Pure altruism and misjudgement: A bad combination?

Stated preference studies on the value of health risk reductions have found valuations elicited from a private perspective to be both higher and lower compared to valuations elicited from a public perspective. Although relevant, the individual's ability to correctly predict the valuation that other individuals assign to the risk reduction has been insufficiently researched. We aim to verify whether individuals exhibit pure altruistic preferences and if this is the case, whether the presence of pure altruism leads to biased valuation of public risk reductions due to misjudgement about other individuals' preferences. We conduct a large-scale online incentivised experiment as a variant of a public good game in which the individual's final endowment is determined by choices made in the experiment. Results suggest that individuals act as pure altruists and hence try to account for the benefits obtained by others of being insured. The results also suggest that individuals fail to correctly predict other individuals' benefits from the insurance, which leads to non-optimal outcomes and biased valuations.     

TESTING PROCEDURAL INVARIANCE IN THE CONTEXT OF HEALTH

Violations of procedural invariance, epitomised by ‘classic’ preference reversals, have been observed for more than 40 years, and yet the study of this phenomenon in health remains nascent. This is an oversight because such violations pose a challenge to health economics, where choice and valuation methodologies often are used interchangeably. This article reports two experiments that aim to test for preference reversals over outcomes defined by health status, using both ‘open’ and ‘assisted’ valuation procedures. Although systematic preference reversals in the direction generally reported in the literature were not observed, the rates of non‐systematic reversal were substantial, measuring 35–40%. By analysing the respondents’ explanations for their answers, it is clear that many of them used heuristics to answer the questions, and they may have good reasons to do so, which undermines the notion that preferences are always fixed and stable. These results, and others like it, pose a challenge to those who unquestioningly assume procedural invariance and maintain that population preferences should be used to inform health policy. Copyright © 2012 John Wiley & Sons, Ltd.     

The role of health education in the policy change process: Lessons from tobacco control

The ‘new public health’ perspective urges a return to an agenda centred on the modification of the determinants of health, with a special emphasis on public policies. This enthusiasm for strategies focusing on the modification of policies may lead, however, to declining interest in health education interventions. The aim of the present analysis is to reflect on the role of health education in the process leading to the adoption of ‘Healthy Public Policies’ by drawing on theories from political science: Hall's Policy Paradigm approach and Sabatier and Jenkins-Smith's Advocacy Coalition Framework. Rejecting the traditional perspective that political actors’ choices and preferences are exclusively framed by an economic rationality, these two frameworks integrate the influence of ideas and values in the policy process. Applying these analytical frameworks to the case of tobacco control, we found that the policy change process is constrained by the worldview of a broad group of actors from the political and social spheres and that the dominant elite's worldview structures such a process. In addition, policies are derived from the ‘policy learning process’ and from events external to the policy domain. We conclude that health education through its health advocacy role and the sensitization of the public is a critical ingredient of the policy process. However, health educators should take part in the process not only by disseminating technical or scientific arguments but also by bringing forward arguments that take into account the fundamental values defended by the policy-makers and the public.     

Preferences for ‘New’ Treatments Diminish in the Face of Ambiguity

New products usually offer advantages over existing products, but in health care, most new drugs are ‘me‐too’, comparable in effectiveness and side effects to existing drugs, but with a more ambiguous evidence base around adverse effects. Despite this, new treatments drive increased health care spending, suggesting a preference for ‘newness’ in this setting. We explore (1) whether preferences for treatments labeled ‘new’ exist and (2) persist once the ambiguity in the evidence base reflecting newness is described. We use a Canadian general population sample (n = 2837) characterized by their innovativeness in adopting new products in normal markets. We found that innovators/early adopters (n = 173) had significant preferences for ‘newer’ treatments (B = 0.162, p = 0.038) irrespective of comparable benefits and side effects and all respondents had significant preferences for less ambiguity in benefit/side effect estimates. Notably, when ‘newness’ was combined with ambiguity, no significant preferences for new treatments were observed regardless of respondent innovativeness. We conclude that preferences for new products exist for some people in health care markets but disappear when the implication of ambiguity in the evidence base for new treatments is communicated. Physicians should avoid describing treatments as ‘new’ or be mindful to qualify the implications of ‘new’ treatments in terms of evidence ambiguity. Copyright © 2016 John Wiley & Sons, Ltd.     

