Health behaviours and socio-economic status in Ontario, Canada

Data from the 1990 Ontario Health Survey were used to investigate the association of socio-economic status with the likelihood of meeting current recommendations for four health behaviours (smoking, fat intake, alcohol consumption, and physical activity level) in adults living in Ontario (Canada). Health behaviours were categorised as unhealthy if they did not meet current recommendations in Ontario (smoking, fat intake < 30% of dietary energy, alcohol intake < 14 units per week, low level of leisure-time physical activity). Two summary variables based on the number ofÔ unhealthyÕ behaviours were also examined: the crude number of unhealthy behaviours reported and the likelihood of reporting 3 or 4 unhealthy behaviours. Four measures of socio-economic status were used: educational achievement, household income status, source of household income, and occupational prestige. Multiple logistic and linear regression analyses were performed to explore the association of each unhealthy behaviour and of the summary variables with socio-economic status indicators (taken independently or simultaneously), controlling for demographic characteristics. Except for the positive relationship between income status and high alcohol intake, measures of unhealthy behaviours were inversely associated with the socio-economic indices, suggesting that individuals in lower socio-economic groups are at an increased risk for health problems.     

Health Care Law

Conclusion One probable success (the case of Mrs Tonge) is not a great deal to set against the courts' overwhelming reluctance to play a part in challenging resource allocation decisions. Nevertheless, where such decisions are inherently unreasonable—for example, as Margaret Brazier has suggested,¹¹ a refusal to treat patients because they are divorced, or because they are Labour Party members—a remedy would be available through the courts. Presumably gender biased rationing decisions would similarly be susceptible to judicial review, although there might be evidential difficulties. Age-related denial of treatment would probably not in itself be considered to be Wednesbury unreasonable. If it could be shown that within the one health authority a particular patient or a group at a set age were denied treatment others at the same age received, there might be scope for an application to the courts. Evidence sufficient to satisfy judges notoriously unwilling to overturn doctors' decisions¹¹ would be hard to collect.While courts cannot be expected to determine health care policy, their refusal to examine in any detail the decision-making processes of Health Service authorities has ratified the opacity of current decision-making.¹² Instead of forcing authorities to take decisions in a reasoned and justified manner, the courts by their very conservative application of the Wednesbury decision have allowed them to hide from public scrutiny.     

Moral strangers and the health care market

In order to reflect on the morality of the health care market this paper critiques some of H. T. Engelhardt's presuppositions. Engelhardt has created the vivid term moral stranger and suggested that there can be a morality of moral strangers. However his position relies either on certain necessary presuppositions which he leaves unmentioned or on presuppositions that are—in a strict sense—not moral ones. Engelhardt advocates the market economy as the guiding principle of health care, and claims that the market needs no moral presuppositions. But when the preconditions of a functioning market are examined it turns out that a functioning market requires property and ownership, and that property and ownership are moral institutions. Therefore the application of the idea of the market to health care undoubtedly has morally serious consequences: most important, the difference between commodities and human beings is obscured.     

Measurement of quality of life in women with breast cancer. Development of a Life Satisfaction Questionnaire (LSQ-32) and a comparison with the EORTC QLQ-C30

The purpose was to develop and validate a new instrument suitable for measuring perceived quality of life in women with breast cancer. The instrument is to be used within conventional cancer therapy as well as in complementary care, and is called the LSQ-32 (Life Satisfaction Questionnaire). The subjects were 362 women with breast cancer in all cancer stages. Cronbach's reliability coefficient of the LSQ was 0.89. The construct validity was estimated by a principal component analysis. Six orthogonal factors were identified: (1) Quality of family relation, (2) Physical symptoms, (3) Socioeconomic situation, (4) Quality of daily activities, (5) Sickness impact and (6) Quality of close friend relation. The criterion-related validity was estimated by comparing the LSQ-32 and the EORTC QLQ-C30. The scales/items of the EORTC QLQ-C30 were represented in the LSQ-32, but the factors Quality of family relation and Quality of close friend relation were not found in the EORTC QLQ-C30. It was concluded that the LSQ-32 as well as the EORTC QLQ-C30 are valuable tools in the measurement of quality of life in women with breast cancer. The LSQ-32, however, also contains an existential factor.The study was approved on 1992 04 08 by the Research Ethical Committee, Faculty of Health Sciences, University of Linköping.     

