR) measures the risk of having
persistent pain among women relative to the risk of persistent
pain among men, after adjusting for age. The all
centers OR was adjusted for age and center. CI indicates
confidence interval.
Table 2.—Subjects Reporting Current Pain at
Different Anatomical Sites and the Number of
Anatomical Sites With Pain Among Subjects With
Persistent Pain, World Health Organization
Psychological Problems in General Health Care
Survey, 1991-1992 (Weighted Data)
Variable
Subjects Reporting
Current Pain, %
Anatomical site
Back pain 47.8
Headache 45.2
Joint pain 41.7
Arms or legs 34.3
Chest 28.9
19. age of patients with a depressive or anxi-
ety disorder between patients with and
without persistent pain was statistically
significant. In contrast, the association
of unfavorable ratings of health status
with persistent pain was less robust
across centers. This difference was sta-
tistically significant for only 5 of the 15
centers (significant differences are indi-
cated by numbers in boldface type in
Table 4). Interviewer-rated work dis-
ability was significantly more common
among those with persistent pain for 5 of
the 15 centers, and patients with persis-
tent pain were significantly more likely
to report 3 or more days of activity limi-
tation in the prior month for 6 of the 15
centers. For the centers with nonsignifi-
cant differences in work disability or in
activity-limitation days between those
with and without persistent pain, pa-
tients with persistent pain almost al-
ways had a higher percentage with ac-
tivity limitation than patients without
persistent pain.
COMMENT
This is the first large-scale cross-na-
tional study of persistent pain among
primary care patients in which standard
methods were applied to estimate its
prevalence and impacts in a wide range
of countries. Even though there was sub-
stantial variation in prevalence rates
20. across centers, persistent pain was a
common problem among patients con-
sulting primary care physicians in every
participating center. It should be noted
that the patients eligible for this study
were seeking professional health care,
and that the care settings were gener-
ally in urban areas. Persons seeking
health care are likely to have higher
prevalence rates of persistent pain than
a general population sample. In addition,
the patient populations studied may dif-
fer from those seeking services from tra-
ditional providers or from persons seek-
ing health care in rural areas. However,
the kinds of primary care settings in-
cluded in this study provide health care
services to large segments of the popu-
lation in each of the countries included in
this study.
This study was not designed to ex-
plain cross-cultural differences in the
prevalence or cross-cultural differences
in the impact of persistent pain. How-
ever, the large variation in rates of
occurrence of persistent pain across cen-
ters, the inconsistency in the relation-
ship between persistent pain and disabil-
ity, and the lack of a readily explainable
pattern for the variation in results
should give pause. This variability, and
the lack of any clear pattern to the varia-
tion across centers, suggests that it may
be difficult to draw meaningful conclu-
21. sions about cultural differences from
samples of patients drawn from a limited
number of health care settings in each
culture being studied. Prior cross-cul-
tural research on chronic pain has often
used samples of pain patients smaller
than the numbers available for the indi-
vidual centers participating in this
study. In this study, 10 of the 15 partici-
pating centers had over 100 patients
with persistent pain (Table 1). Most prior
cross-national studies of pain patients
Table 3.—Indicated Quality-of-Life Impairment by Persistent
Pain Status and the Adjusted Odds Ratio (OR)
for Impairment for Persons With vs Without Persistent Pain,
World Health Organization Psychological
Problems in General Health Care Survey, 1991-1992 (Weighted
Data)
Quality of Life Impairment
Persistent Pain
Present, %
Persistent Pain
Absent, %
Adjusted OR
(95% CI)* P
ICD-10 definition of anxiety
or depressive disorder†
33.7 10.1 4.14 (3.52-4.86) ,.001
Health status rated fair to poor‡ 33.4 20.9 1.26 (1.07-1.49) .006
22. Interviewer-rated interference
with work performance‡
31.4 13.0 2.12 (1.79-2.51) ,.001
$3 Activity-limitation days
in prior month‡
41.2 26.0 1.63 (1.41-1.89) ,.001
*The adjusted OR measures the risk of the indicated form of
impairment among persons with persistent pain
relative to those without persistent pain, after adjusting for
covariates. CI indicates confidence interval.
