Nanny or canny? Community perceptions of government intervention for preventive health

Critics of government intervention for the prevention of lifestyle-related chronic disease often conceptualise such efforts as ‘nanny state’, reflecting a neoliberal perspective and derailing wider debate. However, it is unknown how the community perceives such interventions. Given the importance of public opinion to government willingness to implement population-level system change, we aimed to better understand Australian community attitudes towards government-led prevention, in particular whether nanny state conceptualisations reflect community attitudes. We used an iterative mixed methods approach to data collection and analysis based on focus groups (n = 49) and a national survey (n = 2052). Despite strong endorsement (91%) of personal responsibility for health, 46% of survey respondents thought government plays a large role in prevention. The nanny state conceptualisation was not dominant in either the survey or focus group data. Qualitative data analysis highlighted alternative conceptualisations, namely government as a: canny investor; leader on positive health behaviour; partner or facilitator for health. Respondents’ level of support for specific interventions overlaid these general conceptualisations with considerations of the target population and risk factor, intervention mechanism and government motives. Community perceptions regarding prevention therefore reflect more thoughtful and complex interpretations of preventive actions and policies than suggested by nanny state conceptualisations. We argue that advocates and legislators should not allow debate around preventive measures to be restricted to the nanny state–libertarian continuum, but engage the community in more collectivist considerations of future health costs, beneficiaries, equity and likely outcomes of both action and inaction in order to garner community support and identify information gaps.     

Tularemia in Germany: the tip of the iceberg?

SUMMARYTularemia is a rare, notifiable zoonosis in Germany. Since November 2004, several lines of evidence including outbreaks in humans or animals and confirmed infections in indigenous hare and rodent populations have indicated a re-emergence of tularemia in different German federal states. Unfortunately, reliable basic information on the seroprevalence in different geographical regions, permitting the identification of risk factors, does not exist. Combining a sensitive screening assay with a highly specific confirmative immunoblot test, we performed a serological investigation on 2416 sera from a population-based, cross-sectional health survey of the city population of Leutkirch, Baden-Wuerttemberg. A total of 56 sera gave positive results indicating a seroprevalence of 2.32%. Thus, the seroprevalence is tenfold higher than that previously reported in a nationwide study in 2004. Francisella tularensis can cause a wide variety of clinical syndromes including severe, sometimes fatal disease. Missing epidemiological data on its spatial and temporal distribution in an endemic country complicate an appropriate risk assessment necessary for public health authorities to be prepared for an adequate outbreak management. This is of special concern regarding the extraordinary potential of F. tularensis as an agent of bioterrorism. Our investigation performed in a presumed low-risk area demonstrated that tularemia might be seriously underestimated in Germany and probably in other central European countries as well.     

Determinants of nutritional behaviour: a multitude of levers for successful intervention?

Nutritional behaviour is framed by biological, anthropological, economic, psychological, socio-cultural, and home economics related determinants and it is shaped by the individual situation. From a public health point of view, the outcome is often unsatisfactory, because it is associated with preventable cases of various diseases. This situation evoked the founding of the German Association for Nutritional Behaviour (Arbeitsgemeinschaft Ern?hrungsverhalten, AGEV) which celebrated its 25th anniversary within the scope of the 10th Food Choice Conference in the summer of 2002 with a plenary session on 'Sensible policies for nutrition and life-style intervention'. One might assume that the many determinants of nutritional behaviour provide a whole set of means to intervene into people's food choices. But closer deliberations make clear that there are two important aspects that tend to hinder dietary changes: on the one hand, nutritional behaviour is characterized by many conflicts of its related determinants. In order to cope with them, people develop individual guiding strategies for food choice situations which are quite stable as soon as they proved their suitability. On the other hand, any dietary modification leads to certain gains (like increased health), but losses, as well (like decreased palatability). Thus, a sustainable change can only be expected, if its gains are evaluated higher than its losses. These aspects need to be carefully considered when designing nutrition and life-style related intervention concepts.     

What accounts for the regional differences in the utilisation of hospitals in Germany?

There are huge regional variations in the utilisation of hospital services in Germany. In 2007 and 2008 the states of Hamburg and Baden-Württemberg had on average just under 38 % fewer hospitalisations per capita than Saxony-Anhalt. We use data from the DRG statistics aggregated at the county level in combination with numerous other data sources (e.g. INKAR Database, accounting data from the National Association of Statutory Health Insurance Physicians (KBV), Federal Medical Registry, Germany Hospital Directory, population structure per county) to establish the proportion of the observed regional differences that can be explained at county and state levels. Overall we are able to account for 73 % of the variation at state level in terms of observable factors. By far the most important reason for the regional variation in the utilisation of in-patient services is differences in medical needs. Differences in the supply of medical services and the substitutability of outpatient and inpatient treatment are also relevant, but to a lesser extent.     