Preferences for public involvement in health service decisions: a comparison between best-worst scaling and trio-wise stated preference elicitation techniques

Stated preference elicitation techniques, such as discrete choice experiments and best-worst scaling, are now widely used in health research to explore the public’s choices and preferences. In this paper, we propose an alternative stated preference elicitation technique, which we refer to as ‘trio-wise’. We explain this new technique, its relative advantages, modeling framework, and how it compares to the best-worst scaling method. To better illustrate the differences and similarities, we utilize best-worst scaling Case 2, where individuals make best and worst (most and least) choices for the attribute levels that describe a single profile. We demonstrate this new preference elicitation technique using an empirical case study that explores preferences among the general public for ways to involve them in decisions concerning the health care system. Our findings show that the best-worst scaling and trio-wise preference elicitation techniques both retrieve similar preferences. However, the capability of our trio-wise method to provide additional information on the strength of rank preferences and its ability to accommodate indifferent preferences lead us to prefer it over the standard best-worst scaling technique.     

Discounting life-years: whither time preference?

If elicited time preferences are to be incorporated into economic evaluations, not only social but also individual preferences may be included. The view of this paper is that social intertemporal preferences should govern social intertemporal choices when prioritising between the saving of lives now or in the future. However, the present value of an individual's stream of future health benefits is a matter of private consumption and hence either individual time preferences or social interpersonal preferences could be applied when evaluating the value of extended life or improved quality of life. This paper shows that it is possible to incorporate both types of time preferences in an economic evaluation; using the individual time preference or the social interpersonal preference when discounting the remaining life expectancy and the social intertemporal time preference for discounting the health benefits from the time of the risk reduction to present time. Such a scenario could solve potential problems such as double discounting of QALYs, the paradox of intertemporal equity versus interpersonal equity, as well as include elements of quantity, risk and uncertainty which are otherwise ignored in evaluations of life-saving therapies. © 1998 John Wiley & Sons, Ltd.     

The sexuality of migration: border crossing and Mexican immigrant men

Recently, the hypothesis that state-level political context influences individuals' cultural values – the ‘red states v. blue states’ hypothesis – has been invoked to explain the hyper-polarisation of politics in the USA. To test this hypothesis, we examined individuals' knowledge about abortion in relation to the political context of their current state of residence. Drawing from an internet-survey of 586 reproductive-age individuals in the USA, we assessed two types of abortion knowledge: health-related and legality. We found that state-level conservatism does not modify the existing relationships between individual predictors and each of the two types of abortion knowledge. Hence, our findings do not support the ‘red states’ versus ‘blue states’ hypothesis. Additionally, we find that knowledge about abortion's health effects in the USA is low: 7% of our sample thought abortion before 12 weeks gestation was illegal.     

Decision heuristic or preference? Attribute non‐attendance in discrete choice problems

This paper investigates if respondents' choice to not consider all characteristics of a multiattribute health service may represent preferences. Over the last decade, an increasing number of studies account for attribute non‐attendance (ANA) when using discrete choice experiments to elicit individuals' preferences. Most studies assume such behaviour is a heuristic and therefore uninformative. This assumption may result in misleading welfare estimates if ANA reflects preferences. This is the first paper to assess if ANA is a heuristic or genuine preference without relying on respondents' self‐stated motivation and the first study to explore this question within a health context. Based on findings from cognitive psychology, we expect that familiar respondents are less likely to use a decision heuristic to simplify choices than unfamiliar respondents. We employ a latent class model of discrete choice experiment data concerned with National Health Service managers' preferences for support services that assist with performance concerns. We present quantitative and qualitative evidence that in our study ANA mostly represents preferences. We also show that wrong assumptions about ANA result in inadequate welfare measures that can result in suboptimal policy advice. Future research should proceed with caution when assuming that ANA is a heuristic.     