†The ORs were adjusted for center, age, sex, and physician-
rated severity of physical disease. ICD-10 indicates
International Statistical Classification of Diseases, 10th
Revision.
‡The ORs were adjusted for center, age, sex, physician-rated
severity of physical disease, and presence of an
anxiety or depressive disorder.
Table 4.—Indicated Quality-of-Life Impairment Comparing
Persons With and Without Persistent Pain, World Health
Organization Psychological Problems in Gen-
eral Health Care Survey, 1991-1992 (Weighted Data)*
Participating Center
Depressive or Anxiety
Disorder Health Rated Fair to Poor
Interviewer-Rated
23. Work Interference $3 Activity-Limitation Days
With Pain, % Without Pain, % With Pain, % Without Pain, %
With Pain, % Without Pain, % With Pain, % Without Pain, %
Santiago, Chile 60.1 27.9 31.5 13.3 25.5 13.1 9.0 12.0
Berlin, Germany 23.1 8.8 48.1 24.0 22.1 15.4 38.5 26.5
Rio de Janeiro, Brazil 52.5 20.1 11.6 11.9 15.2 13.2 38.7 28.4
Ankara, Turkey 29.4 5.3 46.9 27.2 13.1 3.1 39.3 22.8
Paris, France 34.7 15.8 22.8 12.8 19.4 13.6 27.4 22.6
Mainz, Germany 27.6 11.5 51.4 37.8 37.7 18.3 50.3 33.1
Groningen, the Netherlands 37.8 10.6 22.3 10.5 51.1 20.7 42.7
35.7
Manchester, England 41.0 14.5 36.7 11.3 100.0 8.6 71.8 29.9
Bangalore, India 36.0 9.3 43.1 29.5 33.5 11.9 61.5 37.9
Seattle, Wash 18.5 5.4 27.8 5.4 22.6 6.0 48.8 20.7
Verona, Italy 27.5 4.0 40.9 29.7 11.9 7.5 23.5 16.3
Shanghai, China 13.3 3.9 21.8 26.5 28.9 16.8 31.6 17.0
Athens, Greece 39.1 14.6 8.3 12.8 25.7 8.5 53.5 25.2
Nagasaki, Japan 12.8 5.8 44.1 38.1 37.0 9.3 49.6 21.7
Ibadan, Nigeria 26.7 5.2 6.9 13.3 21.4 26.6 46.7 40.6
25. across centers.
Differences in prevalence rates from
surveys in different countries are often
difficult to compare because of lack of
comparability of study methods.17,18 In
this study, uniform sampling and assess-
ment procedures were used to reduce
variation due to study methods. How-
ever, it is difficult to guarantee uniform
application of study methods in a widely
dispersed multicenter study conducted
in many different languages. It was only
possible to study a limited number of care
settings in each locale, so differences due
to care setting are confounded with cul-
tural differences. For these reasons, our
results regarding differences in preva-
lence and impacts of persistent pain be-
tween countries are exploratory. While
the differences in prevalence rates across
centers were statistically significant af-
ter controlling for age and sex differ-
ences, this variation may be due to so-
ciodemographic, care setting, and/or
methodological differences rather than
culture.
The observation that women tended to
have elevated rates of persistent pain
relative to men has been reported by oth-
ers.17-20 This study does not shed light on
reasons for this sex difference, other than
to suggest that it is not unique to Western
societies. Prior research has suggested
26. sex differences in pain prevalence for
some anatomical sites and not for oth-
ers,19,20 but this study did not examine site-
specific prevalence rates by sex.