Oral presentations

The relationship between health care expenditure and health outcomes is of interest to policy makers in the light of steady increases in health care spending for most industrialised countries. However, establishing causal relationships is complex because, firstly, health care expenditure is only one of many quantitative and qualitative factors that contribute to health outcomes, and, secondly, measurement of health status is an imperfect process. This study reviews key findings and methodological approaches in this field and reports the results of our own empirical study of countries of the European Union. Our analysis examines life expectancy and infant mortality as the output of the health care system, and various life-style, environmental and occupational factors as inputs. Econometric analyses using a fixed effects model are conducted on a panel data set for the former 15 members of the European Union over the period 1980–1995. The findings show that increases in health care expenditure are significantly associated with large improvements in infant mortality but only marginally in relation to life expectancy. The findings are generally consistent with those of several previous studies. Caveats and improvements for future research are presented.     

Going off the dole: A prudential and ethical critique of the healthfare state

The present healthfare state in the United States in neither practically nor morally justified. The nation currently fails to provide adequate access to health care for tens of millions of uninsured citizens. To suggest that the United States' half-million physicians should provide their care as charity is an inadequate solution. The transfer of assets from the haves to the have-nots through taxation in a healthfare state undermines human compassion, and fails to respect minimal moral requirements. However, alternative strategies are possible. During the next 20 years health care could come to be financed on the basis of sound quasi-libertarian moral and prudential principles. In the interim deliberate political action is required to achieve novel health policy, available and affordable job and career training, and universal employment. It is possible to achieve universal access to adequate health care while sustaining individual choice, and at the same time to reduce or virtually eliminate taxpayersubsidised health care. This approach would, in time, eliminate the healthfare state and eventually encourage and even require citizens to go off the healthfare dole.     

Mercury accumulation in largemouth bass (Micropterus salmoides) in a Florida Lake

Rates of mercury accumulation were examined in male and female largemouth bass (Micropterus salmoides) from Lake Tohopekaliga, Florida, to establish methods for fish consumption advisories for the protection of human health. In addition, concentrations were determined in five lower trophic level fish species. Total mercury concentrations in adult largemouth bass muscle tissue ranged from 0.16 to 1.10 g/g (fresh weight) and increased as fish increased in size and age. Wholebody mercury concentrations of 1990 year-class largemouth bass increased from 0.05 g/g at 20 mm and to 0.32 g/g at 320 mm (age 2). Significant differences were found in the rates of accumulation between sexes for length and weight, but not for age. Therefore, standardized mercury concentrations were determined using bass age to make comparisons among sampling dates. Although there were significant differences in adjusted mean mercury concentrations among two sampling dates, mercury content of standard-age bass remained relatively constant over time. Largemouth bass exceed the Florida Health Advisory level for limited consumption of fish (0.50 g Hg/g) based on a mean concentration of 0.59 g/g for 64 bass. Advisories based on fish morphological characteristics (i.e., length, weight) or age are not possible for Lake Tohopekaliga due to differences in mercury accumulation in male and female bass. Lower trophic level species of sport fish did not exceed the limited consumption level.     

