Do social policies and political context matter for health in the United Kingdom?

This U.K. case study combines lessons from historical assessments with new empirical analyses of trends over the last decade to inform an appraisal of the impact of social actions on health. The empirical analyses examine life expectancy in the 354 local government councils in England by first identifying those that have better or worse health than expected fromtheir socioeconomic profile, and then selecting paired sets of "overachievers" and "underachievers" for more in-depth analysis. The findings taken as a whole provide evidence that social policies and political context do indeed matter for health. The historical material from the first industrial revolution, in particular, provides some of the most compelling evidence for this proposition. The empirical analyses over the last decade found a very powerful inverse association: the more deprived the local council, the lower the life expectancy of the population within that locality. However, even for the same level of deprivation and socioeconomic characteristics, some councils were doing much better than others in terms of health: for example, more than three years difference in life expectancy for carefully matched "urban fringe" councils. The article then examines the councils' political makeup and hence their likely policy perspective.     

Different dental care setting: does income matter?

In this paper we consider the use of mobile dental clinics as a means of improving access to dental care among primary school children in Southern Thailand by reducing the opportunity cost of service use to parents. Parents' willingness to pay (WTP) is measured for three different services provided in a community hospital dental clinic and a school-based mobile clinic. Although the service setting does not affect significantly the WTP for treatment directly, the estimated positive association between WTP and income is modified by setting. The results indicate that the potential for mobile clinics to increase utilization of services among primary school children is associated with parents' income, with the difference in valuation of dental services between the two settings being less among lower income parents than higher income parents. However, even among lower income parents our results indicate that the potential for increasing service utilization among children depends on the improvements in access associated with the mobile clinic not being achieved at the opportunity cost of lower levels of effectiveness.     

Role of neighbourhoods in child growth and development: Does ‘place’ matter?

It is estimated that at least 200 million children – mostly from developing countries – suffer from developmental delays. The study aims to contribute to an understanding of the contextual environment in which a child grows and develops in such setup; and in particular to evaluate the relative contributions of socio-economic status and rural-urban neighbourhoods on growth and psychomotor development. A cross-sectional study was conducted from May to November 2002 in 15 rural and 11 urban communities of Sindh, Pakistan. 1,244 children aged less than 3 years were assessed via home visits using Bayley’s Infant Developmental Scale for psychomotor development, anthropometry and a socio-economic and demographic questionnaire. A socio-economic index was created using principal component analysis, and the study hypotheses explored through hierarchical linear modelling. We found that sub-optimal growth and development were prevalent among the study’s children. Overall the mean psychomotor development (PD) index was 96.0 (SD 16.7), with 23% assessed as having delayed development, and undernourished with 39.8% stunted, 30.9% underweight and 18.1% wasted. Lower socio-economic status and living in a rural rather than urban neighbourhood were all found to have strong associations with lower psychomotor scores and with undernutrition. Rural-urban differences in undernutrition were explained by the lower socio-economic status of families in rural areas. By contrast, rural-urban differences in psychomotor scores remained strong even after controlling for differences in socio-economic status. It was estimated that rural residence accounted for 28% of cases of delayed psychomotor development among study children. Improvements in socio-economic status are vital to achieve optimal growth and development during early childhood. The study draws attention to the importance of taking heed of contextual needs, especially relating to differences between rural and urban neighbourhoods, in the formulation and implementation of early child care and development interventions.     

Maternal and child health services in rural Nepal: does access or quality matter more?

This study seeks to establish the relative importance of service access and quality on utilization of preventive health services in the western and middle-western Hill region of Nepal. Access was measured in terms of travel time to the nearest health post and coverage by outreach workers. The quality of static services was defined in structural terms: physical infrastructure, number of staff, availability of drugs and holding of special maternal and child health clinics. The initial analysis showed that no single indicator of quality was of overriding importance and therefore an overall quality index was constructed. After adjustment for access and for socioeconomic characteristics of families and communities, a very pronounced relationship between overall structural quality of the nearest health post and service uptake persisted. The adjusted odds of using some form of antenatal service were 6.6 times higher in the catchment areas of high quality posts than in areas served by low quality posts. The corresponding figure for receipt of BCG vaccination is 8.1. By comparison, the effects of travel time to the nearest health post are modest. Uptake of services is about twice as high when there is a health post in the community. Regular monthly visits by outreach workers also had a marked effect on service utilization. These results suggest that investment in the quality of health posts is more important than further increases in their number and that a further expansion of outreach services is a priority.     

The choice of detecting Down syndrome: does money matter?

The prenatal diagnosis of Down syndrome (amniocentesis) presents parents with a complex dilemma which requires comparing the risk of giving birth to an affected child and the risk of losing an unaffected child through amniocentesis-related miscarriage. Building on the specific features of the French Health insurance system, this paper shows that variation in the monetary costs of the diagnosis procedure may have a very significant impact on how parents solve this ethical dilemma. The French institutions make it possible to compare otherwise similar women facing very different reimbursement schemes and we find that eligibility to full reimbursement has a largely positive effect on the probability of taking an amniocentesis test. By contrast, the sole fact of being labelled 'high-risk' by the Health system seems to have, as such, only a modest effect on subsequent choices. Finally, building on available information on post-amniocentesis outcomes, we report new evidence suggesting that amniocentesis increases the risk of premature birth and low weight at birth.     

