alcohol consumption and alcohol-related problems: prevalence amongst a general practice population

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Australian Drug and Alcohol Review 1987: 6; 245-252 Alcohol Consumption and Alcohol-Related Problems: Prevalence Amongst a General Practice Population Selina Redman, Jill Cockburn, Alexander L.A. Reid and Robert W. Sanson-Fisher Faculty of Medicine, University of Newcastle, New South Wales Abstract: The prevalence of "at risk" levels of alcohol consumption and of alcohol-related problems in a sample of general practice patients was examined. Consumption was measured using both Quantity Frequency (N=2066) and retrospective diary (N=808) measures. The two measures yielded similar results. The proportwn of females drinking "at risk" levels (40 gins a day) ranged from 0.6% to 1.2% and between 4.1% and 5.8% of males were classified "at r~sk" (60gins~day). Using the SMAST to measure alcohol-related problems, 8.6% of females and 12.1% of males were classified as "probable alcoholic", while "possible alcoholism" was present in a further 15.1% of females and 20.1% of males. Only a weak relationship was found between being at physical risk on the basis of excessive consumption and being identified as having alcohol-related problems by the SMAST. Logistic regression was used in an attempt to delineate predictors of alcohol-related problems. Smoking status, alcohol consumption, age and report of skin problems entered the final model, but the prediction from this model was poor (X~=322.67, dr-- 204, p = 0.122). The results are discussed in terms of strategies for general practitioner detection and intervention with patients with alcohol-related problems. Keywords: Alcohol drinking; alcoholism; physicians, family. Introduction Alcohol represents a major problem for the Australian community, both in health and social terms. Excessive alcohol consumption may result in physical damage, such as cirrhosis of the liver, peripheral neuropathy, cerebral damage and an increased risk of involvement in road traffic accidents. ''~' In addition, alcohol may cause or exacerbate social or behavioural problems, such as difficulties at work, ~'~or in close relationships, ~ as well as legal and financial difficulties. ~ General practitioners are uniquely placed to provide interventions for both excessive consum- ption and alcohol-related problems for several reasons. Firstly, they are readily accessible to the community. General practitioners make contact with a wide segment of the population. In Australia, 64.2% of the community visit a doctor during a six month period and the majority of these visits are with general practitioners. 7 Secon- dly, the provision of preventive health advice is seen as part of their role. A recent survey conducted in Newcastle showed that patients view their general practitioners as knowledgeable and credible sources of health information, with 95% of a randomly selected community sample indicat- ing that they would expect advice about alcohol problems from their doctors. Thirdly, there is evidence that general practitioners are relatively effective in changing alcohol-related behaviours. ~ Despite their potential, few general practition- ers intervene for alcohol abuse. '~c Rather, it appears that most do not take the first step in intervention, namely the detection of those at risk. Several studies have found general practition- ers to be aware of only a small proportion of their patients who are at risk from high consumption. Reid et al." found that a sample of Australian general practitioners were aware of only 27.5% of patients consuming at above risk levels, where risk was defined by the Australian Medical Associa- tion (AMA) classification of 40 gms a day or more

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Page 1: Alcohol Consumption and Alcohol-Related Problems: Prevalence amongst a General Practice Population

Australian Drug and Alcohol Review 1987: 6; 245-252

Alcohol Consumption and Alcohol-Related Problems: Prevalence Amongst a General

Practice Population Selina Redman, Jill Cockburn, Alexander L.A. Reid

and Robert W. Sanson-Fisher Faculty of Medicine, University of Newcastle, New South Wales

Abstract: The prevalence of "at risk" levels of alcohol consumption and of alcohol-related problems in a sample of general practice patients was examined. Consumption was measured using both Quantity Frequency (N=2066) and retrospective diary (N=808) measures. The two measures yielded similar results. The proportwn of females drinking "at risk" levels (40 gins a day) ranged from 0.6% to 1.2% and between 4.1% and 5.8% of males were classified "at r~sk" (60gins~day). Using the SMAST to measure alcohol-related problems, 8.6% of females and 12.1% of males were classified as "probable alcoholic", while "possible alcoholism" was present in a further 15.1% of females and 20.1% of males. Only a weak relationship was found between being at physical risk on the basis of excessive consumption and being identified as having alcohol-related problems by the SMAST. Logistic regression was used in an attempt to delineate predictors of alcohol-related problems. Smoking status, alcohol consumption, age and report of skin problems entered the final model, but the prediction from this model was poor (X~=322.67, dr-- 204, p = 0.122). The results are discussed in terms of strategies for general practitioner detection and intervention with patients with alcohol-related problems.

