What is evidence-based public health?

Evidence based Public Health is the execution and evaluation of the efficiency of interventions, plans, programs, projects and politics in public health through the application of the scientific principles of reasoning, including the systematic use of information and information systems. Evidence based public health involves the use of methodologies similar to those applied in evidence-based clinical medicine, but differs in its contents. In public health two types of evidence are described. The type I evidence in which a strong relation exists between the preventable risk and disease, and type II evidence in which there exists a relative effectivity of the public health interventions. In evidence based Public Health research designs more appropriate for the social sciences are used, as the observational and quasi-experimental studies. Likewise the decisions are more of interdisciplinary teams.     

What sort of networks are public health networks?

BACKGROUND: Re-organization of the English National Health Service (NHS) has fragmented the public health workforce, relocating teams from about 100 health authorities into over 300 primary care trusts (PCTs). The UK Government announced the setting up of public health networks (PHNs) as a solution to the problems created by fragmentation. METHODS: Fifty-seven semi-structured telephone interviews were held with key players in PHNs in all strategic health authority areas in England in early 2003. RESULTS: PHNs appeared to be primarily networks of public health professionals rather than of organizations. Informants were unsure about PCTs' commitment to public health. Predominantly, members were those NHS personnel with a clear and explicit public health role. Most PHNs intended to include others later (e.g. health visitors, environmental health officers), although a few thought that inclusivity was essential from the start. Continuing professional development for public health personnel dominated the work being undertaken, with some collaborative work across PCTs. PHNs were seen as a compulsory reconfiguration of existing networks, and informants doubted that they were appropriate for the many levels of networking that public health work requires. CONCLUSION: The formation of PHNs does not appear to have been either necessary or sufficient. However, the public health community has a well-established tradition of networking, and therefore has the skills to use PHNs advantageously.     

What happens to the student? The neglected variable in educational outcome research

Disputes about the superiority of teaching methods often remain unresolved. The essential question we continuously want to answer is: Which teaching methods yield the best knowledge and skills in students? Abundant literature, in medical education and in education in general, on research with educational methods as independent variables and measures of outcome (e.g., test scores) as the dependent variable often point at "no significant difference" or only small differences between methods. Many factors do influence the educational outcome in students and large statistical power (such as meta analysis) should be helpful to eliminate many sources of error. However, one source we cannot tackle this way. That is, students will usually adapt quantity and quality of studying to meet testing requirements. In doing so, they may compensate for teaching quality. Some teaching may generate more effort in students than other teaching. Since test scores reflect primarily student activities, it is their efforts that may bring differences in teaching methods close to equality in test scores. Therefore, knowledge and skills should not be considered the primary outcome of teaching but the outcome of learning activities. If we want to discriminate between teaching methods, we must at least consider what happens to students.     

Going beyond health efficiency: What really matters?

Both citizens and policymakers demand the best possible results from a country's healthcare system. It is of utmost importance to accurately and objectively assess the efficiency of a healthcare system and to note the key indicators, where resources are lost, and possibilities for improvement. This paper evaluates the efficiency of health systems in 38 countries, mainly members of the Organization for Economic Co-operation and Development, using data envelopment analysis (DEA). In the first stage, bootstrapped Ivanovic distance is used to generate weights for the indicators, thus taking into consideration different country's goals, but not to the extent of reducing the possibility of comparison. The analysis shows that human resources are the most important health system resource and countries should pay special attention to developing and employing competent medical workers. The reorganization of human resources and the funds allocated to them could also increase efficiency. The second stage examines environmental indicators to find the causes of inefficiency. No proof is found that any one basic health system funding model produces better health outcomes than the others. Obesity is identified as a major issue.     

More physicians in public health: less public health work?

AIM: The object was to assess changes in work priorities in local public health medicine in Norway over the period from 1994 to 1999. METHODS: Two cross-sectional studies were undertaken of physicians working in local public health medicine in all Norwegian municipalities, using a postal questionnaire. RESULTS: Half of the physicians working in public health in 1999 were recruited after 1994. Although the number of physicians working in public health increased from 505 in 1994 to 555 in 1999 (10%) an estimation of the total weekly hours worked decreased by 3.7% from 8,715 hours in 1994 to 8,386 hours in 1999. The vast majority of physicians worked in combined posts (87%), and they reduced their engagement in public health by 2.6 hours on average from 1994 to 1999. The reduction depended on remuneration model, speciality in community medicine, and municipality size. CONCLUSIONS: Local public health in Norway was under pressure in the 1990s. For public health physicians, preventive medicine lost out to clinical work. No promising signals of change in the professional or political framework or in incentives for public health work are seen.     

Why feminism in public health?