Overall, persistent pain was associated
with marked reductions in several differ-
ent indicators of well-being, particularly
psychological illness and interference
with activities. Differences in self-rated
health status were of smaller magnitude,
although they were statistically signifi-
cant for all centers combined. In the
pooled analysis, patients with persistent
pain were more likely to have impaired
work role functioning and to have missed
3 or more days from their usual activities
in the prior month. While patients with
persistent pain were more disabled than
those without persistent pain overall, this
association was not consistently statisti-
cally significant across the participating
centers. However, the trend was in the
same direction in almost every center for
both disability measures.
The commonly reported association of
persistent pain with psychological ill-
ness16,17,21,22 was confirmed by this study.
A significant association was found in ev-
ery participating center. This study does
not address the direction of causality
between persistent pain and affective
illness. Prior studies have yielded dif-
fering results on this question.16,23,24 The
results of this study indicate that psy-
27. chological disorder is a common corre-
late of persistent pain, and that this
association is observed in a wide range
of cultural settings.
In conclusion, persistent pain was com-
mon among primary care patients in many
different cultures. Across all centers, per-
sistent pain was associated with psycho-
logical disturbance and significant ac-
tivity limitations. Further research is
needed to better understand cross-na-
tional variation in the prevalence of per-
sistent pain, and variation in the effects of
persistent pain on well-being and func-
tioning. The results of this study point to
the difficulty in drawing conclusions about
cultural differences in the frequency or
the impacts of persistent pain from mod-
est samples of pain patients sampled from
a limited number of care settings in a par-
ticular culture. While further research is
needed, this study shows that persistent
pain is a common problem among primary
care patients in a wide range of cultural
settings.
Dr Von Korff’s work on this report was supported
in part by grant DE08773-10 from the National In-
stitutes of Health, Bethesda, Md.
The data reported in this article were collected as
part of a World Health Organization’s Psychological
Problems in General Health Care project. Partici-
pating investigators include O. Ozturk and M.
Rezaki, Ankara, Turkey; C. Stefanis and V.
28. Mavreas, Athens, Greece; S. M. Channabasavana
and T. G. Sriram, Bangalore, India; H. Helmchen
and M. Linden, Berlin, Germany; W. van der Brink
and B. Tiemens, Groningen, the Netherlands; M.
Olatawura, Ibadan, Nigeria; O. Benkert and W.
Maier, Mainz, Germany; S. Kisely, Manchester,
England; Y. Nakane and S. Michitsuji, Nagasaki,
Japan; Y. Lecrubier and P. Boyer, Paris, France; J.
Costa e Silva and L. Villano, Rio de Janeiro, Brazil;
R. Florenzano and J. Acuna, Santiago, Chile; G. E.
Simon, Seattle, Wash; Y. He-Quin and X. Shi Fu,
Shanghai, China; and M. Tansella and C. Bellan-
tuono, Verona, Italy. The study advisory group
include J. Costa e Silva, D. P. Goldberg, Y. Lecru-
bier, Michael Von Korff, and H-U Wittchen. Coor-
dinating staff at World Health Organization head-
quarters include N. Sartorius and T. B. Ustun.
References
1. Schappert SM. National Ambulatory Medical
Care Survey: 1989 summary. National Center for
Health Statistics. Vital Health Stat 13. 1992; No. 11.
2. Turk DC, Rudy TE. Toward an empirically de-
rived taxonomy of chronic pain patients: integration
of psychological assessment data. J Consult Clin
Psychol. 1988;56:233-238.
3. Von Korff M, Ormel J, Keefe FJ, Dworkin SF.
Grading the severity of chronic pain. Pain. 1992;50:
133-149.
4. Bates MS, Rankin-Hill L, Sanchez-Ayendez M, Men-
dez-Bryan R. A cross-cultural comparison of adapta-
tion to chronic pain among Anglo-Americans and na-
tive Puerto Ricans. Med Anthropol. 1995;16:141-173.
5. Moore R. Ethnographic assessment of pain cop-
ing perceptions. Psychosom Med. 1990;52:171-181.
29. 6. Sanders SH, Brena SF, Spier CJ, Beltrutti D,
McConnell H, Quintero O. Chronic low back pain
patients around the world: cross-cultural similari-
ties and differences. Clin J Pain. 1992;8:317-323.