A win-win solution?: A critical analysis of tiered pricing to improve access to medicines in developing countries

This article addresses an area that has been largely underserved by the development community, and one in which there is a particularly good opportunity for the private sector to take a lead in making a difference to employees, customers and local communities: chronic, non-communicable diseases (NCDs). It highlights the extent of the epidemic of NCDs in developing countries, sets out the 'business case' for the private sector to act on NCDs, and gives examples of initiatives by business to ensure that the healthy choice really is an easier choice for employees, consumers and local communities. It makes the case that, to be genuinely sustainable, businesses should be addressing health as a core part of what they do and, by working in partnership - as called for by the Millennium Development Goals - they can make a real difference and become part of the solution. Identifying ways in which this can be done should form a key part both of planning for, and action after, the UN High-level Meeting on NCDs, to be held in September 2011.     

Was there sufficient justification for the 10-fold increase in the TLV for silica fume? A critical review

In 1992, the Threshold Limit Value (TLV) for amorphous silica fume produced as a by-product of metallurgical processes was revised upwards from 0.2 mg/m³ (respirable dust) to 2.0 mg/m³. Comparison of the documentation justifying the lower TLV published by the ACGIH in 1989, with the subsequent documentation justifying the higher value published in 1992, does not support this increase. Following an outline of the problem areas existing in interpretational difficulties of experimental and review material in the silica fume bibliography, this paper provides a detailed examination of the six additional references cited in the 1992 documentation. All additional material suggests a need for extra caution, particularly with respect to recent experimental work in Australia on the sizing of silica fume. This paper concludes that the health evidence supports a TLV for silica fume closer to 0.3 mg/m³ rather than the current 2.0 mg/m³ now adopted in the U.S. and Australia. Am. J. Ind. Med. 33:212–223, 1998. © 1998 Wiley-Liss, Inc.     

Promoting adherence to medicines: possible lessons for Canada?

Non-adherence to medication regimens is a major issue that can negatively impact patient health and wastes health care system resources. This commentary considers whether approaches to strategies undertaken in Israel to promote adherence could be viable in Canada. The structure of the Canadian health care system and budgetary constraints make new initiatives similar to those in Israel seem unlikely in Canada without some compelling stimulus.     

DRGs in psychiatric hospital financing exemplified by Hungary. A model for Germany?

One of the most important provisions incorporated in the reform of the German health sector has been the introduction of a per case prospective payment system for hospitals with the exception of admissions to psychiatric care. The reasons for the exclusion of psychiatric care are unclear, but it is as a result all the more interesting to look at the experience of Hungary, where in-patient psychiatric care has been financed on the basis of diagnosis-related groups (DRGs) for the past seven years. The article describes how in the early 1990's the funding of the Hungarian health service was reorganized from being a state-financed system with a set budget to a system financed by contributions. Parallel to this development, service-related financing was introduced. In the hospital sector this involved DRGs. At the beginning of 1993 the Hungarian DRGs comprised only 437 categories, but this has since increased to 758. Furthermore, other characteristics are listed which, apart from the number of groups, differentiate the Hungarian DRGs from the AP-DRGs. Among other things, service-related financing includes non-typical areas such as psychiatry. In this case, it covers in-patient psychiatric care in an unusual combination of DRGs in the acute case category (50% of all beds in psychiatric units in Hungary are for acute cases) with daily nursing charges in the chronic case category. An analysis is given in the article of 16 homogeneous diagnostic categories in psychiatric care, followed by experiences gathered in conjunction with the application of this approach in this particular sphere, with special reference to three problem areas. These are as follows: the trend towards diagnoses with a relatively high weighting; the practice of charging for psychiatric DRGs in somatic wards; and, finally, the perpetuation of poor service structures and practices through DRGs. In general, evidently the introduction of psychiatric DRGs may also be recommended in Germany because of the danger that otherwise psychiatry might be marginalized and isolated in a corner for chronic medical cases. As the only discipline or specialist sphere with a non-service based budget there is a real threat that funding would be kept low. Thus, under the superior financial conditions in Germany, the disadvantages registered in Hungary would not occur or would become manifest only in a milder form. However, it is important that prior to implementation costing is done with extreme care to determine the relative weighting and duration of treatment for each of the categories and that following introduction of DRGs there is a regular control of coding practices, structure of diagnoses and case-mix changes.     

Cognitive intervention programmes on patients affected by Mild Cognitive Impairment: A promising intervention tool for MCI?

Purpose  

This paper examines and reviews studies on the efficacy of computer-based cognitive intervention programmes in the elderly affected by Mild Cognitive Impairment (MCI). MCI patients are at higher risk to progress to dementia. Recent effort has been made to slow the cognitive decline and delay the onset of dementia in this population.     

What influences government adoption of vaccines in developing countries? A policy process analysis

This paper proposes a framework for examining the process by which government consideration and adoption of new vaccines takes place, with specific reference to developing country settings. The cases of early Hepatitis B vaccine adoption in Taiwan and Thailand are used to explore the relevance of explanatory factors identified in the literature as well as the need to go beyond a variable-centric focus by highlighting the role of policy context and process in determining the pace and extent of adoption. The cases suggest the feasibility and importance of modeling 'causal diversity'-the complex set of necessary and sufficient conditions leading to particular decisional outcomes-in a broad range of country contexts. A better understanding of the lenses through which government decision-makers filter information, and of the arenas in which critical decisions are shaped and taken, may assist both analysts (in predicting institutionalization of new vaccines) and advocates (in crafting targeted strategies to accelerate their diffusion).     

