Measurement Issues in Health Disparities Research

Background. Racial and ethnic disparities in health and health care have been documented; the elimination of such disparities is currently part of a national agenda. In order to meet this national objective, it is necessary that measures identify accurately the true prevalence of the construct of interest across diverse groups. Measurement error might lead to biased results, e.g., estimates of prevalence, magnitude of risks, and differences in mean scores. Addressing measurement issues in the assessment of health status may contribute to a better understanding of health issues in cross-cultural research.
Objective. To provide a brief overview of issues regarding measurement in diverse populations.
Findings. Approaches used to assess the magnitude and nature of bias in measures when applied to diverse groups include qualitative analyses, classic psychometric studies, as well as more modern psychometric methods. These approaches should be applied sequentially, and/or iteratively during the development of measures.
Conclusions. Investigators performing comparative studies face the challenge of addressing measurement equivalence, crucial for obtaining accurate results in cross-cultural comparisons.     

Food, health, the environment and consumers' dietary choices

The aim of this paper is to examine some of the issues that surround food and the environment, particularly conventional and organic agriculture and food distribution, and to look at some of the health implications. It is argued that the links between food, health and the environment are strong. Consumers have the power to have an impact positively or negatively on the environment via their dietary choices. By providing information and advice about the environmental as well as the health impact of food choices, health and nutrition professionals could increase consumers' awareness of such issues.     

Improving the quality of child health services: participatory action by providers.

OBJECTIVE: To test a quality improvement approach called COPE (Client-Oriented, Provider-Efficient services), for use in strengthening health systems and supporting Integrated Management of Child Health (IMCI) efforts. DESIGN: Pre- and post-intervention observations of client/provider interactions, facility audits, staff and client surveys, and focus groups to evaluate differences between eight COPE intervention and eight matched non-intervention facilities after a 15-month intervention in 2001. SETTING: Primary care clinics in Guinea and Kenya. STUDY PARTICIPANTS: Health care providers and child caregivers. INTERVENTIONS: Over 15 months, the intervention supported four COPE exercises at each intervention site, supported supervisor training in quality management, and organized minimal training in topics selected by site staff as areas where training was needed. MAIN OUTCOME MEASURES: Differences in staff's and child caregiver's knowledge, attitudes, and practices; differences in the quality of services provided. RESULTS: On almost every quality indicator (over 65 indicators), whether reported by staff, observed by evaluators, or reported by clients, the intervention sites performed statistically significantly better than control sites. INTERVENTION: sites were cleaner and more pleasant, with more respect and information for clients, and more privacy. Staff had better personal communication skills, better diagnostic skills, and prescribing practices and gave better home care instructions to carers. Clients in intervention sites were more informed and more satisfied, and their children had better immunization coverage than those in control sites. CONCLUSION: COPE is a simple process, yet our study confirms that it can have a very dramatic effect on the quality of services. This study demonstrated how all areas of quality can be addressed by empowering health care providers to take action by using COPE. We suggest that COPE can complement Integrated Management of Childhood Illness (IMCI) training and can help to achieve better health for children.     

Patient satisfaction with health care providers in South Africa: the influences of race and socioeconomic status.

OBJECTIVE: The first democratic government elected in South Africa in 1994 inherited huge inequalities in health status and health provision across all sections of the population. This study set out to assess, 4 years later, the influence of race and socioeconomic status (SES) on perceived quality of care from health care providers. DESIGN: A 1998 countrywide survey of 3820 households assessed many aspects of health care delivery, including levels of satisfaction with health care providers among different segments of South African society. RESULTS: Fifty-one percent (n = 1953) of the respondents had attended a primary care facility in the year preceding the interview and were retained in the analysis. Both race and SES were significant predictors of levels of satisfaction with the services of the health care provider, after adjusting for gender, age, and type of facility visited. White and high SES respondents were about 1.5 times more likely to report excellent service compared with Black and low SES respondents, respectively. CONCLUSION: In South Africa, race and SES are not synonymous and can no longer be considered reliable proxy indicators of one another. Each has distinct and significant but different degrees of association with client satisfaction. Any assessment of equity-driven health policy in South Africa should consider the impacts of both race and SES on client satisfaction as one of the indicators of success.     

Clothing size as an indicator of adiposity, ischaemic heart disease and cardiovascular risks

OBJECTIVE: To relate subjects' clothing sizes to waist circumference, body mass index (BMI) and to the risks of ischaemic heart disease, hypertension and diabetes mellitus, and to derive cut-off levels of clothing size that correspond to increased health risks. DESIGN: Cross-sectional study. Setting Glasgow Royal Infirmary. PARTICIPANTS: A stratified subsample of 201 men and 161 women aged 27-67 years from the Glasgow monitoring coronary (MONICA) risk factor survey. MAIN OUTCOME MEASURES: Measured waist, weight and height, blood pressure and history of ischaemic heart disease (angina, myocardial infarction or angioplasty), hypertension and diabetes mellitus, and medications. RESULTS: There were 15.5% of men and 11.2% of women with ischaemic heart disease, 14.9% of men and 12.4% of women with hypertension, and 4.5% of men and 3.1% of women with diabetes mellitus. Age and smoking adjusted prevalences of these cardiovascular risks, as well as increased adiposity (waist circumference > or =102 cm in men, > or =88 cm in women or BMI > or = 30 kg m(-2)) rose with increasing clothing size. Clothing size correlated (P < 0.001) linearly with indices of adiposity. Clothing sizes which correspond to waist circumference action level 1 (94 cm in men, 80 cm in women) and action level 2 (102 cm in men, 88 cm in women) or to standardized BMI cut-offs (25 and 30 kg m(-2)) were estimated. Height has minimal influences on clothing size. Compared with men with trouser waist below 36 inches or women with UK dress size below 16, the age and smoking adjusted odds ratios for the risk of having at least one of the major health problems (ischaemic heart disease, hypertension or diabetes mellitus) were 3.9 (95% CI: 1.8-8.3) in men and 7.0 (95% CI: 2.5-19.4) in women who had trouser size > or =38 inches or UK dress size > or =18, respectively. CONCLUSIONS: The present study showed that men and women with large clothing size are at increased risk of ischaemic heart disease, hypertension and diabetes mellitus. Men's trouser size equal or larger than 38 in the UK and USA or 97 in Europe and women's dress size equal or larger than 18 in the UK or 16 in the USA or 48 in Europe could be used to promote self-awareness of increased health risks by the general public.     

