Can policy analysis theories predict and inform policy change? Reflections on the battle for legal abortion in Indonesia

The relevance and importance of research for understanding policy processes and influencing policies has been much debated, but studies on the effectiveness of policy theories for predicting and informing opportunities for policy change (i.e. prospective policy analysis) are rare. The case study presented in this paper is drawn from a policy analysis of a contemporary process of policy debate on legalization of abortion in Indonesia, which was in flux at the time of the research and provided a unique opportunity for prospective analysis. Applying a combination of policy analysis theories, this case study provides an analysis of processes, power and relationships between actors involved in the amendment of the Health Law in Indonesia. It uses a series of practical stakeholder mapping tools to identify power relations between key actors and what strategic approaches should be employed to manage these to enhance the possibility of policy change. The findings show how the moves to legalize abortion have been supported or constrained according to the balance of political and religious powers operating in a macro-political context defined increasingly by a polarized Islamic-authoritarian-Western-liberal agenda. The issue of reproductive health constituted a battlefield where these two ideologies met and the debate on the current health law amendment became a contest, which still continues, for the larger future of Indonesia. The findings confirm the utility of policy analysis theories and stakeholder mapping tools for predicting the likelihood of policy change and informing the strategic approaches for achieving such change. They also highlight opportunities and dilemmas in prospective policy analysis and raise questions about whether research on policy processes and actors can or should be used to inform, or even influence, policies in 'real-time'.     

Can I find a doctor? Availability of primary care physicians in the San Francisco Bay Area

OBJECTIVES: Primary care physicians function as "gatekeepers" in many managed care systems. With the rapid growth of managed care enrollment, it is crucial that patients have adequate access to primary care physicians. We investigated factors associated with new-patient appointment availability of primary care physicians in the San Francisco Bay Area. STUDY DESIGN: Observational cohort. POPULATION: Cross-sectional survey of primary care physician offices in 2 San Francisco Bay Area counties (n=438). OUTCOMES MEASURED: New-patient appointment availability. RESULTS: Seventy-five percent of primary care physicians participating in managed care had an appointment available for a new patient. Appointments were more likely to be available with primary care physicians who had been in practice for 10 years or less (odds ratio [OR]=4.2; 95% confidence interval [CI], 1.7-10.3), compared with more established physicians; and with primary care physicians who had graduated from a medical school outside of the United States (OR=3.5; 95% CI, 1.7-7.3), compared with US graduates. Appointments within 30 days were less available with female primary care physicians (OR=0.4; 95% CI, 0.2-0.7) than for male primary care physicians. CONCLUSIONS: The limited availability of appointments for new patients may create barriers to primary care in the San Francisco Bay Area, a region with high managed-care penetration.     

What is the optimal recall period for verbal autopsies? Validation study based on repeat interviews in three populations

Background

One key contextual feature in Verbal Autopsy (VA) is the time between death and survey administration, or recall period. This study quantified the effect of recall period on VA performance by using a paired dataset in which two VAs were administered for a single decedent.

Methods

This study used information from the Population Health Metrics Research Consortium (PHMRC) Study, which collected VAs for “gold standard” cases where cause of death (COD) was supported by clinical criteria. This study repeated VA interviews within 3–52 months of death in PHMRC study sites in Andhra Pradesh, India, and Bohol and Manila, Philippines. The final dataset included 2113 deaths interviewed twice and with recall periods ranging from 0 to 52 months. COD was assigned by the Tariff method and its accuracy determined by comparison with the gold standard COD.

Results

The probability of a correct diagnosis of COD decreased by 0.55% per month in the period after death. Site of data collection and survey module also affected the probability of Tariff Method correctly assigning a COD. The probability of a correct diagnosis in VAs collected 3–11 months after death will, on average, be 95.9% of that in VAs collected within 3 months of death.

Conclusions

These findings suggest that collecting VAs within 3 months of death may improve the quality of the information collected, taking the need for a period of mourning into account. This study substantiates the WHO recommendation that it is reasonable to collect VAs up to 1 year after death providing it is accepted that probability of a correct diagnosis is likely to decline month by month during this period.