Keywords: Alcohol drinking; alcoholism; physicians, family.

Introduction

Alcohol represents a major problem for the Australian community, both in health and social terms. Excessive alcohol consumption may result in physical damage, such as cirrhosis of the liver, peripheral neuropathy, cerebral damage and an increased risk of involvement in road traffic accidents. ''~' In addition, alcohol may cause or exacerbate social or behavioural problems, such as difficulties at work, ~'~ or in close relationships, ~ as well as legal and financial difficulties. ~

General practitioners are uniquely placed to provide interventions for both excessive consum- ption and alcohol-related problems for several reasons. Firstly, they are readily accessible to the community. General practitioners make contact with a wide segment of the population. In Australia, 64.2% of the community visit a doctor during a six month period and the majority of these visits are with general practitioners. 7 Secon- dly, the provision of preventive health advice is

seen as part of their role. A recent survey conducted in Newcastle showed that patients view their general practitioners as knowledgeable and credible sources of health information, with 95% of a randomly selected community sample indicat- ing that they would expect advice about alcohol problems from their doctors. Thirdly, there is evidence that general practitioners are relatively effective in changing alcohol-related behaviours. ~

Despite their potential, few general practition- ers intervene for alcohol abuse. '~c Rather, it appears that most do not take the first step in intervention, namely the detection of those at risk. Several studies have found general practition- ers to be aware of only a small proportion of their patients who are at risk from high consumption. Reid et al." found that a sample of Australian general practitioners were aware of only 27.5% of patients consuming at above risk levels, where risk was defined by the Australian Medical Associa- tion (AMA) classification of 40 gms a day or more

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for females and 60 gms a day or more for males. Similar findings have been reported for alcohol- related problems. Only 8% of patients identified by the Michigan Alcohol Screening Test (MAST), a standardised assessment instrument for detecting alcohol-related problems'-' were known to their general practitioners.' .... The reasons for the failure of general practitioners to detect and intervene with patients with alcohol-related problems appear to be complex. T M However, one factor which seems likely to be important is the scarcity of information about the nature and extent of existing problems with alcohol in general practice. Although necessary for effective detec- tion, neither the prevalence of high consumption nor the prevalence of alcohol-related problems amongst Australian general practice patients is known. There have been several general commun- ity surveys of alcohol consumption in Australia. Although the definition of "at risk" levels differs between the studies from 50 gms" to 80 gms'Vday for men, the proportion of people at risk has been fairly uniform across studies. Estimates of the proportion of people at risk from high consump- tion lie between 6-11% for males and approx- imately 1-2% for females. '~-'8 However, given the demographic differences between community and general practice samples, the extent to which these findings generalise to the general practice setting is unknown.

There have been no Australian studies assessing the prevalence of alcohol-related problems in either a community or general practice setting. When using the MAST, American studies report a prevalence of alcohol-related problems in family practices of around 30%. '"'" However, as there are marked cultural differences in relation to alco- hol, :° it is not clear whether similarly high levels of problems would be observed in the Australian c o n t e x t .

In addition to an awareness of prevalence estimates, general practitioners also need informa- tion about the pattern of problems with alcohol .amongst their patients if they are to detect and intervene effectively. Two types of information may be of particular use in general practitioner screening. First, there is a need for clarification of the relationship between high consumption and alcohol-related problems in general practice patients. Although medical interventions are most frequently targetted at reducing consumption, there is some evidence to suggest that alcohol- related problems may occur even at relatively low levels of consumption. -'' To the extent that they represent separate problems, the general prac- titioner may require different detection and in-

tervention strategies for high consumption and for alcohol-related problems. Second, the characteris- tics of those patients at risk from alcohol are not clear. Previous studies have observed a relation- ship between problems with alcohol and a number of variables including age, socioeconomic class and sex.::-'-' However, the possible associations between these characteristics and problems with alcohol have not been explored either within general practice or in the wider Australian com- munity.

