Why the prevention paradox is a paradox, and why we should solve it: a philosophical view

This paper provides some philosophical comments on Rose's prevention paradox, suggesting why that paradox seems so difficult, and why policy-makers should care about solving it. The assumptions underlying the paradox section sets out two ways of understanding the notion of "benefit" in public health programmes, and shows how the prevention paradox arises from combining both understandings. Thinking through the paradox section argues that if we find the second understanding of benefit appealing, then we should rethink how we typically assess preventive public health measures. The implications section shows how these theoretical arguments imply that public health practitioners should care about solving the prevention paradox, rather than simply denying the legitimacy of one of the two views from which it arises.     

Supporting positive dimensions of health,challenges in mental health care

This paper will explore two contrasting paradigms in mental health care and their relationship to evidence-based practice. The biomedical perspective of pathogenesis and the health perspective of salotogenesis are two major diverse views in mental health care. Positive dimensions of health are traditionally viewed as software not suitable for statistical analysis, while absence of symptoms of disease are regarded as measurable and suitable for statistical analysis and appropriate as a foundation of evidence-based practice. If the main goal of mental health care is to enhance subjectively experienced health among patients, it will not be sufficient to evaluate absence of symptoms of disease as a measure of quality of care. The discussion focuses on the paradox of evidence-based absence of illness and disease versus subjectively experienced health and well-being as criterions of quality of care in mental health care.     

The Latina paradox: an opportunity for restructuring prenatal care delivery

Latina mothers in the United States enjoy surprisingly favorable birth outcomes despite their social disadvantages. This "Latina paradox" is particularly evident among Mexican-born women. The social and cultural factors that contribute to this paradox are maintained by community networks--informal systems of prenatal care that are composed of family, friends, community members, and lay health workers. This informal system confers protective factors that provide a behavioral context for healthy births. US-born Latinas are losing this protection, although it could be maintained with the support of community-based informal care systems. We recommend steps to harness the benefits of informal systems of prenatal care in Latino communities to meet the increasing needs of pregnant Latina women.     

Socioeconomic,cultural, and behavioral factors affecting Hispanic health outcomes

Evidence suggests that social and economic factors are important determinants of health. Yet, despite higher porverty rates, less education, and worse access to health care, health outcomes of many Hispanics living in the United States today are equal to, or better than, those of non-Hispanic whites. This paradox is described in the literature as the epidemiological paradox or Hispanic health paradox. In this paper, the authors selectively review data and research supporting the existence of the epidemiological paradox. They find substantial support for the existence of the epidemiological paradox, particularly among Mexican Americans. Census undercounts of Hispanics, misclassification of Hispanic deaths, and emigration of Hispanics do not fully account for the epidemiological paradox. Identifying protective factors underlying the epidemiological paradox, while improving access to care and the economic conditions among Hispanics, are important research and policy implications of this review.     

State of the Dutch health care: need for more refined and specific indicators

The 'World health report 2000' follows a trend towards the use of performance indicators in public services. The indicators used by WHO are in need of conceptual refinement and valid measurement, especially the more subjective ones. The use of indicators for final goals of health (care) systems makes it difficult to translate lack of performance into policy. Instrumental goals are also needed for the latter. It is concluded that the overall performance of the Dutch health care system is built up of the performance of its individual sections. The concrete areas for improvement within these sections need to be identified, while at the same time a performance paradox should be avoided.     

Lessons for (and from) America

Drawing lessons from international experience for health care reform in the United States requires striking a difficult balance between historical determinism and free will, between cynical pessimism and na?ve optimism. The key to this puzzle may lie in a paradox: the United States is the most successful exporter of public health policy ideas and instruments yet has failed to build an effective health care system. General ideas (like notions about the role of competition) and microinstruments (like diagnosis-related groups) travel better than do health care systems. Ideas can be adapted to local circumstances, and instruments may easily fit into preexisting systems. Importing systems from countries with different histories and institutions would require a tectonic shift in the American political landscape.     