DDT Residues in samples of human milk,and in mothers' and cord blood serum,in a continental town in Croatia (Yugoslavia)*

Summary Concentrations of p,p'-DDE, p,p-DDD, and p,p-DDT were determined in 34 samples of human milk obtained 3–5 days after delivery and in 37 samples obtained at later times of lactation (up to 55 weeks). All samples contained p,p-DDE, but only several contained p,p-DDD and p,p-DDT. The concentrations of p,p-DDE were 31 g/l in the beginning of lactation and 53 g/l at later time intervals. The concentration ranges in both groups overlap almost completely and the difference in the mean values is not significant.Serum samples from 35 mothers and cord blood were also analyzed. All samples contained p,p-DDE, the concentrations being 18 g/l and 6.8 g/l in the mothers' and cord blood serum, respectively. Serum samples of 24 nonpregnant women contained the same amount of p,p-DDE (20 pg/1) as mothers' sera.All samples were collected in a continental town of Croatia (Yugoslavia) between 1977 and 1979. The concentrations of DDT residues were determined by gas chromatography, and two methods for extraction from milk were used and compared.This work was supported in part by the Environmental Protection Agency (USA) and the World Health Organization (Geneva)     

Processes of persuasion: Social interests and total quality in a UK hospital trust

This paper examines some of the processes which have contributed to the development of a total quality (TQ) approach within British health care. The paper challenges the idea that TQ is part of a redistribution of power within the NHS. Rather it is argued that through the elaboration of consumer-led market identities TQ misrepresents the interests of management and constructs a version of the self which obscures new forms of management control. TQ constrains alternative forms of social organisation, local knowledge and the social interests invested in them. An example of a competing set of assumptions is discussed. It is suggested that clinical groups — who are primarily motivated by the principles of professional, collegiate control — seek to free themselves from the constraints of TQ. Thus clinical discourse appropriates a professionally led version of the market and protects the traditional autonomy of professionals whilst seeming to render their interests synergistic with those of management. This casts quality, and perhaps even the market, as conceptual sites upon which different groups strive to construct and legitimate their own interests. It is concluded that the changes explicitly associated with TQ are not as fundamental as they seem.     

The development of a new site-specific measure of quality of life for breast problems: The Cardiff breast scales

The management of women presenting to primary care with symptoms of breast disease is of increasing interest given recent organisational changes aimed at improving accuracy and speed of referrals. As part of a randomised controlled trial, 1063 women were recruited following a primary care consultation for a variety of breast-related problems. In the absence of a suitable outcome measure for such women, a site-specific instrument was developed to complement a generic quality of life scale (SF-36). Items were generated using key informant interviews with health professionals. Draft scale items were piloted using a postal questionnaire and subsequent patient debrief interviews. A sample of respondents were also sent the same questionnaire 1month later to assess test–retest reliability. Across the whole sample (n = 848), three factors were identified: general well-being, concerns and relationships. These factors accounted for 60% of total variance. Evidence of scale validity, reliability and responsiveness are reported for this new outcome measure for use in women presenting with breast problems.     

Measuring change over time: a comparison of results from a global single item of health status and the multi-dimensional SF-36 health status survey questionnaire in patients presenting with menorrhagia

This paper compares the sensitivity to change of a multi-item, multi-dimensional health status measure with a single global health status question, in the assessment of treatment for menorrhagia. A cohort study of patients recruited by general practitioners, was carried out, with a follow up at eighteen months. Questionnaires were administered postally at baseline and follow up. General practices in Berkshire, Buckinghamshire, Northamptonshire and Oxford-shire supplied three hundred and nine women who reported heavy menstrual bleeding, and received either drug treatment alone or both drug and surgical treatment (endometrial resection or hysterectomy) during the eighteen months between the two admini-strations of the questionnaires. A single global question was given to patients asking them to rate their overall health status as excellent, very good, good, fair or poor. The eight dimensions of the SF-36 health survey questionnaire were also given to patients to complete. The dimensions of the SF-36 indicated only small levels of improvement for patients who received drug treatment. However, on many dimensions of the SF-36, a moderate to large improvement was detected for the surgical group. However, small changes were reported in overall health status, as indicated by the single global question, for both groups. Single item measures of health status may not provide a sufficiently accurate indication of health status to be appropriate for use in longitudinal studies.     