The aim of this study was to examine problems with alcohol in general practice, in order to provide information useful for detection and intervention. The prevalence of those at risk from either high consumption or alcohol-related problems was assessed. The relationship between the two measures was explored, and an attempt made to identify characteristics of patients more likely to be at risk from alcohol-related problems.

Method

Subjects The data were collected as part of a large scale

direct observational study in general practice in Newcastle, New South Wales. A random sample of 108 general practitioners was asked to par- ticipate in a study involving the videotaping of their consultations. Fifty-six doctors agreed, yiel- ding a consent rate of 52%. A questionnaire :~ concerning attitudes and beliefs about medical practice was administered to both consenting and non-consenting doctors, and no significant dif- ferences were found between the two groups of doctors with regard to age, sex or beliefs and attitudes about medical practice. :~ Response bias, as measured by these means, was therefore minimal.

The patient sample was recruited in the waiting rooms of the 56 consenting general practitioners. Patients were eligible for inclusion if they were over 18 years, could speak and read English and were not too ill to complete questionnaires. Only the general purpose of the study, that is, an investigation of the doctor-patient interaction, was outlined to patients during the consent procedure. Patients were told that procedures involved in participation would include complet- ing questionnaires before the consultation and at home after the consultation. Of the 5,253 patients approached, 2,934 met the eligibility criteria. Of these patients, 497 declined to participate, yield- ing a consent rate of 83.1%. A comparison of consenting and non-consenting patients showed that although there was no association between

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patient gender and consent, patients who consen- ted tended to be younger than patients who refused. However, as at no time was alcohol consumption or related problems mentioned as a topic of interest, there is little reason to suspect that patients who declined to participate would be more likely to have a drinking problem they wished to hide.

Measures Two measures of alcohol consumption were

used: quantity frequency questions (QF) and a retrospective alcohol diary. Both measures were included because although the diary is considered to be a more accurate measure, -'6 the QF measure is more frequently used in research. '~,~'7 Inclusion of the QF therefore enables comparison with other Australian research.

Prior to their consultation, all 2437 consenting patients were asked to complete a questionnaire which included the QF questions. The measure consisted of two items: a frequency question, "How often do you usually drink alcohol?" and a quantity question, "On a day when you drink alcohol, how many drinks do you usually have?". Responses to both questions were ordinal with the frequency question allowing six possible respon- ses ranging from "don't drink" to "every day", and the quantity question offering seven alter- natives ranging from "don't drink" to "more than twenty drinks". A standard drink was defined as a 30ml nip of spirit, a 60ml glass of sherry or port, a 120ml glass of wine, a 285ml middy or twist-top of beer. Each drink therefore contains about 10g of alcohol. A schooner or can of beer (425ml) was classed as one and a half drinks. The amount of alcohol reported to be consumed on the QF was calculated as follows. For each of the 12 possible combinations of quantity and frequency category, the maximum and minimum number of drinks which could be consumed for the week was calculated by multiplying the minimum number of days from the frequency category by the minimum number of drinks given in the quantity category. The maximum number of drinks for each category was calculated similarly from the maximum number of days multipl[ed by the maximum number of drinks. The mean of the maximum and minimum values was calculated and used to indicate the average number of drinks consumed weekly.

A random sample of 1,080 patients was also asked to complete an additional questionnaire at home within 24 hours of the consultation. This questionnaire included a one-week retrospective diary measure of alcohol consumption. Subjects

were first asked whether they had consumed alcohol during the past year. If alcohol had been consumed, they were requested to state the number of drinks consumed on each day of the previous week, starting with "yesterday" and working backwards through the week. The total number of drinks recorded was summed over the 7 days.