7. Ustun TB, Sartorius, N, eds. Mental Illness in
General Health Care: An International Study. New
York, NY: John Wiley & Sons Inc; 1995.
8. Sartorius N, Ustun TB, Costa e Silva JA, et al. An
international study of psychological problems in pri-
mary care. Arch Gen Psychiatry. 1993;50:819-824.
9. Von Korff M, Ustun TB. Methods of the WHO
Collaborative Study on Psychological Problems in
General Health Care. In: Ustun TB, Sartorius N,
eds. Mental Illness in General Health Care: An In-
ternational Study. New York, NY: John Wiley &
Sons Inc; 1995.
10. Ormel J, Von Korff M, Ustun TB, Pini S, Korten
A, Oldehinkel T. Common mental disorders and dis-
ability across cultures. JAMA. 1994;272:1741-1748.
11. Goldberg D, Williams P. A Users’ Guide to the
General Health Questionnaire: GHQ. Windsor,
Berkshire, England: NFER-NELSON Publishing
Co Ltd; 1988.
12. World Health Organization. Composite Inter-
national Diagnostic Interview. Geneva, Switzer-
land: World Health Organization, Division of Men-
tal Health; 1989. Publication MNH/NAT/89.
13. World Health Organization. International Sta-
tistical Classification of Diseases, 10th Revision
(ICD-10). Geneva, Switzerland: World Health Or-
ganization; 1992.
14. Wiersma D, DeJong A, Ormel J. The Groningen
Social Disability Schedule: development, relation-
ship with ICIDH, and psychometric properties. Int
J Rehabil Res. 1988;11:213-224.
30. 15. Von Korff M, Ustun TB, Ormel J, Kaplan I, Si-
mon G. Self-report disability in an international pri-
mary care study of psychological illness. J Clin Epi-
demiol. 1996;49:297-303.
16. Von Korff M, Simon G. The relationship of pain
and depression. Br J Psychiatry. 1996;168(suppl 30):
101-108.
17. Magni G, Marchetti M, Moreschi C, Merskey H,
Luchini SR. Chronic musculoskeletal pain and de-
pressive symptoms in the National Health and Nu-
trition Examination, I: epidemiological follow-up
study. Pain. 1993;53:163-168.
18. Andersson HI, Ejlertsson G., Leden I, Rosen-
berg C. Chronic pain in a geographically defined
general population: studies of differences in age,
gender, social class, and pain localisation. Clin J
Pain. 1993;9:174-182.
19. Von Korff M, Dworkin SF, LeResche L, Kruger
A. An epidemiologic comparison of pain complaints.
Pain. 1988;32:173-183.
20. Le Resche L, Von Korff M. Epidemiology of
chronic pain. In: Block AR, Kremer EF, Fernandez
E, eds. Handbook of Pain Syndromes: Biopsycho-
social Perspectives. Mahwah, NJ: Lawrence Er-
baum Associates Inc. In press.
21. Roy R, Thomas M, Matas M. Chronic pain and
depression: a review. Compr Psychiatry. 1984;25:
96-105.
22. Romano JM, Turner JA. Chronic pain and de-
pression: does the evidence support a relationship?
Psychol Bull. 1985;97:18-34.
23. Polatin PB, Kinney RK, Gatchel RJ, Lillo E,
Mayer TG. Psychiatric illness and chronic low-back
pain: the mind and the spine—which goes first?
Spine. 1993;18:66-71.
32. sored by governmental or other private organizations is rarely
questioned. Ignoring the possibility that the granting agen-
cies may have specific agendas for the research they sponsor,
there are substantial pressures on scientists to publish and a
well-known bias against publication of negative data. I wonder
how publications not sponsored by the pharmaceutical indus-
try would stand up to FDA-style scrutiny.
To the shame of the pharmaceutical industry, some compa-
nies have suppressed data from publication4 or published data
in a manner not consistent with that reviewed by the FDA.5
Such cases have become public embarrassments that received
widespread coverage in the popular press. These examples
are the exception, not the rule. Physicians and the public should
be assured of the validity of pharmaceutical clinical research
and of the integrity of those who conduct and oversee it.