Well-being: A philosophical basis for health services

This paper develops and defends the claim that the promotion of human well-being is a philosophical basis or rationale for health services. It first sketches a case for this thesis, then defends it against various objections arising from the contrary position, here dubbed The Sceptical View. Later sections of the paper elaborate on the meaning of well-being, the nature of well-being, and the scope of appropriate health service concern with well-being. In particular, distinctions are made between thick and thin well-being, and between well-being and its various measures. These discussions generate further defences of the philosophical centrality of human well-being to health services.     

Towards a Theory of the Everyday: The Ordinary and the Special in Daily Living in Residential Care

This paper begins with a debate about the relative place of ordinary and special approaches to everyday living with young people in residential care and treatment. It argues for a considered approach to this distinction between the ordinary and the special, based on assessments of children's needs and stages of development, and on the purpose of their residential placement. From this beginning it enters into a broader proposal about the need for a comprehensive theory of the everyday in residential work. The argument focuses on the need for an underpinning framework for the planning and analysis of daily group care practice with young people. Finally, it explores how different assumptions and theoretical frameworks may operate in support of a programme for everyday practice which is differentiated according to the needs of the children and the task of the organisation.     

Translation,cultural adaptation,and initial reliability and multitrait testing of the Kidney Disease Quality of Life instrument for use in Japan

Background: The Kidney Disease Quality of Life instrument (KDQOL) consists of 79 items: 36 asking about health-related quality of life (HRQOL) in general (the Medical Outcomes Study SF-36) and 43 asking about QOL as it is affected by kidney disease and by dialysis. Aim: Translation, cultural adaptation and initial reliability and multitrait testing of the KDQOL for use in Japan. Methods: Translation and cultural adaptation began with two translations into Japanese, two backtranslations into English, and discussions among the translators, the project coordinators in Japan, and the developers of the original (US-English) version. Focus-group discussions and field testing were followed by analyses of test–retest reliability, internal consistency, and convergent and discriminant construct validity. Results: All eight of the SF-36 scales met the criterion for internal consistency (Cronbach's ranged from 0.73 to 0.92) and were reproducible (intraclass correlations between test and retest scores ranged from 0.60 to 0.82). Of the 10 kidney-disease-targeted scales, only two had coefficients of less than 0.70: sleep (0.61) and quality of social interaction (0.35). One item on the quality of social interaction scale had a very weak correlation with the remainder of that scale (r = 0.10). Eliminating that item from scoring increased the coefficient of the scale from 0.35 to 0.64. All three items on the quality of social interaction scale had very strong correlations with other scales. Conclusions: First, in Japanese patients receiving dialysis the SF-36 scales are internally consistent and their scores are reproducible. Second, with the possible exception of the quality of social interaction scale, the Japanese version of the KDQOL,can provide psychometrically sound kidney-disease-targeted data on quality of life in such patients.     

DDT,DDD, and DDE contamination of sediment in the Newark Bay estuary,New Jersey

Two hundred and forty-six surface and buried sediment samples from Newark Bay, New Jersey, and its major tributaries (Passaic River, Hackensack River, Newark Bay, Arthur Kill, Elizabeth River, and Kill Van Kull) were assayed for p,p-dichlorodiphenyltrichloroethane (p,p-DDT), p,p-dichlorodiphenyldichloroethane (p,p-DDD), and p,p-dichlorodiphenylchloroethylene (p,p-DDE) between February 1990 and March 1993. Chronological profiles in sediments from pre-1940 to the present were determined by radioisotope activities of ²¹⁰Pb and ¹³⁷Cs. The concentrations of these chemicals were compared to National Oceanic and Atmospheric Administration (NOAA) benchmark sediment values (Long and Morgan 1991). The objectives were to (a) determine the spatial and temporal distributions of DDT compounds in sediments, (b) identify possible sources, and (c) assess the potential for sediment toxicity within the estuary. Mean concentrations in surface sediments in individual waterways ranged from 5 to 473 g/kg for p,p-DDT, 18 to 429 g/kg for p,p-DDD, and 5 to 111 g/kg for p,p-DDE. A regional background mean concentration of approximately 100–300 g/kg p,p-DDT (sum of p,p-DDT, p,p-DDD, and p,p-DDE) was measured in surface sediments throughout the estuary, with the exception of the Arthur Kill, where mean concentrations exceeded 700 g/kg. The elevated concentrations found in recently deposited surface sediments in the Arthur Kill may be due to the presence of ongoing sources. The highest concentrations in buried sediments occurred in the lower Passaic River at depths corresponding to historical deposits from 1940 to 1970, the peak time period for production and usage of DDT in the United States. Comparisons to NOAA benchmark sediment toxicity values indicate that p,p-DDT, p,p-DDD, and p,p-DDE concentrations in surface sediments may pose a potential hazard to fish, shellfish, and other benthic and demersal organisms in some portions of the estuary, particularly in the upper and lower Arthur Kill.     