The presence of alcohol-related problems was measured using the Shortened Michigan Alcohol Test (SMAST). -'~ The SMAST is a 13-item ques- tionnaire containing a subset of questions used in the MAST. It has baen found to correlate highly with the MAST -'7 and to have demonstrated reliability and validity.: ..... The SMAST was in- cluded on the questionnaire which patients com- pleted at home. Again, only patients who repor- ted consuming any alcohol in the last vear were asked to complete the SMAST. The SMAST was scored according to the recommendations of Seizer. :~ A point score of 1 was given for each problem the respondent indicated as ever ex- periencing, for example, ever feeling guilt over drinking or ever being in trouble at work because of drinking. The range of possible responses, therefore, ranged from 0-13. Subjects scoring 0-1 were considered non-alcoholic, those scoring 2 points possibly alcoholic, and those with 3 or more points probable alcoholic. Questions 6 ("Have you ever attended a meeting of Alcoholics Anonymous?"), 10 ("Have you ever gone to anyone for help about your drinking?") and 11 ("Have you ever been in hospital because of your drinking?") were diagnostic in that a positive response to any of these questions resulted in the patient being classified as probable alcoholic.

As part of the pre-consultation questionnaire, patients were asked for demographic details in- cluding age, sex, occupation and highest level of education obtained. The questionnaire also con- tained the 30-item General Health Question- naire, ~: a standardised measure of non-psychotic psychiatric disturbance. Data on patients' smok- ing status and self reported symptoms including nerves, diarrhoea, palpitations, aches and pains, accidents, constipation and skin problems were also obtained.

Return of questionnaires Subjects were given reply-paid envelopes for

returning take-home questionnaires. If the ques- tionnaire was not received within one week, a reminder letter was sent, and a phone call was made two weeks later if a reply was still outstand- ing. This procedure resulted in a return rate of 79%, being 848 questionnaires. Comparisons

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using QF data were made between patients who returned questionnaires and those that did not. No significant difference in alcohol consumption was found between the two groups, indicating that the sample with the alcohol diary and SMAST data were representative of the overall sample and response bias from non-return of questionnaires was minimal. -"

Results

Prevalence of high consumption The first question of interest was the proportion

of patients who were at physical risk as a result of their high levels of alcohol consumption. AMA cutpoints of 40 gms or more per day for females and 60 gms or more per day for males were used to categorise high levels of drinking." "Binge" drinking was defined as drinking 100 gms or more for males and 60 gins or more for females on one or more occasion during the week with drinking on other days being insufficient for average daily consumption to exceed the AMA cutpoints.'-" Of the 2437 QF questionnaires administered, 2066 contained complete QF data. Of the 848 take home questionnaires returned, 808 had completed the alcohol diary. Data from four questionnaires could not be used because the patients' gender was missing. The prevalence of at-risk consumption as assessed by the QF and by the diary is shown in Table 1 separately for males and females.

In general, the two measures yielded similar results, although more people were classified at risk by the diary than by the QF. The majority of both male and female patients were non-drinkers or drinking below risk levels. Among the female

patients, 5.4% (diary) to 3.2% (QF) were clas- sified as %inge drinkers" and an additional 0.6% (QF) to 1.2% (diary) as "at risk". A higher proportion of male patients were classified as drinking hazardously. Of the males, 4.6% (QF) to 6.2% (diary) were classified as "binge drinkers" and 4.1% (QF) to 6.9% (diary) as "at risk". Overall, the proportion of individuals consuming at high levels (binge plus at risk) ranged from 5.7% (QF) to 9.1% (diary).

Prevalence of alcohol-related problems as measured by the SMAST

The prevalence of alcohol related problems as assessed by the SMAST amongst those individuals who had consumed alcohol in the past year is shown in Table 2. 503 patients provided complete data on the SMAST. Data from one patient were not included in the analysis as gender was omitted.

The SMAST classified 8.6% of females and 12.1% of males as "probable alcoholics", with ~possible alcoholism" present in a further 15.1% of females and 20.1% of males. In all, some level of alcohol-related problems were reported by 27.5% of the patient sample who had drunk alcohol in the past year.