The impact of public spending on health: does money matter?

We use cross-national data to examine the impact of both public spending on health and non-health factors (economic, educational, cultural) in determining child (under-5) and infant mortality. There are two striking findings. First, the impact of public spending on health is quite small, with a coefficient that is typically both numerically small and statistically insignificant at conventional levels. Independent variation in public spending explains less than one-seventh of 1% of the observed differences in mortality across countries. The estimates imply that for a developing country at average income levels the actual public spending per child death averted is $50,000-100,000. This stands in marked contrast to the typical range of estimates of the cost effectiveness of medical interventions to avert the largest causes of child mortality in developing countries, which is $10-4000. We outline three possible explanations for this divergence of the actual and apparent potential of public spending. Second, whereas health spending is not a powerful determinant of mortality, 95% of cross-national variation in mortality can be explained by a country's income per capita, inequality of income distribution, extent of female education, level of ethnic fragmentation, and predominant religion.     

Communication patterns in medical encounters for the treatment of child psychosocial problems: does pediatrician-parent concordance matter?

This study examined how pediatrician-parent social status concordance related to communication patterns in medical encounters during which children received treatment for psychosocial problems indicating attention deficit disorder or attention deficit hyperactivity disorder. Using data from 28 pediatric medical encounters occurring in a large southeastern metropolitan city during 2003, we focused on concordance according to race, gender, and education, and its relation to laughter, concern, self-disclosure, question asking, and information-giving utterances, and patient-centeredness. Results indicated that race-concordant pediatricians and parents frequently laughed, whereas parents asked many biomedical questions in gender-concordant encounters. Education-concordant pediatricians and parents expressed concern repeatedly, exchanged biomedical information freely, and shared communication control. Pediatricians also self-disclosed when interacting with college-educated parents.     

Screening for depleted uranium in the United Kingdom armed forces: who wants it and why?

BACKGROUND: Depleted uranium (DU) use has been implicated in the poor health of many service personnel who have served in the Gulf and the Balkans. Although the health related risks are thought to be small the UK government has offered to set up a voluntary screening programme for service personnel. This study aimed to find out the characteristics and possible exposures to DU for those personnel who desire DU screening. METHODS: This study looks at 2369 UK service personnel who were asked if they wanted to be screened for DU. Subjects were asked about their perceived exposure to deployment associated risks including DU and a number of psychological health measures. RESULTS: The study found that 24% of the cohort wanted screening, a figure that if extrapolated to all those who have been offered screening would represent 36720 requests for screening. Those who wanted DU screening were younger, of lower rank, and more likely to be from the Royal Navy or Army rather than the Royal Air Force. Those requesting DU screening reported poorer health both subjectively and as measured by the GHQ-12 and a symptom checklist. They also reported more exposure to DU and to other deployment associated risks while in military service. Using combat exposure as a proxy for a significant risk of having been exposed to DU, there was a significant correlation. CONCLUSIONS: This study found that the desire for DU screening is more closely linked to current health status rather than plausible exposure to DU.     

Risk-based regulation and reforms to fitness to practise tribunals in the United Kingdom: Serving the public interest?

In this paper, I outline recent policy reforms to the General Medical Council (GMC) and how these are designed to promote greater public confidence in its management of the patient complaint and fitness to practise tribunal process. I explore how in spite of a decade of reform, potential for bias remains in relation to how issues of race and ethnicity, disability, age, class, gender and English language proficiency intersect with complaint making and case progression. I draw on reviews of and data from the GMC to examine the key issues surrounding the representativeness of the medical tribunal process, in terms of members’ age, gender and race and ethnicity. I note that, as in other high-income countries, there is a tendency within the United Kingdom (UK) for the risk-focused regulatory system to focus its reforming agenda on the more effective performance management of cost and risk, rather than on inculcating a more diverse patient presence and biographical profile within the day-to-day operation of regulatory regimes. I argue that this might unintentionally lead to the promotion of an optimism bias within risk-focused regulatory systems, potentially leading to a failure to communicate realistic perceptions of medical risk to patients and their families, and in doing so perhaps serving to further exacerbate the situation when instances of medical error and negligence occur. I conclude that current regulatory reforms in the UK are unlikely as a result to as fully promote the public interest and patient safety as they intend.     