教育对健康的影响及其作用机制研究——基于中国家庭追踪调查的实证分析

目的：研究个体教育水平对健康的影响,分析教育对健康的作用机制。方法：利用CFPS2020数据,通过Logit模型与线性回归分析教育水平对健康是否存在影响,运用中介效应分析对其作用机制进行探讨。结果：以身体不适、自评健康和心理健康为因变量,受教育年限的提升对个体健康存在显著正效应,但高等教育个体中该效应不显著;中介效应分析显示,以代表健康行为的吸烟、锻炼和代表预算约束的收入水平为中介变量,教育对健康的中介作用存在,支持健康行为说和预算约束说。结论：教育对健康存在正向影响,但其主要体现在初中等教育阶段;更高的受教育年限促使个体通过改善健康行为和收入,进而提高健康水平。     

Paying more for faster care? Individuals' attitude toward price-based priority access in health care

Increased competition in the health care sector has led hospitals and other health care institutions to experiment with new access allocation policies that move away from traditional expert based allocation of care to price-based priority access (i.e., the option to pay more for faster care). To date, little is known about individuals' attitude toward price-based priority access and the evaluation process underlying this attitude. This paper addresses the role of individuals' evaluations of collective health outcomes as an important driver of their attitude toward (price-based) allocation policies in health care.The authors investigate how individuals evaluate price-based priority access by means of scenario-based survey data collected in a representative sample from the Dutch population (N = 1464). They find that (a) offering individuals the opportunity to pay for faster care negatively affects their evaluations of both the total and distributional collective health outcome achieved, (b) however, when health care supply is not restricted (i.e., when treatment can be offered outside versus within the regular working hours of the hospital) offering price-based priority access affects total collective health outcome evaluations positively instead of negatively, but it does not change distributional collective health outcome evaluations. Furthermore, (c) the type of health care treatment (i.e., life saving liver transplantation treatment vs. life improving cosmetic ear correction treatment – priced at the same level to the individual) moderates the effect of collective health outcome evaluations on individuals' attitude toward allocation policies.For policy makers and hospital managers the results presented in this article are helpful because they provide a better understanding of what drives individuals' preferences for health care allocation policies. In particular, the results show that policies based on the “paying more for faster care” principle are more attractive to the general public when treatment takes place outside the regular working hours of a hospital.     

What do patients really want? Patients’ preferences for treatment for angina

Objective To measure preferences for angina treatments among patients admitted from accident and emergency with acute coronary syndrome. Background Evidence suggests variability in treatment allocations amongst certain socio‐demographic groups (e.g. related to age and sex), although it is unclear whether this reflects patient choice, as research on patients’ treatment preferences is sparse. Given current policy emphasis on ‘patient choice’, providers need to anticipate patients’ preferences to plan appropriate and acceptable health services. Design Self‐administered questionnaire survey. Setting In‐patients in a UK hospital. Participants A convenience sample of 53 newly admitted patients with acute coronary syndrome. Exclusion criteria were: a previous cardiologist consultation (including previous revascularization); a clinical judgement of too ill to participate; post‐admission death; non‐cardiac reasons for chest pain. Main outcome measures Patients’ preferences for coronary artery bypass graft (CABG); angioplasty; and two medication alternatives. Results Angioplasty was the preferred treatment (for 80% of respondents), and CABG was second (most preferred by 19%, but second most preferred for 60%). The two least preferred (and least acceptable) treatments were medications. The majority of patients (83%) would ‘choose treatment based on the extent of benefits’ and ‘accept any treatment, no matter how extreme, to return to health’. There were some differences in preference related to age (>70 years preferred medication to a greater degree than <70 years) and sex (males preferred CABG surgery more than females). Conclusions There was general preference for procedural interventions over medication, but most patients would accept any treatment, however extreme, to return to former health. There was some evidence of differences in preferences related to age and sex. Furthermore, most patients preferred to have some input into treatment choice (e.g. nearly half wanted to share decision responsibility with their doctor), with only 4% preferring to leave the decision entirely to their doctor. Given these findings, and past findings that suggest there may be variability in treatment allocation according to certain socio‐demographic factors, this study suggests a need to develop and use preference measures, and makes a step towards this.     

