Long-term contracts in the NHS: a solution in search of a problem?

Purchasers and providers in the National Health Service (NHS) are now required to move from annual contracting cycles to longer-term contracts. The benefits are expected to include more efficient investment and improved sharing of financial risk. This paper argues that the economic analysis of longer-term contracts has assumed implicitly that agents operate in the private sector. Once the constraints of the public sector are introduced, the apparent economic benefits of longer-term contracts become doubtful. The paper explores these issues using evidence collected from analysis of the contracts of a sample of Health Authorities and from semi-structured interviews with individuals involved in the contracting process. We conclude that with the property rights and financial structure of the public sector, the move from short- to long-term contracts is unlikely to produce the improvements in performance expected by the government.     

“Sleeping in a boundary” constructing the meaning of health in a refugee camp

Sociopolitical discourses surrounding refugee migration and resettlement are characterized by divisiveness, assumptions, and fear. When these discussions are grounded in the narratives of women refugees a deeper understanding of issues impacting health, family, and resilience emerges. We examine how 26 Karen women living in camps along the Thai-Burma border construct meaning around health, in relation to livelihoods. Through directed content analysis, themes emerged: precursors to achieving health, health and livelihoods, and position and agency. Women identified barriers and facilitators to health, identified a dynamic relationship between health and livelihoods, and described their position and agency in the systems they navigate.     

Illustrating a “consequential” shift in the study of health inequalities: a decomposition of racial differences in the distribution of body mass

Purpose

We present a conceptual introduction to “distributional inequalities”—differences in distributions of risk factors or other outcomes between social groups—as a consequential shift for research on health inequalities. We also review a companion analytical methodology, “distributional decomposition”, which can assess the population characteristics that explain distributional inequalities.

Evaluation of effectivenness of prenatal assistance in a Family Health Unit in a city of the São Paulo State

Considering the importance of prenatal care quality to reduce maternal and perinatal morbidity and mortality, the aim of this study was to evaluate quality in the assistance to low-risk pregnant women by means of quality indicators stated by the Health Ministry. This is an evaluating, quantitative and retrospective study carried out in a Prenatal Service in a Family Health Unit in a city in the state of S?o Paulo. The results showed that the Family Health Program provides a quality prenatal assistance and that the link established between the Unit professionals and the Health Community Agents with pregnant women is imperative for the adherence to the Prenatal Assistance Program.     

Assessment of the health status of a population living in the catchment area of the Kuĭbyshev water reservoir

An analysis of trends in primary morbidity in the regions belonging to the catchment area of the Kuibyshev water reservoir within the Republic of Tatarstan has shown its rise in the examined classes of diseases. There is the highest increase in morbidity in the areas located in the river basins of Kama, Sviyaga, Kazanka, Mesha, which are the main tributaries of the Kuibyshev water reservoir in the Republic of Tatarstan. The cumulative hazard index in the assessment of a noncancer risk to the health of the population consuming the portable water and fish from the Kuibyshev reservoir is 0.34, which suggests that there is no serious hazard to human health. With oral intake of lead and cadmium, the cancer risk corresponds to the maximum acceptable value.     

Psychometric properties of the Korean version of the effort–reward imbalance questionnaire: a study in a petrochemical company

Objective To evaluate the criterion validity, factorial validity, and internal consistency of Korean version of effort–reward imbalance (ERI) for the scales of effort, reward, and overcommitment as well as to examine the effect of psychosocial factors on physical and mental illness among petroleum refinery workers in South Korea. Methods The Korean version of ERI questionnaire was constructed using the translation and back-translation technique, and its psychometric properties were explored among 908 male workers in a large petroleum refinery in South Korea in 2002. Cronbach’s alpha coefficient was used to test internal consistency. An exploratory factor analysis was conducted on all items of the instrument. Confirmatory factor analyses were conducted on each dimension of effort, reward and overcommitment. Physical and mental health was measured by self-rated health (SF-8). The lowest tertiles of the scores were defined as illness. Multiple logistic regression models were used to test the effect of job stress on the physical and mental health (criterion validity of ERI scales). Results The Cronbach’s alpha coefficients for effort, reward, and overcommitment were 0.71, 0.86, and 0.75, respectively, indicating satisfactory internal consistency. Exploratory factor analysis found three latent factors, which closely corresponded to the theoretical structure of the ERI model. Acceptable construct validity was shown using confirmatory factor analysis. The highest tertile of effort–reward ratio was significantly associated with physical illness (OR 2.4, 95% CI 1.7–3.6) and mental illness (OR 2.9, 95% CI 2.0–4.2), compared to lower tertiles. Overcommitment was significantly associated with mental illness, but not with physical illness. Conclusions These findings contribute to the validity and reliability of the Korean ERI questionnaire. Importantly, in the context of a rapid change in the labour market, the lack of reciprocity between efforts and rewards at work is strongly associated with self-rated physical and mental health.     