     

Accumulated occupational class and self-rated health. Can information on previous experience of class further our understanding of the social gradient in health?

Previous research has shown a social gradient in health with better health for people in more advantaged positions in society. This research has mainly been on the relationship between current position and health, or social position in childhood and health, but less is known about the potential accumulative impact of positions held in adulthood. In this paper I use the economic activity histories from the Swedish Level of Living survey to examine the relationship between accumulated occupational class positions and health. Step-wise linear probability models are used to investigate how to best capture the potential association between class experience and self-rated health (SRH), and whether the effect of current class is modified when measures of accumulated class are included. I then further test the potentially lasting association between previous exposure to the health risk of working class by analysing only individuals currently in higher or intermediate level service class; the classes under least exposure.I find a positive association between accumulated experiences of working class and less than good SRH. Furthermore, even for employees currently in non-manual positions the risk for less than good SRH increases with each added year of previous experience within working class. This suggests that the social gradient can be both accumulative and lasting, and that more information on the mechanisms of health disparities can be found by taking detailed information on peoples' pasts into account. Although gender differences in health are not a focus in this paper, results also indicate that the influence of class experiences on health might differ between men and women.     

Optimizing the design of clinical trials where the outcome is a rate. Can estimating a baseline rate in a run‐in period increase efficiency?

It is well known that the statistical power of randomized controlled trials with a continuous outcome can be increased by using a pre-randomization baseline measure of the outcome variable as a covariate in the analysis. For a trial where the outcome measure is a rate, for example in a therapeutic trial in Alzheimer's disease, the relevant covariate is a pre-randomization measure of that rate. Obtaining this requires separating the total follow-up period into two periods. In the first 'run-in' period all patients would be 'off-treatment' to facilitate the calculation of baseline atrophy rates. In the second 'on-treatment' period half of the patients, selected at random, would be switched onto active treatment with the others remaining off treatment. In this paper we use linear mixed models to establish a methodological framework that is then used to assess the extent to which such designs can increase statistical power. We illustrate our methodology with two examples. The first is a design with three evenly spaced time points analysed with a standard random slopes model. The second is a model for repeated 'direct' measures of changes used for the analysis of imaging studies with visits at multiple time points. We show that run-in designs can materially reduce sample size provided that true between-subject variability in rates is large relative to measurement error.     

Can the impact on health of a government policy designed to create more liveable neighbourhoods be evaluated? An overview of the RESIDential Environment Project

There is growing interest in the impact of community design on the health of residents. In 1998, the Western Australian Government began a trial of new subdivision design codes (i.e. Liveable Neighbourhoods Community Design Code) aimed at creating pedestrian-friendly neighbourhoods to increase walking, cycling and public transport use. The trial provided a unique opportunity for a natural experiment to evaluate the impact of a government planning policy on residents. Nevertheless, evaluations of this kind present a number of methodological challenges in obtaining the highest quality evidence possible. This paper describes the RESIDential Environment Project's study design and discusses how various methodological challenges were overcome.     

Is questionnaire information valid in the study of a chronic disease such as diabetes? The Nord-Tr?ndelag diabetes study.

STUDY OBJECTIVE--The aim was to validate information about diabetes mellitus collected by questionnaire in a large epidemiological survey. DESIGN--Questions on diabetes diagnosis, medical treatment for diabetes, diabetes duration, and hypertension treatment were selected from the Nord-Trøndelag health survey questionnaires. One of the municipalities was selected for the validation study. SETTING--The health survey 1984-86 addressed all inhabitants > or = 20 years of age in Nord-Trøndelag county, Norway; 76,885 (90.3%) of the eligible population participated in answering the question on diabetes. PARTICIPANTS--All inhabitants in the municipality answering "yes" to the question on diabetes (n = 169) and the persons with the same sex born closest before and after each diabetic patient and answering "no" to the diabetes question (n = 338) were included. MEASUREMENTS AND MAIN RESULTS--A very thorough search was made in the medical files of the general practitioners in the municipality for corresponding information. Compared to the files, diabetes was verified in 163 out of the 169. The commonest cause of discrepancy was renal glycosuria. One out of the 338 registered non-diabetic persons was found to have diabetes. Diabetic patients tended to overestimate diabetes duration significantly. Insulin treatment was verified in 19/20 (95%) and treatment with oral hypoglycaemic agents in all 44 with an affirmative questionnaire answer. A negative answer on insulin and oral hypoglycaemic agents was verified in 100% and 99% respectively. CONCLUSIONS--The concordance was considerably higher than in a comparable Norwegian study performed 10 years earlier. Patient administered questionnaires may be a very reliable source of information for epidemiological purposes in a well defined chronic disease such as diabetes mellitus.     