The issues raised in this editorial and exemplified within a number of the studies reported in this issue indicate new directions for public health, directions which take feminist scholarship, both outside and within the medical framework, into account. The changing potential of feminist public health, as derived from the articles in this issue, can be summarised within the following issues: new research areas, positioning women as actors, development of theoretical frameworks, reflexive theory of science, interplay between sex and gender, gender-sensitive methods, diversities among women/men, pro-feminist research on men's health and using the results for change. Thus, feminist public health represents a shift towards the new public health, with holistic and multidisciplinary activities, based on theoretical pluralism, multiple perspectives and collective actions with the aim of improving the health of gender-subordinated groups.     

Explaining educational inequalities in adolescent life satisfaction: do health behaviour and gender matter?

Objectives

There is little evidence on the explanation of health inequalities based on a gender sensitive perspective. The aim was to investigate to what extent health behaviours mediate the association between educational inequalities and life satisfaction of boys and girls.

Methods

Data were derived from the German part of the Health Behaviour in School-aged Children (HBSC) study 2010 (n = 5,005). Logistic regression models were conducted to investigate educational inequalities in life satisfaction among 11- to 15-year-old students and the relative impact of health behaviour in explaining these inequalities.

Results

Educational inequalities in life satisfaction were more pronounced in boys than in girls from lower educational tracks (OR 2.82, 95 % CI 1.97–4.05 and OR 2.30, 95 % CI 1.68–3.14). For adolescents belonging to the lowest educational track, behavioural factors contributed to 18 % (boys) and 39 % (girls) in the explanation of educational inequalities in life satisfaction.

Conclusions

The relationship between educational track and life satisfaction is substantially mediated by health-related behaviours. To tackle inequalities in adolescent health, behavioural factors should be targeted at adolescents from lower educational tracks, with special focus on gender differences.     

What should (public) health insurance cover?

In any system of health insurance, a decision must be made about what treatments the insurance should cover. One way to make this decision is to rank treatments by their ratios of health benefits to treatment costs. If treatments that are not offered by the health insurance can be purchased out of pocket, the socially optimal ranking of treatments to be included in the health insurance is different from this standard cost-effectiveness rule. It is no longer necessarily true that treatments should be ranked higher the lower are treatment costs (for given health benefits). Moreover, the larger are the costs per treatment for a given benefit-cost ratio, the higher priority should the treatment be given. If the health budget in a public health system does not exceed the socially optimal size, treatments with sufficiently low costs should not be performed by the public health system if treatment may be purchased privately out of pocket.     

Economics and ethics in public health?

The topic suggests a conflict between ethics and economy in medical care. It is often argued that today's welfare state in affluent societies with their social insurance systems makes it easier for the doctor to translate ethical demands into reality without being hampered by economic restrictions. Both doctors and patients took advantage of this system of medical care by mingling social guarantees for health with the doctor's income. Hence, medical expenses expanded rapidly, additionally promoted by technical progress in medicine. This entailed a proportionate increase in medical expenses in relation to personal income, especially wage income. Budgets of state authorities were streamlined or deficits became larger. This state of affairs was promoted further by mechanisms of distribution of national income in accordance with the slogan "less state, more market". While national income continued to grow, although at a slower rate, the number of jobless persons grew continually and thus also the social expenses, this was not due, as is usually assumed and pretended, to an economic crisis. Society and economy are facing a crisis of distribution of national income under conditions of technical progress as a job killer, making economic production more productive and efficient. Not taking into account the new challenge of social market economy--the German innovation in market economy creating the economic miracle after World War II--reforms of the system of medical care took place and are still continuing along market principles, particularly the latest German reform law leading to individual contracts between patients and their doctors in respect of cost charging. However, marketing principles promote economy in medicine, but they do not promote medical ethics. Further German guidelines for medical care should take stock of past experiences. There will be more competition in the "growing market of medical care" (private and public) and this will need--as economic experience has shown and economists have affirmed--new organisational devices to ensure better outcomes for the individual patient as a consumer and the doctors as suppliers. More responsibility should be given to the different suppliers of collective security in medical care (private or social systems of insurance). No individual patient as a mere consumer has a genuine chance in handling contracts with doctors carefully who are considered to be "gods in white" according to a popular German saying. These consumers have only a slight chance when arguing in courts of justice for the performance of contracts. Diagnosis and therapy, the system of doctors who treat members of statutory social insurance schemes (National Health general practitioners in the U.K.) and doctors as "free entrepreneurs" in the growing market of medical care should be separated due to the different rules of charging costs and offering medical care. "Classless medical care" does not have a better chance by applying market principles. The same is true for ethics versus economy. Doctors as "free entrepreneurs" must learn that markets will not guarantee reimbursement of costs but react to supply and demand. Hence, regulation of medical care by economic instruments creates better chances even for ethics in medical care against economy.