Can health equity survive epidemiology? Standards of proof and social determinants of health

Objective

This article examines how epidemiological evidence is and should be used in the context of increasing concern for health equity and for social determinants of health.

Method

A research literature on use of scientific evidence of “environmental risks” is outlined, and key issues compared with those that arise with respect to social determinants of health.

Results

The issue sets are very similar. Both involve the choice of a standard of proof, and the corollary need to make value judgments about how to address uncertainty in the context of “the inevitability of being wrong,” at least some of the time, and to consider evidence from multiple kinds of research design. The nature of such value judgments and the need for methodological pluralism are incompletely understood.

Conclusion

Responsible policy analysis and interpretation of scientific evidence require explicit consideration of the ethical issues involved in choosing a standard of proof. Because of the stakes involved, such choices often become contested political terrain. Comparative research on how those choices are made will be valuable.     

Nutrition—an essential component of health and health care.

Nutrition and medicine interface in a variety of ways and combine to serve as a dynamic force in health as well as in disease. A conceptual understanding of this interrelationship is critical to the continued and effective development of clinical nutrition in medical education. The physician may play an important role in critical-care medicine, long-term health care, research, education, and preventive medicine. While there is great potential for the physician to impact on nutrition status in both health and disease, there is clear evidence that greater emphasis needs to be placed on providing adequate nutrition training for every physician.     

Consumers’ misunderstanding of health insurance

We report results from two surveys of representative samples of Americans with private health insurance. The first examines how well Americans understand, and believe they understand, traditional health insurance coverage. The second examines whether those insured under a simplified all-copay insurance plan will be more likely to engage in cost-reducing behaviors relative to those insured under a traditional plan with deductibles and coinsurance, and measures consumer preferences between the two plans. The surveys provide strong evidence that consumers do not understand traditional plans and would better understand a simplified plan, but weaker evidence that a simplified plan would have strong appeal to consumers or change their healthcare choices.     

Which health information systems for the evaluation of health actions?

The evaluation of health actions requires large amounts of information allowing an assessment of relevance, coherence, efficacy, efficiency and impact of these interventions. Information systems should support evaluation processes by helping to obtain pertinent indicators, tracers and standard operating procedures. To reach this objective, specific functions need to be implemented, including traceability, documentation, investigation and scientific awareness. But this supposes that health information systems respect quality criteria that this article defines. The following criteria are considered: simplicity, validity, acceptability, informative value, representativeness, continuity, reactivity, fluidity, flexibility of the system, and also confidentiality of information. The historical developments of medical informatics have induced the creation of independent information systems, answering to specific objectives. This lack of integration is an obstacle to the evaluation of health actions because of the difficulty to view transversally and longitudinally the sequence of actions for a same patient. Thus integrated health information systems, organised around patient care episodes, are necessary to support evaluation and to contribute effectively to decision making in public health, because the evaluation of health actions implies the availability of information about the individuals who are the targets of these actions.     

Do risk factors and health behaviours contribute to self-ratings of health?

This study examined the relative importance of five risk factors and health behaviours (namely dietary habits, leisure time exercise, smoking, alcohol consumption and body mass index) on self-ratings of health among the Swedish adult population. The data come from the 1991 Swedish Level of Living Survey, a face-to-face survey interview based on a sample representative of the Swedish population aged between 18 and 75 years (n = 5306). The analyses were carried out using logistic regression analysis. With the exception of the consumption of dietary fat, all the risk factors and health behaviours studied were associated with self-rated health. When they were adjusted for health problems and functional limitations most of the associations weakened or disappeared altogether, but smoking and use of vegetables in the diet were still associated with self-rated health. Self-ratings of young adults (18-34 years) were found to be related to body mass index even when health problems were adjusted for, with both obesity and underweight contributing to less than good self-rated health. The results indicate that risk factors and health behaviours do not, in general, directly contribute to self-ratings of health. Instead, their effect is mediated by more specific health problems and their functional consequences. However, smoking and not consuming vegetables, as well as obesity and underweight among young respondents, were found to have an independent association with self-rated health. This may reflect the effects of health problems not captured by our indicators of ill health, but may also indicate that risk factors and risky behaviours are considered to have an effect on one's perceived health even in the absence of health consequences.     

Does decentralization influence efficiency of health units? A study of opinion and perception of health workers in Odisha

Background

Health systems in low and middle income countries are struggling to improve efficiency in the functioning of health units of which workforce is one of the most critical building blocks. In India, Rogi Kalyan Samiti (RKS) was established at every health unit as institutions of local decision making in order to improve productive efficiency and quality. Measuring efficiency of health units is a complex task. This study aimed at assessing the perception (opinion and satisfaction) of health workers about influence of RKS on improving efficiency of peripheral decision making health units (DMHU); examining differences between priority and non-priority set-ups; identifying predictors of satisfaction at work; and discussing suggestions to improve performance.