What accounts for good practice? Assessment of obesity prevention projects for kindergarten children in Germany

Objective  

Up to now, no guideline has been set up that provides criteria for good practice in universal and selective childhood obesity prevention projects for children aged 3 to 6 in the kindergarten setting. Hence, based on guidelines for targeted prevention, the present study not only aims at assessing the current state of German universal and selective childhood obesity prevention projects in kindergartens, but also at deriving criteria of good practice in order to help fill this gap.     

The reform of hospital financing in Germany: an international solution?

From 2003, each inpatient's stay at a German hospital will be reimbursed according to diagnosis related groups. The former German hospital financing system, which consisted partly of per diem rates and partly of per-case rates, was abolished in an attempt to increase efficiency in hospitals. This can be seen as the government's attempt to act on the principles of evidence-based policy. Since there is no strict global budget for inpatient treatment, it is not certain that those diagnosis related groups will actually decrease overall expenditures on hospitals. Also, it is argued that the introduction of diagnosis related groups in Germany may not be the last step in rebuilding the German health care system. The manner, scope and timing of this reform suggests that it will not succeed. Reforms lead to yet more reforms.     

Treatment of hypertension in Germany: is there a social gradient?

Objectives  

Effective hypertension control remains low without much improvement since the 1990s. However, information is limited whether and how social status impacts on hypertension control.     

Coronary heart disease: acceptance of guideline recommendations irrelevant in Germany?

It is important to conduct research on how guidelines are acceptedand implemented among GPs and to look for barriers to theirimplementation. We believe, however, that a comparison betweencountries must be made with great care; we know that there aredifferences in the organization of primary care between differentEuropean countries. We also know there are differences in theprocess of implementing guidelines between     

A mental health brief intervention in primary care: does it work?

An onsite adjunctive service appears to improve the care of patients with mental health disorders.     

How innovative are pharmaceutical innovations?: the case of medicines financed through add-on payments outside of the French DRG-based hospital payment system

Objective

To analyze the characteristics of inpatient medicines placed on the list of innovative high-cost medicines funded in addition to DRG-based payment, and to identify whether they really are innovative and/or high-cost.

Methodology

The medicines placed on the list of innovative and high-cost medicines were analyzed on the basis of criteria describing their innovative nature and cost. They were categorized as innovative and high-cost, only high-cost, only innovative and neither innovative nor high-cost.

Results

Among the medicines financed in addition to DRG-based payment, 25.5% were classified as innovative and high-cost, 23.5% only high-cost, 22.9% only innovative and 28.1% neither innovative nor high-cost.

Conclusions

The list of innovative and high-cost medicines contains medicines other than innovative and high-cost medicines. Stricter criteria for placing medicines on this list should be considered in order to limit the increase in expenditure.     

Quality of generic medicines in South Africa: Perceptions versus Reality ¿ A qualitative study

ABSTRACT: BACKGROUND: Generic Medicines are an important policy option allowing for access to affordable, essential medicines. Quality of generic medicines must be guaranteed through the activities of national medicines regulatory authorities. Existing negative perceptions surrounding the quality of generic medicines must be addressed to ensure that people use them with confidence. Campaigns to increase the uptake of generic medicines by consumers and providers of healthcare need to be informed by local norms and practices. This study sought to compare South African consumers' and healthcare providers' perceptions of quality of generics to the actual quality of selected products. METHODS: The study was conducted at the local level in three cities of South Africa: Johannesburg, Durban and Cape Town. Purposive sampling was used to recruit consumer participants (n = 73) and random sampling used to recruit healthcare providers from public and private sectors (n = 15). Data were obtained through twelve focus group discussions with consumers and semi-structured interviews (n = 15) with healthcare providers in order to gain familiarity with perceptions of quality. One hundred and thirty five products comprising paracetamol tablets (n = 47), amoxicillin capsules (n = 45) and hydrochlorothiazide tablets (n = 43) were sourced from public and private sector healthcare providers. These products were subjected in-vitro dissolution, uniformity of weight and identity (Fourier Transformed Infrared Spectroscopy) tests using prescribed methods from the British (2005) and United States Pharmacopeias (2006). RESULTS: Respondents described drug quality in relation to the effect on symptoms. Procurement and use behavior of healthcare providers was influenced by prior experience, manufacturers' names and consumers' ability to pay. All formulations passed the in vitro tests for quality. CONCLUSIONS: This study showed clear differences between perceptions of quality and actual quality of medicines suggesting deficiencies in public engagement by government regarding the implementation of generic medicines policy. Implementation of generic medicines policy requires the involvement of consumers and healthcare providers to specifically address their information gaps and needs.