Smoking practices in New York City: The use of a population-based survey to guide policy-making and programming

To inform New York City’s (NYC’s) tobacco control program, we identified the neighborhoods with the highest smoking rates, estimated the burden of second-band smoke exposure, assessed the early response to state taxation, and examined cessation practices. We used a stratified random design to conduct a digit-dialed telephone survey in 2002 among 9,674 New York City adults. Our main outcome measures included prevalence of cigarette smoking, exposure to second-hand smoke, the response of smokers to state tax increases, and cessation practices. Even after controlling for sociodemographic factors (age, racelethnicity, income, education, marital status, employment status, and foreign-born status) smoking rates were highest in Central Harlem and in the South Bronx. Sixteen percent of nonsmokers reported frequent exposure to second-hand smoke at home or in a workplace. Among smokers with a child with asthma, only 33% reported having a no-smoking policy in their homes. More than one fifth of smokers reported reducing the number of cigarettes they smoked in response to the state tax increase. Of current smokers who tried to quit, 65% used no cessation aid. These data were used to inform New York City’s smoke-free legislation, taxation, public education, and a free nicotine patch give-away program. In conclusion, large, local surveys can provide essential data to effectively advocate for, plan, implement, and evaluate a comprehensive tobacco control program. Dr. Mostashari (the guarantor) made substantial contributions to the conception, design, and supervision of this paper, the analysis and interpretation of data, the drafting of the paper, critical revisions of the paper for important intellectual content, and the acquisition of data and funding for this research. Dr. Kerker made substantial contributions to the analysis and interpretation of data, the drafting of the paper and critical revisions of the paper for important intellectual content. Ms. Hajat made substantial contributions to the acquisition of data and critical revisions of the paper for important intellectual content. Dr. Miller made substantial contributions to the conception of this paper and critical revisions of the paper for important intellectual content. Dr. Frieden made substantial contributions to the conception, design, and supervision of this paper and critical revisions of the paper for important intellectual content.     

Work Place Health Promotion

This article deals with the question of whether and how much workplace health promotion measures have infiltrated the working world and which factors determined the results of health promotion programs for the enterprises. To answer this question we conducted a longitudinal study (measuring times: 1997 and 2003) in 150 enterprises in Hessen and Thueringen of the service sector and metal branch. A standardized questionnaire was used to collect the data. One of the results was that the high level of occupational safety and health (OSH) obtained was greatly appreciated by the enterprises interviewed. Many of the enterprises (82.7%) were able to implement at least one workplace health promotion (WHP) measure, mostly assessments of occupational health risks and behavior-oriented offers. The portion of businesses with a very good to sufficient level of workplace health promotion increased clearly from 16.0% in 1997 to 27.4% in 2003. Half of the enterprises interviewed confirmed the need for information and consultation in questions about occupational safety and health issues and workplace health promotion. They expected support particularly from the institutions for statutory occupational accident insurance, health insurance companies, public institutions for labor protection and safety engineering, as well as from the advisory boards of the trade unions. These institutions definitely need to address the consultation requests from the enterprises, as the lack of information and contact persons was one of the reasons why workplace health promotion measures could not be implemented.This study was commissioned by the Hans Boeckler Foundation and the SMBG and translated by Evelyn Jäck     

Routine Physical Examination and Forgone Health Care among Latino Adolescent Immigrants in the United States

Knowledge concerning patterns of health care utilization among Latino-adolescent immigrants is needed to develop culturally-appropriate programs. The objectives of this study were to estimate the annual prevalence of having had a routine physical exam and episodes of adolescents’ not seeking health care when they thought they should (forgone health care) among Latino adolescents by immigrant-generational status. Cross-sectional analysis of data from Latino adolescents in Wave I of the National Longitudinal Adolescent Health Study. First-generation immigrants who had lived in the U.S. ≤ 5 years were less likely to receive routine care than third-generation immigrants (39.0% vs. 54.9%). This disparity decreased after adjustment for insurance status, parental education and poverty among Mexican origin adolescents. On average, 16.0% of first-generation immigrants who had lived in the U.S. ≤ 5 years and 22.5% of third-generation immigrants reported forgoing health care. After adjustment for age, insurance status, parental education and routine care, recent arrivals were less likely than third-generation immigrants to forgo health care. Recent arrivals were less likely to receive a routine physical exam and to forgo care than third-generation immigrants. Future studies should explore the effect of acculturation on knowledge, beliefs and perceptions about health, illness and care-seeking behaviors.     

关于我国公共卫生体系建设现状及对策的思考

公共卫生问题直接关系到群众的身心健康，特别是全球化进程的加快，食品卫生、疾病控制等问题是各国共同面临的问题。作者通过对奥地利卫生管理、体系建设、食品安全等方面的考察，进行分析、思考，对我国卫生体制改革提出了建议。作者认为，深化卫生改革，要进一步加强食品卫生监督执法，要重视和加强职业卫生，要加强医疗救治和医疗机构监督管理，要进一步完善社会医疗保险体系，要加强卫生管理理论的培训。