Methods

Following a cross-sectional, comparative study design, 130 health workers from 30 institutions were selected through a multi-stage stratified random sampling. A semi-structured questionnaire was administered to assess perception and opinion of health workers about influence of RKS on efficiency of decision making at local level, motivation and performance of staff, and availability of funds; improvement of quality of services, and coordination among co-workers; and participation of community in local decision making. Three districts with highest infant mortality rate (IMR), one each, from 3 zones of Odisha and 3 with lowest IMR were selected on the basis of IMR estimates of 2011. The former constituted priority districts (PD) and the latter, non-priority districts (NPD). Composite scores were developed and compared between PD and NPD. Adjusted linear regression was conducted to identify predictors of satisfaction at work.

Results

A majority of respondents felt that RKS was efficient in decision making that resulted in improvement of all critical parameters of health service delivery, including quality; this was significantly higher in PD. Further, higher proportion of respondents from PD was highly satisfied with the current set of provisions and manners of functioning of the sample health units. Active community engagement, participation of elected representatives, selection of a pro-active Chairman, and training to RKS members were suggested as the immediate priority action points for the state government. Mean scores differed significantly between PD and NPD with regard to: influence of RKS on individual-centric, organizational-centric and patient-centric performance, and the responsibilities to be entrusted with RKS. Absenteeism was strongly associated with satisfaction and local self-governance. Work-related factors, systemic factors, local accountability and patients’ involvement were found to be the key predictors of satisfaction of health workforce.

Conclusion

The understanding on quality improvement strategies was found to be very poor among the health workers. Tailor-made capacity building measures at district and sub-district levels could be critical to equip the peripheral health units to achieve the universal health coverage goals. Work environment, systemic factors and accountability need to be addressed on priority for retention of health workforce. The hypothesized link between efficient local decision making, perception of health workers about efficiency of health units and the health status of population needs further investigation.

     

"Remnants of feudalism"? Women's health and their utilization of health services in rural China

Almost five decades ago, the Chinese Communist Party wished to abolish all "remnants of feudalism," including the patriarchal social order. Just one year after the revolution, the Marriage Law endorsed women's rights within the family, but no operative measures were taken to enforce it. Some of the economic reforms since independence even strengthened patrilocality and, possibly, patriarchal values. The purpose of this study was to explore the degree to which patrilocality served to maintain the traditional patriarchal stratification among women in the household by exploring women's health patterns and utilization of health services. Data were collected from 3859 women residing in rural Hebei, and variation in health and help seeking of six categories of relation to household head--mothers, wives, daughters, daughters-in-law, family heads, and other relatives--were explored. Utilization of health services is not dependent on women's position in the household, but primarily on per-capita income. Health patterns seem to indicate that mothers of the head of the household still have a considerable power to define their roles and share of household work. Women head of family, most of whom are married, appear to be under strain, which could be a result of their culturally "deviant" position. We conclude that old patriarchal values are intertwined with values of equality in current rural China.     

Do medical house officers value the health of veterans differently from the health of non-veterans?

Background

Little information is available regarding medical residents' perceptions of patients' health-related quality of life. Patients cared for by residents have been shown to receive differing patterns of care at Veterans Affairs facilities than at community or university settings. We therefore examined: 1) how resident physicians value the health of patients; 2) whether values differ if the patient is described as a veteran; and 3) whether residency-associated variables impact values.

Methods

All medicine residents in a teaching hospital were asked to watch a digital video of an actor depicting a 72-year-old patient with mild-moderate congestive heart failure. Residents were randomized to 2 groups: in one group, the patient was described as a veteran of the Korean War, and in the other, he was referred to only as a male. The respondents assessed the patient's health state using 4 measures: rating scale (RS), time tradeoff (TTO), standard gamble (SG), and willingness to pay (WTP). We also ascertained residents' demographics, risk attitudes, residency program type, post-graduate year level, current rotation, experience in a Veterans Affairs hospital, and how many days it had been since they were last on call. We performed univariate and multivariable analyses using the RS, TTO, SG and WTP as dependent variables.