Failure in the control of the number of traffic accident victims in Spain. Is this a result of the correct answer to the wrong question?

Although various measures have been implemented in Spain with the aim to modifying the behavior of motor vehicle users, it has not been observed a descending trend in traffic accident and injuries from traffic accident. This article considers the question of whether the measures taken to reduce motor vehicle crash-related injuries in Spain have targeted the causes that are truly responsible for this trend. Using several sources of data, beginning in 1990 it has been observed a significant reduction in traffic accidents and their consequences, but in the second half of the 90s the growth in motor vehicle crash-related injuries was similar to the increase observed in the 80s. Likewise per capita alcohol consumption shows a downward trend from 1980 while the number of injuries has been strong associated with the economic cycle during the last twenty years. We conclude pointing out that intervention measures to control this problem in Spain have focused mainly on modifying behaviour that increases the risk and severity of traffic accident injuries and have ignored the macro-economic determinants that explain the trend in the frequency of this health problem.     

Survival of the Fittest in a Parasuicidal Group — A Twenty-Year Follow-Up of Suicide in Sweden

Objectives: A longitudinal prospective twenty-year follow-up of the survival of patients who had been brought to the Department of Internal Medicine at the Serafimer Hospital in Stockholm, Sweden because of attempted suicide (parasuicidal poisonings) compared with matched general population controls.

Methods: There were 538 parasuicidal patients (probands), 201 males and 337 females, who were followed from 1972 to 1992. The age range was 16-75 years. The matched general population controls recruited at the same time as the suicide attempts of the probands were stratified with regard to age and a sample was drawn up of men and women, 500 of each, with 70-72 persons in each of the age groups 16-19, 20-29 etc. to 70-79 years. Data were analysed by the Chi-square test and relative risk in the statistical analyses and means were compared by t-tests.

Results: The death rate was significantly higher for the male probands (56%) and the female probands (40%); 46% of the men and 40% of the women died as early as at the ages of 16-49 years. The mortality for the general population controls from this region of Greater Stockholm during the 20-year follow-up period was only 18% for the men and 13% for the women.

Conclusions: The part of the proband sample that survived suicidal attempts came significantly less often from broken homes or had parents with alcohol or drug abuse, nervous problems and successful or attempted suicide. They had fewer problems during childhood and no problems at school. This is a group that is better equipped to survive than those who came from homes which predisposed them to succeed in their suicidal attempts. Parasuicidal poisonings should be followed up because these individuals run the highest risk of repeated suicide attempts. We found that the best help for parasuicidal patients and the most effective way to prevent new suicidal attempts was to have the patients' GPs give supporting therapy for several     

Predictors related to the occurrence of a measles epidemic in the city of S?o Paulo in 1997.

A matched case-control study was performed to identify risk factors for measles during an epidemic that occurred in 1997 in the city of S?o Paulo, in the Brazilian state of the same name. Measles cases from the city of S?o Paulo from 1 January 1997 to 15 August 1997 were included in the study. The criteria for case definition were age below 30 years, having received no measles vaccine 5-21 days before the onset of rash, and laboratory confirmation by IgM antibodies detection. From a bank of confirmed measles cases, 130 cases for each of five age ranges (under 1 year, 1-5 years, 6-20 years, 21-24 years, and 25-29 years) were picked at random according to a systematic criterion proportional to the number of cases in seven areas of the city. Data were collected through a home survey, and for each measles case studied two controls matched by age and place of residence were selected. The matched conditional logistic regression analysis for the potential risk factors from the univariate analysis showed that the best predictors for acquiring measles during the epidemic were: lack of measles vaccination, previous contact with a measles-like disease at home or on the job, having been born either outside the state of S?o Paulo or in a rural area, being employed, and spending time in a semiclosed institution, such as a nursery, day care center, or school. The risk factors were not homogeneous for the different age groups. The data in the present survey suggest that, in addition to lack of vaccination, other risk factors should be considered when planning a measles vaccination strategy for a developing country.     