Kenneth J. Gorelick, MD
DuPont Merck Pharmaceutical Company
Wilmington, Del
1. Barnes DE, Bero LA. Why review articles on the health
effects of passive smoking
reach different conclusions. JAMA. 1998;279:1566-1570.
2. Cho MK, Bero LA. The quality of drug studies published in
symposium proceed-
ings. Ann Intern Med. 1996;124:485-489.
3. Rochon PA, Gurwitz JH, Simms RW, et al. A study of
manufacturer-supported tri-
als of nonsteroidal anti-inflammatory drugs in the treatment of
arthritis. Arch Intern
Med. 1994;154:157-163.
4. Rennie D. Thyroid storm [published correction appears in
JAMA. 1997;277:1762].
JAMA. 1997;277:1238-1243.
5. Wenzel RP. Anti-endotoxin monoclonal antibodies—a second
33. look. N Engl J Med.
1992;326:1151.
In Reply.—Every independent scientific body that has re-
viewed the scientific evidence has concluded that exposure to
passive smoke is harmful to health.1 As the title of our article
suggests, the goal of our study was to determine why many
published review articles reach conclusions that differ from
these independent scientific bodies. We investigated several
factors in addition to quality and funding source that might be
associated with outcome, including peer review, date of pub-
lication, and topic of review. The only factor associated with
the conclusion of a review article was the affiliation of its au-
thor: 94% of reviews by tobacco industry–affiliated authors
concluded that passive smoking is not harmful compared
with 13% of reviews by authors without tobacco-industry
affiliations.
We did not define tobacco-industry affiliation “generously,”
as Dr Heck states. Rather, we used strict, well-defined crite-
ria: an author must have received funding from the tobacco
industry, submitted a statement on behalf of the tobacco in-
dustry regarding the Environmental Protection Agency’s risk
assessment on passive smoking, or participated in (not simply
attended, as misstated by Heck) at least 2 tobacco-industry–
sponsored symposia. Moreover, our data are not “testament to
the legitimate diversity of scientific opinion on the topic of
ETS,” as Heck suggests. Rather, our findings suggest that,
among scientists who are not affiliated with the tobacco in-
dustry, there is consensus that passive smoking is harmful.
The only diversity of opinion comes from the authors with
tobacco-industry affiliations.
Dr Gorelick takes issue with 2 articles we cited to support
our statement that original research articles sponsored by the
pharmaceutical industry tend to draw proindustry conclu-
34. sions. A careful reading of both articles reveals that they do
support our statement. The article by Cho and Bero2 did not
examine “only articles from symposia sponsored by single drug
companies.” It examined 127 articles from symposia (of which
39% were sponsored by a single drug company) and 45 articles
from peer-reviewed journals: 98% of the articles with drug
company support favored the drug of interest compared with
79% of the articles without drug company support (P,.01).
In the article by Rochon et al,3 the analysis was limited to
manufacturer-associated trials due to “the scarcity of non-
manufacturer-associated trials.” However, the authors found
that the manufacturer-associated drug was reported as com-
parable or superior to the comparison drug in all cases and that
the claims often were not supported by trial data.
We do not suggest that industry-sponsored research is al-
ways biased. However, to our knowledge, every study that has
examined the relationship between sponsorship and outcomes
has found that industry-sponsored research is more likely to
draw proindustry conclusions than non–industry-sponsored
research. We recommend that financial interests always
should be disclosed and that readers of research articles should
consider these disclosures when deciding how to judge an ar-
ticle’s conclusions.
Lisa A. Bero, PhD
University of California, San Francisco
Deborah Barnes
University of California, Berkeley
1. Barnes DE, Bero LA. Why review articles on the health
effects of passive smoking
reach different conclusions. JAMA. 1998;279:1566-1570.
2. Cho MK, Bero LA. The quality of drug studies published in
symposium proceed-