Discounting future health benefits: the poverty of consistency arguments

In economic evaluation of health care, main stream practice is to discount benefits at the same rate as costs. But main papers in which this practice is advocated have missed a distinction between two quite different evaluation problems: (1) How much does the time of program occurrence matter for value and (2) how much do delays in health benefits from programs implemented at a given time matter? The papers have furthermore focused on logical and arithmetic arguments rather than on real value considerations. These ‘consistency arguments’ are at best trivial, at worst logically flawed. At the end of the day, there is a sensible argument for equal discounting of costs and benefits rooted in microeconomic theory of rational, utility maximising consumers' saving behaviour. But even this argument is problematic, first because the model is not clearly supported by empirical observations of individuals' time preferences for health, second because it relates only to evaluation in terms of overall individual utility. It does not provide grounds for claiming that decision makers with a wider societal perspective, which may include concerns for fair distribution, need to discount health benefits and costs equally. This applies even if health benefits are measured in monetary terms. Copyright © 2010 John Wiley & Sons, Ltd.     

‘Developing the “whole me”’: Citizenship,neo-liberalism and the contemporary health and physical education curriculum

In several Australian states in recent years, the fields of health education and physical education have been united in schools as a single learning area. This article identifies the discourses on health that are evident in the context of a specific contemporary health and physical education curriculum–that operating in Australian schools in the state of Victoria. By analysing the curriculum document and teachers' accounts of the principles of the curriculum and their experiences in teaching it, it is shown that particular notions of health, related to neo-liberal ideas about citizenship, holism and personal identity, currently dominate. There is strong evidence of the influence of ‘the new public health’ tenets and ideas about the importance of emotional management and self-esteem in both the curriculum document and teachers' accounts. It is argued, however, that while the dominant tenets of the curriculum are generally espoused by teachers, there is also evidence of resistance, either intended or unintended, to these tenets at the site of the school.     

Training for certainty

This paper offers a critique of the idea of ‘uncertainty’ in the sociology of medicine, particularly in the context of studies of medical education. The work of Renée Fox is used as the main example of the work against which this criticism is levelled. It is argued that the idea of ‘training for uncertainty’ has been over-emphasized in previous literature. The notion of ‘training for certainty’ is proposed as a corrective. Finally, however, it is argued that an adequate phenomenology of medical knowledge, education and practice must recognize ‘certainty’ and ‘uncertainty’ as two different ‘attitudes’, which may co-exist simultaneously, reflecting different practical and theoretical interests.     

Social tariffs and democratic choice—Do population‐based health state values reflect the will of the people?

In economic evaluations of health technologies, health outcomes are commonly measured in terms of quality‐adjusted life years (QALYs). QALYs are the product of time and health‐related quality of life. Health‐related quality of life, in turn, is determined by a social tariff, which is supposed to reflect the public's preference over health states. This study argues that, because of the tariff's role in the societal decision‐making process, it should not be understood as merely an operational (statistical) definition of health, but as a major instrument of democratic participation. I outline what implications this might have for both the method used to aggregate individual preferences, and the set of individuals whose preferences should count. Alternative tariff specifications and decision rules are explored, and future research directions are proposed.     

Is Best–Worst Scaling Suitable for Health State Valuation? A Comparison with Discrete Choice Experiments

Health utility indices (HUIs) are widely used in economic evaluation. The best–worst scaling (BWS) method is being used to value dimensions of HUIs. However, little is known about the properties of this method. This paper investigates the validity of the BWS method to develop HUI, comparing it to another ordinal valuation method, the discrete choice experiment (DCE). Using a parametric approach, we find a low level of concordance between the two methods, with evidence of preference reversals. BWS responses are subject to decision biases, with significant effects on individuals' preferences. Non parametric tests indicate that BWS data has lower stability, monotonicity and continuity compared to DCE data, suggesting that the BWS provides lower quality data. As a consequence, for both theoretical and technical reasons, practitioners should be cautious both about using the BWS method to measure health‐related preferences, and using HUI based on BWS data. Given existing evidence, it seems that the DCE method is a better method, at least because its limitations (and measurement properties) have been extensively researched. Copyright © 2016 John Wiley & Sons, Ltd.     