Humanization of care from the perspective of the family health strategy teams in a city in the interior of São Paulo, Brazil

This study analyzes the understanding of professionals composing teams of the Family Health Strategy concerning humanization of care. This qualitative survey was carried out in a city in the interior of S?o Paulo through interviews with 20 professionals. The data analysis method used was Interpretation of Meanings based on the hermeneutic-dialectic perspective. The meaning of humanization according to the interviewed professionals includes an enlarged view, respect for ethical principles and facilitated access. The difficulties refer to the lack of prepared professionals, excessive demand and deficiencies in service organization. The professionals propose to educate and qualify professionals, make activities adequate given the professionals' roles and improve the organization of services. The professionals demonstrate understanding of the meaning of humanization and acknowledge the need to cope with difficulties.     

Is there a place for sexuality in the holistic care of patients in the palliative care phase of life?

Being diagnosed with a life-limiting condition is a traumatic event. The journey to the moment of death is usually only done once--so it is a time of fears and uncertainty. Sexuality is particularly vulnerable at this time. It may be difficult for both patient and partner to deal with the changes in sexuality without professional assistance. It is "sexuality" rather than "sex" that defines the meaningful relationships people have with themselves and significant others. When sexuality is lost or changed, important benefits may be lost. Studies show that many patients do value sexuality and want assistance in making the best of their sexual potential during the palliative care phase. Health professionals regularly acknowledge the importance of sexuality for their patients but have difficulties acting on their beliefs. Sexuality, within the patient's functional ability and desire for it, must be acknowledged and included in holistic management. It is the health professional's responsibility to raise this issue.     

What's in a care pathway? Towards a cultural cartography of the new NHS

Maps are increasingly understood as socio-cultural and political constructs, rather than mirrors of nature. Drawing on the insights of cultural cartographers, this paper presents a critical analysis of a specific instance of map-making in health policy, namely the growing use of care pathways in care planning and service delivery. Widely regarded to date as devices for ensuring quality of care, equity of treatment, optimal resource allocation and a rational division of labour between healthcare professionals, they have been seen as helpful--and technically neutral--tools for routing patients through the system. By contrast, we argue that the metaphors are misleading: lived experience and its objectification in pathway maps continually re-create one another, as we explore the slippage between map, map-making and mapping. This paper is based on interviews and observations with a variety of healthcare workers in three areas of south eastern England. We trace the development of a series of pathways-in-process, and show how they configure the patient, highlighting some aspects of their experiences, whilst silencing others. We also analyse the role of pathways in the carving up and surveillance of space round the emergence of the 'hybrid professional', particularly new practitioners such as GP specialists, specialist nurses, extended scope therapists and others. In considering the wider implications of care pathways as part of the contemporary discourse on policy, the paper critiques the rationalist, and sometimes evangelical assumptions underpinning their current popularity. In particular, we suggest that a critical and processual understanding of pathways might contribute to a more informed appreciation of their potential (and their limitations) as mechanisms for healthcare policy implementation.     

Did a severe flood in the Midwest cause an increase in the incidence of gastrointestinal symptoms?

Severe flooding occurred in the midwestern United States in 2001. Since November 2000, coincidentally, data on gastrointestinal symptoms had been collected for a drinking water intervention study in a community along the Mississippi River that was affected by the flood. After the flood had subsided, the authors asked these subjects (n = 1,110) about their contact with floodwater. The objectives of this investigation were to determine whether rates of gastrointestinal illness were elevated during the flood and whether contact with floodwater was associated with increased risk of gastrointestinal illness. An increase in the incidence of gastrointestinal symptoms during the flood was observed (incidence rate ratio = 1.29, 95% confidence interval: 1.06, 1.58), and this effect was pronounced among persons with potential sensitivity to infectious gastrointestinal illness. Tap water consumption was not related to gastrointestinal symptoms before, during, or after the flood. An association between gastrointestinal symptoms and contact with floodwater was also observed, and this effect was pronounced in children. This appears to be the first report of an increase in endemic gastrointestinal symptoms in a longitudinal cohort prospectively observed during a flood. These findings suggest that severe climatic events can result in an increase in the endemic incidence of gastrointestinal symptoms in the United States.