Understanding and supporting African Americans' perspectives of end-of-life care planning and decision making

Ethnicity has been found to explain some differences across ethnic groups regarding end-of-life care choices. African Americans appear to be less likely to know about advance directives and to complete them. Five community-based focus groups, consisting of 27 African Americans, were convened to explore their perspectives of end-of-life care planning and decision making. Content analysis revealed six themes: death is not an option, religiosity and end-of-life care planning is a paradox, the health care system is a microcosm of societal and historical events, a "trusted" family member or friend is the contract for life-and-death options, ethnically relevant initiatives are essential to increase advance directives participation, and people are people. These themes serve to guide health care professionals in minimizing actions that increase African Americans' mistrust of the health care system not only in end-of-life situations but also in all of health care-related interactions.     

A Participatory Model of the Paradox of Primary Care

PURPOSE

The paradox of primary care is the observation that primary care is associated with apparently low levels of evidence-based care for individual diseases, but systems based on primary care have healthier populations, use fewer resources, and have less health inequality. The purpose of this article is to explore, from a complex systems perspective, mechanisms that might account for the effects of primary care beyond disease-specific care.

METHODS

In an 8-session, participatory group model-building process, patient, caregiver, and primary care clinician community stakeholders worked with academic investigators to develop and refine an agent-based computer simulation model to test hypotheses about mechanisms by which features of primary care could affect health and health equity.

RESULTS

In the resulting model, patients are at risk for acute illness, acute life-changing illness, chronic illness, and mental illness. Patients have changeable health behaviors and care-seeking tendencies that relate to their living in advantaged or disadvantaged neighborhoods. There are 2 types of care available to patients: primary and specialty. Primary care in the model is less effective than specialty care in treating single diseases, but it has the ability to treat multiple diseases at once. Primary care also can provide disease prevention visits, help patients improve their health behaviors, refer to specialty care, and develop relationships with patients that cause them to lower their threshold for seeking care. In a model run with primary care features turned off, primary care patients have poorer health. In a model run with all primary care features turned on, their conjoint effect leads to better population health for patients who seek primary care, with the primary care effect being particularly pronounced for patients who are disadvantaged and patients with multiple chronic conditions. Primary care leads to more total health care visits that are due to more disease prevention visits, but there are reduced illness visits among people in disadvantaged neighborhoods. Supplemental appendices provide a working version of the model and worksheets that allow readers to run their own experiments that vary model parameters.

CONCLUSION

This simulation model provides insights into possible mechanisms for the paradox of primary care and shows how participatory group model building can be used to evaluate hypotheses about the behavior of such complex systems as primary health care and population health.     

Economic evaluation of innovative technologies in health care should include a short-run perspective

Knowledge about the cost-effectiveness of innovative technologies or new guidelines in health care is more and more a necessary condition for implementation in common practice. However, there are situations where implementation of a new technology that is found more effective and cost effective and is strongly advocated by the medical profession stagnates. The reason for this is the discrepancy between long-run efficiency, on which cost effectiveness is based, and short-run efficiency. This paper addresses the potential paradox between long-run and short-run efficiency in health care and explores possibilities to overcome hurdles to implementation due to that paradox.     

Factors conditioning primary care services utilization. Empirical evidence and methodological inconsistencies

INTRODUCTION: In Spain, the degree and characteristics of primary care services utilization have been the subject of analysis since at least the 1980s. One of the main reasons for this interest is to assess the extent to which utilization matches primary care needs. In fact, the provision of an adequate health service for those who most need it is a generally accepted priority. FACTORS CONDITIONING USE: The evidence shows that individual characteristics, mainly health status, are the factors most closely related to primary care utilization. Other personal characteristics, such as gender and age, could act as modulators of health care need. Some family and/or cultural variables, as well as factors related to the health care professional and institutions, could explain some of the observed variability in primary care services utilization. Socioeconomic variables, such as income, reveal a paradox. From an aggregate perspective, income is the main determinant of utilization as well as of health care expenditure. When data are analyzed for individuals, however, income is not related to primary health utilization. METHODOLOGICAL INCONSISTENCIES: The situation is controversial, with methodological implications and, above all, consequences for the assessment of the efficiency in primary care utilization. Review of the literature reveals certain methodological inconsistencies that could at least partly explain the disparity of the empirical results. Among others, the following flaws can be highlighted: design problems, measurement errors, misspecification, and misleading statistical methods.Some solutions, among others, are quasi-experiments, the use of large administrative databases and of primary data sources (design problems); differentiation between types of utilization and between units of analysis other than consultations, and correction of measurement errors in the explanatory variables (measurement errors); consideration of relevant explanatory variables (misspecification); and the use of multilevel models (statistical methods).