Relationship between alcohol-related problems and consumption

As shown in Tables 1 and 2, a much greater proportion of general practice patients appear to have alcohol-related problems than are at physical risk from high consumption. In order to deter- mine whether drinking at at-risk levels is as- sociated with alcohol-related problems, a compar- ison was made of drinking individuals who

Table 1: Percentage ot patients classified as non-drinkers, below-risk drinkers and at-risk drinkers on the quantity frequency and diary measures

Diary Quantity, Frequency' M F Total M F Total

(N = 306) (N = 500) (N = 806) (N = 813) (N = 1249) (N = 2 0 6 2 )

Non-drinkers 25.2 48.2 39.5 18.3 39.0 30.8

Below-risk 61.8 45.2 51.5 73.1 57.3 63.5

Binge =. 6.2 5.4 5.7 4.6 3.2 3.8

At-risk*:" 6.9 1.2 3.4 4.1 0.6 1.9

Total 100 100 100 100 100 100

* Binge drinking was defined as drinking 100 gms or more on one day for males and 60 gms or more for females with drinking o n other days being insufficient for average daily consumption to exceed AMA cutpoin~s.

** At-risk was defined as an average per day of 60 gms or more for males and 40 gins or more for females.

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Table 2: Percentage of drinking patients classified by the SMAST as not alcoholics, possible alcoholics or probable alcoholics

Males Females Total (m = 224) (N = 278) (N = 502)

Not alcoholic 67,9 76.3 72.5

Possible alcoholic 20,1 15.1 17.3

Probable alcoholic 12.1 8.6 10.2 Total 100 100 100

reported alcohol-related problems with those defined as at risk on the basis of reported consumption on the diary. The diary measure was chosen as the index of consumption as it is a more accurate indicator of levels of consumption than the QF. -'~ 496 patients had complete data for both the diary and SMAST measures.

It is evident from Table 3 that there was only a weak relationship between being at risk on the basis of excessive consumption and being iden- tified as having some level of alcohol related problems by the SMAST. Of those individuals who were consuming at above risk levels, only 35% (9/26) reported alcohol- related problems, whereas 43% (18/42) of the binge drinkers were classified as having problems. In addition, of those patients assessed as having alcohol-related problems, only a very small percentage (7% - - 9/ 136) were drinking at above risk levels, or binge drinking (13% - - 18/136). A similar lack of association between excessive consumption and alcohol-related problems has been reported in some previous studies. "''4

Characteristics of patients at risk for alcohol- related problems

Informat ion about patient characteristics predictive of alcohol- related problems may serve as cues to alert the general practitioner to the possible presence of problems in particular patients. Therefore, logistic regression analysis was undertaken to explore predictors of alcohol- related problems in the patient sample. The analysis allows the strength of association between each predictor variable and the dependent variable to be estimated while controlling for the effects of other predictor variables." The dependent variable was SMAST classification, dichotomized into alcoholic/possible alcoholic (score 2 +). Predictor variables used in the analysis were sex, age, level of education, occupation, degree of psychological disturbance as measured by the General Health Questionnaire, '° smoking status, alcohol intake as measured by the diary and self-reported symp- toms.

Complete data on all variables were available for 320 patients. Of these 86 were classified as

Table 3: A comparison of those patients defined as at-risk by alcohol consumption with those classified as having alcohol-related problems by the SMAST

Consumption (Diary) No Risk Binge High Risk Drinker Drinker Drinker Total

No problems 319 24 17 360

SMAST Alcoholic/ Possible Alcoholic 109 18 9 136 Total 428 42 26 496

* Risk defined at 40 gms or more per day for females and 60 gms or more per day for males.

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possible or probable alcoholics by the SMAST. Four variables were included in the final model: smoking status, alcohol intake, age and the report of skin problems. However, the goodness of fit chi-square for the final model (X-'=322.67; df= 294; p = 0.122) indicated that a large proport- ion of the variability in the SMAST scores was not explained by this model. This indicates that the prediction of alcohol-related problems by the variables which entered the equation is poor.

Discussion This study examined the prevalence of at-risk

alcohol consumption and alcohol-related problems in general practice. Predictors of alco- hol-related problems were also examined.