A qualitative exploration of treatment decision-making role preference in adult asthma patients

Objectives To explore preferred treatment decision‐making roles, and rationales for role preference, and to identify perceived facilitators to and barriers from attaining preferred role. Design Qualitative design. Setting and Participants One secondary care and four primary care sites in North‐west England. Purposive sample of 32 adult asthma patients with varied socio‐economic backgrounds and disease severity. Methods Tape‐recorded focused‐conversation style interviews. Interview topic guide derived from the literature. Sort cards employed to provide the focus for exploration of role preferences. Results Active (n = 7), collaborative (n = 11) and passive (n = 14) decisional role preferences were identified. Respondents cited level of knowledge; trust; duration of condition; severity of condition at the decisional juncture; lifelong nature of asthma; a perception that ‘it is my body’; characteristics of the individual and their response to health professionals as influencing role preference. Perceived facilitators and barriers to participation included condition‐related knowledge, practical issues (e.g. lack of time during consultation) and clinicians' interpersonal skills. Conclusions Most respondents wished to contribute to or feel involved in treatment decision‐making, but not necessarily to control it. Some hindrances to participation would be amenable to intervention. The quality of the provider–patient relationship is central to facilitating participation.     

The role of time and risk preferences in adherence to physician advice on health behavior change

Changing physical activity and dietary behavior in chronic disease patients is associated with significant health benefits but is difficult to achieve. An often-used strategy is for the physician or other health professional to encourage behavior changes by providing advice on the health consequences of such behaviors. However, adherence to advice on health behavior change varies across individuals. This paper uses data from a population-based cross-sectional survey of 1849 individuals with chronic disease to explore whether differences in individuals’ time and risk preferences can help explain differences in adherence. Health behaviors are viewed as investments in health capital within the Grossman model. Physician advice plays a role in the model in that it improves the understanding of the future health consequences of investments. It can be hypothesized that the effect of advice on health behavior will depend on an individuals’ time and risk preference. Within the survey, which measured a variety of health-related behaviors and outcomes, including receipt and compliance with advice on dietary and physical activity changes, time preferences were measured using financial planning horizon, and risk preferences were measured through a commonly used question which asked respondents to indicate their willingness to take risks on a ten-point scale. Results suggest that time preferences play a role in adherence to physical activity advice. While time preferences also play a role in adherence to dietary advice, this effect is only apparent for males. Risk preferences do not seem to be associated with adherence. The results suggest that increasing the salience of more immediate benefits of health behavior change may improve adherence.     

Dangerous knowledge vs. dangerous ignorance: Risk narratives on sex education in the Russian press

The paper is devoted to analysis of the debates on sex education in the Russian press. ‘Risk narrative structure’ of media articles on sex education was determined. This structure represents a system of mutually constituting elements, which include object of risk, risks themselves, solutions to their prevention, solutions opponents, and type of society these solutions presuppose. It is argued that analysis of risks with the aid of ‘risk narrative structures’ can be a useful development of sociocultural theory of risk, as competing risk narratives can be fully grasped only when considered not as discrete claims about different ‘risks’ but as coherent systems of interrelated meanings. On the basis of this structure, competent risk media narratives of proponents and opponents of sex education were reconstructed. In these narratives different definitions of ‘children’ as objects of risk were constructed, and so were types of risks, and types of society. It would be oversimplifying to consider debates on sex education as a battle of ‘enlightened rationality’ against ‘dark irrationality.’ In each risk narrative the solution (introduction or ban of sex education) is a logically following element in the respective risk narrative. While sex education advocates were concerned about negative consequences of children's sexual behaviour and defence of the ‘civilised society's moral boundaries, the opposite side was concerned about retaining children's moral purity and defence of ‘traditional’ moral boundaries.     

Care = organisation + physical labour + emotional labour

The formula‘care = organisation + physical labour + emotional labour' identifies component parts of ‘carework’ as they were observed at a hospice. A comparison between women's domestic carework and that of the hospice nurses is made firstly to clarify the component elements of care and secondly to show how the interrelation and balance of the components differs in the two settings. It is argued that family care has been a model for hospice care but that division of labour in hospices, which replicates hospital labour-divisions, results in an inflexibility in hospice care which is incompatible with the ‘family’ model. In the final section it is suggested that emotional labour is likely to be increasingly recognised as part of health care but that the concept of ‘total care’ needs to be questioned.