How does community context influence coalitions in the formation stage? a multiple case study based on the Community Coalition Action Theory

Background  

Community coalitions are rooted in complex and dynamic community systems. Despite recognition that environmental factors affect coalition behavior, few studies have examined how community context impacts coalition formation. Using the Community Coalition Action theory as an organizing framework, the current study employs multiple case study methodology to examine how five domains of community context affect coalitions in the formation stage of coalition development. Domains are history of collaboration, geography, community demographics and economic conditions, community politics and history, and community norms and values.     

Can the case-control method be used to assess the impact of water supply and sanitation on diarrhoea? A study in the Philippines.

This study had 2 objectives: 1) to determine whether a case-control approach is an effective measure for assessing the effect of improved sanitation on bacterial diarrhea, and 2) to assess the effects of environmental sanitation on diarrheal disease in Cebu. The study took place during the warm, rainy months (July-September) of 1985. The study population consisted of 281 children under 2 who were treated at 1 of 16 clinics for diarrhea due to Escherichia coli, salmonella, shigella, and Vibrio cholerae. The controls were 384 children under 2 who were brought to the clinics for respiratory ailments and did not have diarrhea. Environmental sanitation was classed as "good" if the bacterial count in the water supply was low (i.e., water was obtained from the municipal water supply or bore holes) and if excreta disposal was adequate (i.e., there were flush toilets, sealed latrines, or pit latrines). Water quantity was measured by the number of times the child was bathed. The effects of the exposure variables on the study children were determined by logistic regression analyses adjusted for confounding variables, which included sex, educational level of the household, breast feeding, attendance at well-baby clinics, number of children under 5 in the household, and frequency of bathing the child. The results of the study showed that improved sanitation reduced the episodes of bacterial diarrhea by 40%, and that case-control studies with sample sizes of about of about 500 cases and 500 controls are adequate to detect disease reductions of 33% or more.     

From what and why did genetics emerge as a medical specialism in the 1970s in the UK? A case-history of research, policy and services in the Manchester region of the NHS. National Health Service.

The history of genetics has concentrated on eugenics in the first half of the 20th century and molecular genetics in the second. There is yet little historical analysis of the emergence of genetics as a medical specialism, even for the USA. This paper explores the creation of a regional genetic service in Manchester, UK. It surveys the ways in which hereditary diseases were managed and investigated in the first two decades of the NHS (1948-68), and the marginality of geneticists in this period. It suggests that the emergence of consultant geneticists as conspicuous service specialists depended heavily on their ability to create and control laboratory and counselling services for antenatal diagnosis, especially of Down's syndrome, from the late 1960s. These services, for syndromes that were not strongly hereditary, helped extend the meaning of 'genetic' in medicine from 'hereditary' to 'related to chromosomes and genes'. The services received government support because of popular demand for diagnoses (following the Abortion Act of 1967), because 'preventive services' were seen as cost effective, and because geneticists could argue that inadequate counselling might give rise to legal difficulties. By linking laboratory services and counselling, geneticists offered an integrated service, in line with other consultant-led services (e.g. for kidneys) which linked research, laboratory services, clinical work, and education/public health functions. We suggest such services fitted the hospital-dominated political economy of medicine which underlay the NHS re-organisation of 1974; and that the salience of the new genetics owed much to this combination of high-science and public concern. Geneticists were then able to integrate molecular genetics into key regional centres, so shaping the initial phases of the 'molecular' revolution. We maintain that this local study offers useful wider insights, not only into the development of a key specialism, but also into the changing dynamics of research and policy in the NHS.