No alternative? The regulation and professionalization of complementary and alternative medicine in the United Kingdom

In conjunction with its growing popularity, complementary and alternative medicine (CAM) in the United Kingdom has witnessed increasing professionalization, partly prompted by the landmark Parliamentary Inquiry that reported in November 2000. Professionalization has become a significant strategy for practitioner associations and a key focus for the government, media, and patient groups. It is being driven by concern over the interests of patients and consumers, and in relation to the possible integration of certain forms of CAM into publicly funded healthcare. It is, moreover, being reconfigured in explicitly national terms. This paper draws on research into practitioner associations representing nine CAM modalities in the UK-aromatherapy, Chinese herbal medicine, chiropractic, crystal healing, feng shui, 'lay' homeopathy, medical homeopathy, osteopathy, and Radionics-, examining the recent wave of professionalization in relation to Foucault's concern with 'techniques of the self.' It highlights the contrasting experience of an association of Chinese herbalists seeking statutory self-regulation (SSR) and an association of chiropractors that was instrumental in securing SSR for chiropractic.     

Genetic testing in the European Union: does economic evaluation matter?

Objective

We review the published economic evaluation studies applied to genetic technologies in the EU to know the main diseases addressed by these studies, the ways the studies were conducted and to assess the efficiency of these new technologies. The final aim of this review was to understand the possibilities of the economic evaluations performed up to date as a tool to contribute to decision making in this area.

Methods

We have reviewed a set of articles found in several databases until March 2010. Literature searches were made in the following databases: PubMed; Euronheed; Centre for Reviews and Dissemination of the University of York—Health Technology Assessment, Database of Abstracts of Reviews of Effects, NHS Economic Evaluation Database; and Scopus. The algorithm was “(screening or diagnosis) and genetic and (cost or economic) and (country EU27)”. We included studies if they met the following criteria: (1) a genetic technology was analysed; (2) human DNA must be tested for; (3) the analysis was a real economic evaluation or a cost study, and (4) the articles had to be related to any EU Member State.

Results

We initially found 3,559 papers on genetic testing but only 92 articles of economic analysis referred to a wide range of genetic diseases matched the inclusion criteria. The most studied diseases were as follows: cystic fibrosis (12), breast and ovarian cancer (8), hereditary hemochromatosis (6), Down’s syndrome (7), colorectal cancer (5), familial hypercholesterolaemia (5), prostate cancer (4), and thrombophilia (4). Genetic tests were mostly used for screening purposes, and cost-effectiveness analysis is the most common type of economic study. The analysed gene technologies are deemed to be efficient for some specific population groups and screening algorithms according to the values of their cost-effectiveness ratios that were below the commonly accepted threshold of 30,000€.

Conclusions

Economic evaluation of genetic technologies matters but the number of published studies is still rather low as to be widely used for most of the decisions in different jurisdictions across the EU. Further, the decision bodies across EU27 are fragmented and the responsibilities are located at different levels of the decision process for what it is difficult to find out whether a given decision on genetic tests was somehow supported by the economic evaluation results.     

Is the standardised term ‘Black African’ useful in demographic and health research in the United Kingdom?

Objective. The main objective of this paper is to review the literature on the term ‘Black African’ with respect to a number of themes: its use in the census and official data collections; the acceptability of a colour-based term; the heterogeneity concealed within the ‘Black African’ collectivity; the invisibility of distinct populations; the concealment of disparities in health, health care, and determinants; the capture of ‘Black Africans’ in other countries; and a set of possible alternatives for classifying this population.

Design. Structured searches were undertaken on a wide range of government and other grey literature sources and on two biomedical databases (Medline and EMBASE), using combinations of search terms for the collectivity and specific national origin groups.

Results. Analyses of the data show that the term ‘Black African’ conceals substantial heterogeneity with respect to national origins, religion, and language. It includes many who have come to the UK since the 1960s from former colonies but also sizeable groups arriving as refugees and asylum seekers from a wide range of African countries. Moreover, its boundaries are fuzzy, especially with regard to those originating in Horn of Africa countries. Marked variations are found in the (albeit limited) available disaggregated data on health and the determinants of inequalities.

Conclusions. Given the substantial increase in the size of the group, the extent to which such heterogeneity can continue to be tolerated in a single term must be questioned. The ‘Black African’ collectivity merits categorisation that addresses this issue and the proposed regional subdivisions in the Scotland 2006 Census Test currently offer the best solution.     

Control and end-of-life care: does ethnicity matter?

Patient control and autonomy are core values in Western bioethics and important components of end-of-life (EOL) care. However, the centrality of the patient as decision maker may not be relevant to culturally diverse groups of people. The purpose of this article is to present results of a literature review of patient control and ethnicity within the context of EOL care. The review revealed that the interplay between control and ethnicity in EOL care is complex and unpredictable. Implications for clinical care and future research are presented.     

Measles in the United Kingdom 1990–2008 and the effectiveness of measles vaccines

We identified all children in the UK General Practice Research Database diagnosed with measles from 1990 to 2008 and calculated annual incidence according to age and geographic region by dividing the number of cases per year by the number of children who were active in the population. We evaluated the effectiveness of the measles vaccines by comparing the vaccination histories of children who were diagnosed with measles (cases) to children who were not (controls). The annual incidence of measles fell after the introduction of the MMR vaccine in late 1988. However, a modest outbreak of measles occurred in 1994, leading to large nationwide programs to immunize children. Since 1996, the incidence of measles has fallen by more than 80%. Prior measles vaccination is highly effective and has substantially reduced the risk of measles.