Results

Eighty-one residents (89.0% of eligible) participated, with 36 (44.4%) viewing the video of the veteran and 45 (55.6%) viewing the video of the non-veteran. Their mean (SD) age was 28.7 (3.1) years; 51.3% were female; and 67.5% were white. There were no differences in residents' characteristics or in RS, TTO, SG and WTP scores between the veteran and non-veteran groups. The mean RS score was 0.60 (0.14); the mean TTO score was 0.80 (0.20); the mean SG score was 0.91 (0.10); and the median (25th, 75th percentile) WTP was $10,000 ($7600, $20,000) per year. In multivariable analyses, being a resident in the categorical program was associated with assigning higher RS scores, but no residency-associated variables were associated with the TTO, SG or WTP scores.

Conclusion

Physicians in training appear not to be biased either in favor of or against military veterans when judging the value of a patient's health.

     

Can a health unit take action on the determinants of health?

There is growing interest in improving population health by multi-sectorial partnerships that address the determinants of health. The Leeds, Grenville and Lanark District Health Unit worked with some 80 other community agencies to form the Lanark, Leeds and Grenville Health Forum in the spring of 2000. The goals of this Health Forum were to evaluate the determinants of health of the population over a five-year period, identify activities within an overall Health Improvement Plan to address these determinants, pursue ongoing resources for interventions, assess their impact on health, and modify plans and activities accordingly. The Health Forum identified that their region had increased mortality rates from cardiovascular disease and cancers compared with the rest of Ontario. The local district health unit offered three possible determinants to explain this: socio-economic determinants (residents below provincial average for income and education), behavioural determinants (residents had higher rates of smoking, sedentary activity and high fat diets) and lack of access to health care. The Health Forum developed a Health Improvement Plan to work on each of these determinants. Throughout its lifetime, the Health Forum proved to be both active and productive, leading to many cooperative ventures. This paper provides a brief overview of the approach taken with its Health Improvement Plan, as well as the successes and limitations of this approach. The experience of the Leeds, Grenville and Lanark Health Forum offers a practical model for public health units to work with partner agencies to address the determinants of health, as well as some insights into the requirements to sustain such a model.     

Corporate colonization of health activism? Irish health advocacy organizations' modes of engagement with pharmaceutical corporations.

This article is based on a study that aimed to shed light on the "cultures of action" of Irish health advocacy organizations, and particularly their modes of engagement with pharmaceutical corporations. Debates about what some interpret as the "corporate colonization" of health activism provide the backdrop for the analysis. The empirical dimension of the study involved a survey of 112 organizations and in-depth study of a small number of organizations that manifest diverse modes of engagement with the pharmaceutical industry. The varying modes of interaction are plotted along a continuum and characterized as corporatist, cautious cooperation, and confrontational. Evidence is presented of a strong and growing cultural tendency in Irish health advocacy organizations to frame pharmaceutical corporations as allies in their quests for better health. The analysis of four constitutive dimensions of organizations' cultures of action can reveal the legitimating logics underlying their diverging positions around pharmaceutical industry sponsorship. While the research shows that pharmaceutical corporations have largely succeeded in defining themselves as a philanthropic force and rightful players in Irish health activism, it cautions against a simplistic conclusion that this is evidence of corporate colonization.     

The national health service plan: further reform of British health care?

Less than three years after initiating a series of health service reforms, the Blair government has launched another plan for the U.K. National Health Service. This article considers the origins and contents of the plan. A major investment program is designed to bring health care spending up to European averages over the next five years. In return, the government seeks to challenge the existing settlement between organized medicine and the state through tighter regulatory control, altered contractual frameworks, and a new public-private concordat. The plan does not represent a radical change in government policy but rather reaffirms existing approaches to increasing access to health services, integrating health and social care, and empowering users. Notwithstanding arrangements to increase the autonomy of health service organizations, the plan increases central control through a range of new bodies and regulatory frameworks. It represents an incremental adjustment of the existing tax-funded system. Should this reinvigoration of the state monopoly fail, alternative sources of funding will no doubt have to be reconsidered.     

Perception of health among the Guarany Mbyá ethnic group and health care

The article results from a qualitative research on the perception of health of the Guarany Mbyá ethnic group held in 3 villages in the South of Brazil. The cultural characteristics of the group were surveyed in the literature, observed in fieldwork and confirmed in the 20 open interviews conducted with community members and health professionals from the National Health Foundation (FUNASA), responsible for the basic assistance to the villages. The results show that the Mbyá consider the cultural shock with the surrounding society the main factor of illness, emphasizing the importance of preserving and enhancing their traditional way of living for maintaining the health of individuals and communities. The data allow to associate their health representations to the land and social justice problems experienced by the groups. They point to the importance of improving the training of the technical health staff, specifically related to the understanding of the inter-ethnic differences between the Mbyá and Western culture to ensure the effectiveness of treatments and programs. The analyses also highlights positive and negative aspects of the operationalization of health care in the villages and in the final considerations are given suggestions aiming its improvement.