Spatial analysis of Percutaneous Transluminal Coronary Angioplasty (PTCA) in Austria

Study objectives: To investigate the geographical distribution of Percutaneous Transluminal Coronary Angioplasty (PTCA) and morbidity for coronary heart disease, angina pectoris and myocardial infarction by spatial analysis of the standardized morbidity rates (SMR) on district level. To identify clusters by Moran's I Statistic and the Regional Spatial Autocorrelation Coefficient (RSAC) of Munasinghe and Morris. To investigate demand factor morbidity and supply factor health care infrastructure on the district level as reasons for geographical disparity. To describe characteristics of the cluster population and intervention centres. Study design: Retrospective record linkage study. Setting: All hospitals and cardiological centres in Austria (n = 150) which performed the Minimum Basic Data Set (MBDS). Patients: All Austrian residents who were diagnosed for myocardial infarction, coronary heart disease or angina pectoris in 1995 (n = 87,174). Measurements and main results: One positive PTCA cluster (all SMRs 0.96) and one negative PTCA cluster (all SMRs 0.59) were identified. They differed significantly in morbidity rate, intervention rate and available cardiological beds. The tendency to inverse relation between PTCA utilization and morbidity in the negative cluster supported the thesis of inverse care law. Austrianwide no significant correlation was found between the SMR of PTCA-application and both demand factor and supply factors. Nevertheless, differences between the clusters concerning number and capacity of intervention centres and density of specialists pointed to supply factors as reasons for geographical disparity. The ongoing trend of steady expansion of existing intervention centres and establishment of new ones will reduce the extent of geographical variation in future.     

Adolescent substance abuse, the importance of family, school and peers: data from the health behaviour in school children

Summary. Objectives: To determine the possible factors associated with adolescent substance use in a country having recently experienced war.Methods: The survey applied the World Health Organization research protocol for cross-national survey – HBSC: a cross-sectional study among 1540 15-year old adolescents in Belgrade was conducted. The research instrument was a self-administered questionnaire.Results: Substance abuse is associated with living in a single parent family, living in a family without support, having a poor commitment to school, displaying aggressive behaviour, and spending a lot of time with friends.Conclusions: Factors associated with adolescent substance use include social background, family, school and peers. Such associations could help to focus on better measures to eliminate or reduce the risk of substance use.