Between 5% and 10% of this general practice population were found to be consuming alcohol at above recommended levels. For the female patients, the majority of the high consumers were "binge drinkers", that is, persons drinking a large quantity of alcohol on one occasion rather than a large daily average. Only a small proportion of the women in the sample reported mean weekly consumption levels of greater than 40 gms per day. The low levels are similar to those reported in general population surveys. ~ ....... Among the male patients consuming at high levels, approximately half were classified as "binge drinkers" and the remainder on the basis of consumption of a daily average above 60 gms. In the present study, the prevalence of at- risk drinking among males was lower than that reported in community studies in Australia. '°"~"~'

It seems likely that the smaller numbers of males drinking at at- risk levels may be a function of the characteristics of general practice patients compared with the community as a whole. In particular, the general practice sample included a smaller percentage of young males, who are frequently found to be heavier drinkers than the community as a whole.' ....... In addition, the general practice population is likely to include a higher proportion of ill individuals, who may be drinking less than their healthy community coun- terparts.

Overall, the consumption data suggest that the proportion of heavy drinkers in general practice is relatively small. These data emphasize the need for general practitioners to ask about "binge drinking" amongst their patients, rather than relying on average daily intake.

The prevalence rate for alcohol-related problems was considerably higher than that for consumption, being around 27.5%. This

prevalence rate is also higher than that estimated by general practitioners. In one study, doctors estimated that only 1% of their patients were problem drinkers,36 while a New Zealand study found that 64% of general practitioners believed that 5% or less of their patients had alcohol- related prob[ems?; It seems that general prac- titioners considerably underestimate the extent of alcohol-related problems amongst their patients. This suggests the need to educate general prac- titioners about the extent of alcohol-related problems and also to train doctors in the skills necessary for detection and intervention with these patients.

The SMAST was selected for the current study because among existing measures of alcohol-re- lated problems it has good validity and reliability, and has been the most widely used instrument in research studies. In addition, an examination of the content of the items suggests that positive responses reflect minimally a concern about alco- hol. However, it should be noted that the SMAST was developed and validated primarily on clinical populations and its appropriateness for general practice populations has not been thoroughly assessed. The suitability of the SMAST for use in general contexts has recently been questioned'" and the prevalence data reported here should therefore be viewed cautiously. If the general practitioner is to detect and intervene effectively, a screening instrument tailored to general practice needs to be developed.

Those individuals who report alcohol-related problems but are consuming at below risk levels are of particular interest. In the present study, this group comprised approximately 22% (109/496) of the sample. These patients may be reflecting simply a concern about alcohol. Although they are drinking relatively little, they may be worried about alcohol or its potential impact on their life. Alternatively, the results may indicate the ability of alcohol to cause or exacerbate existing life problems at relatively low doses.-" A further possibility is that the SMAST may over-diagnose current alcohol related problems by categorising those individuals with past problems as alcoholics. A closer examination of the group of patients who are consuming alcohol at below risk levels but report alcohol-related problems using more soph- isticated assessment tools would provide useful information about the pattern of alcohol-related problems in general practice.

The observed lack of association between con- sumption and alcohol-related problems has im- portant implications for both detection and treat- ment within general practice. Since the majority of

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those reporting alcohol-related problems are not drinking excessively, general practitioner ques- tions directed only at consumption will miss much of the alcohol-related morbidity. Similarly, in- terventions aimed only at reducing consumption are unlikely to be effective in reducing the overall burden of illness resulting from alcohol misuse. Rather, there is a need for the development of separate detection and intervention strategies for the two types of problems. Given the relatively greater numbers of patients with alcohol-related problems, it may be more effective to focus detection and treatment in this area rather than on consumption.

This study also showed that it was not possible to readily identify patient characteristics which accurately predict the presence of alcohol-related problems. Consequently, to effectively detect alcohol related problems, general practitioners will need to screen all patients rather than concentrate on any one patient group.

Conclusions In the present study, a much larger proportion

of general practice patients reported alcohol-re- lated problems than appeared to be at physical risk from high consumption. There was little overlap between those at risk on the two variables. Consequently, there is a need for separate detec- tion and intervention strategies for consumption and alcohol-related problems within this setting. In addition, as there are no readily identifiable characteristics of those with alcohol-related problems, doctors need to screen all patients in order to detect those at risk.

Acknowledgements The collaboration of the general practitioners

and their patients in this research is gratefully acknowledged. The data were collected as part of a large research project, the Primary Care Project; the Principal Investigator was Professor R.W. Sanson-Fisher.

Correspondence and requests for reprints to: Dr. S. Redman, Lecturer in Behavioural Science in Relation to Medicine, University of Newcastle, NSW 2308.

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