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Zusammenfassung. Missbrauch von Substanzen bei Jugendlichen, Bedeutung von Familie, Schule und peers: Angaben aus BelgradFragestellung: Ziel der Forschung ist, Faktoren zu bestimmen, die für den Substanzmissbrauch bei Jugendlichen mitverantwortlich sind.Methoden: Die Forschung ist ein Teil des Projektes Gesundheitliches Verhalten bei Schulkindern, das gemäss dem Protokoll der WHO für internationale komparative Studien, bei 1540 Jugendlichen in Belgrad durchgeführt wurde. Es wurde ein Fragebogen benutzt, der von den Befragten selbst ausgefüllt wurde. Die Ergebnisse sind mit Methoden der deskriptiven Statistik analysiert worden, d.h. mittels Chi2-Tests sowie der logistischen Regression.Ergebnisse: Die Ergebnisse deuten darauf hin, dass der Substanzmissbrauch mit folgenden Faktoren in Zusammenhang steht: Leben in einer Familie mit nur einem Elternteil, Leben in einer Familie ohne Unterstützung, einem sehr niedrigen Engagement für die Schule, leichter Kommunikation mit Freunden des anderen Geschlechts, mit agressivem Verhalten sowie dem Verbringen eines grossen Teils seiner Freizeit mit den Gleichaltrigen.Schlussfolgerung: Es besteht ein Zusammenhang zwischen dem Substanzenmissbrauch bei Jugendlichen und den verschiedenen sozialen Verhältnissen wie Familie, Schule und Gleichaltrige. Die Erkennung dieses Zusammenhangs wird uns die Fokussierung auf die Massnahmen ermöglichen, die den Expositionseffekt zum Risiko beseitigen, reduzieren oder auf irgendeine Weise schwächer machen können.

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Résumé. Labus de substances chez les adolescents limportance de la famille, de lécole et des pairs (Health Behaviour in School Children – Belgrade)Objectifs: Déterminer les facteurs pouvant provoquer un abus de substances chez les adolescents dans un pays ayant souffert récemment de la guerre.Méthodes: Le projet Health Behaviour in School Children a été réalisé parmi 1540 adolescents à Belgrade selon le protocole de lOMS, avec un questionnaire auto-administré.Résultats: Labus de substances est en lien avec la présence dune structure familiale monoparentale ou avec labsence de soutien familial, avec un comportement agressif, avec un investissement scolaire limité de même quavec le temps passé auprès des pairs.Conclusions: Les facteurs en lien avec labus de substances chez les adolescents à Belgrade sont dorigine sociale comme par exemple la famille, lécole, les pairs. La mise en évidence de ces facteurs pourrait contribuer à améliorer les mesures prises pour éliminer ou réduire le risque dabus de substances.

     

Medium-Sized Business Employees Speak Out about Smoking

A health promotion study, funded by a state health department to meet objectives 3.4 and 3.11 of Healthy People 2000, was designed to: (1) identify tobacco use; (2) assess employees' beliefs on one's health and family member's health; and (3) assess the type of smoking policies favored. Using the Health Belief Model, it was hypothesized that there were differences in the health beliefs of tobacco users, former users, and never users. A 34-item questionnaire was administered to 1090 employees with a return rate of 603 (55%). Results: tobacco users perceived weight control and reduction of tension as benefits; they accepted warning label as hazardous but reported smokeless not as harmful; they perceived heart disease and cancer as related to tobacco use; and 62% had tried to quit smoking. Former and never users wanted total ban policies while, tobacco users wanted designated areas for smoking. All perceived their smoking and environmental tobacco smoke hazardous to their health and the health of family.     

The importance of quality of life research for health care reform in the USA and the future of public health

Quality of life research data have significant implications for the social and public policy in the USA as it can be used to evaluate the cost-effectiveness of various permutations of treatment as well as the human effectiveness of health care system restructuring. The USA spends more on health care per capita than any other industralized nation, yet on major health indicators, such as infant mortality rate, this expenditure is not related to beneficial effects on the community. When epidemiological and quality of life data drive national health care planning, improved approaches to the management of health service delivery may become apparent. Ultimately only the patient or consumer can determine if a particular treatment is successful; the same may be true for health care reform.     

The significance of age and duration of effect in social evaluation of health care

To give priority to the young over the elderly has been labelled ageism. People who express ageist preferences may feel that, all else equal, an individual has greater right to enjoy additional life years the fewer life years he or she has already had. We shall refer to this asegalitarian ageism. They may also emphasise the greater expected duration of health benefits in young people that derives from their greater life expectancy. We may call thisutilitarian ageism. Both these forms of ageism were observed in an empirical study of social preferences in Australia. The study lends some support to the assumptions in the QALY approach that duration of benefits, and hence old age, should count in prioritising at the budget level in health care.