Showing papers in "European Journal of Public Health in 1994"

Explanations for socio-economic differentials in mortality

Abstract: Socio-economic differentials in mortality are examined using the explanatory framework advanced by the Black Report. The evidence reviewed largely relates to studies carried out in Britain, although data from other European countries and the United States have also been considered. The many possible forms of artefactual distortion of associations between socio-economic status and mortality risk are examined and judged to have little effect; if anything, artefactual factors mean that conventional ideas about the magnitude of socio-economic differentials in mortality are an underestimate. Social selection is also considered to have little effect. Neither intragenerational downward drift nor direct intergenerational selection contribute significantly to the size of the differentials. Indirect selection has yet to be evaluated, although whether ft should be considered as a form of health selection rather than one form of accumulated disadvantage is unclear. Behavioural factors, while making important contributions to mortality risk, do not adequately account for the differences between social groups. Materialist factors, that is differential exposure to physical hazards determined by the distribution of income and opportunity, are an attractive explanatory category, since the persisting (or growing) socio-economic and geographical mortality differentials, seen during a period of broad secular declines in mortality rates, would be the anticipated outcome of their action. However, neither the social processes determining risk exposure nor the mechanisms by which exposures produce disease are well understood. Progress jn this area will depend upon studies which can examine how exposures interact and accumulate over the course of life to produce the observed pattern of mortality risk.

Sense of coherence, social structure and health : evidence from a population survey in Sweden

Abstract: In order to understand how health can be preserved under very stressful conditions Antonovsky has introduced the concept of sense of coherence (SOC). A number of studies have also been able to show a relationship between SOC and health. Although explicitly developed to explain healthiness among persons exposed to extreme stress, differences in SOC ought to be an additional explanation for differences in ill health between individuals and between groups of people. Focusing on the health consequences of having a low SOC could be one way of reaching a better understanding of the social differentiation of ill health. In this paper we focus on the distribution of low SOC over social classes, age groups and between men and women and the relationship between low SOC on the one hand and psychological distress and circulatory problems on the other. The data set includes 3,949 persons who were 25-75 years old in 1991 and who participated in both the 1981 and 1991 waves of the Swedish Level of Living Survey. The analyses show that workers and farmers have a greater than average risk of reporting a low SOC, whereas the opposite is true for white-collar workers and the self-employed. Older people also tend to run a higher risk of having a low SOC. On the other hand, men and women do not differ. We also find a strong relationship between a low SOC and mental and circulatory health problems, when controlling for age, sex and social class. This relationship is weaker but still strongly significant when possible confounding variables are controlled for.

Health inequalities among men and women in contrasting welfare statesBritain and three Nordic countries compared

Abstract: This paper compares the degree and patterning of health inequalities among men and women in 4 different welfare states: in Britain and in 3 Nordic countries (Finland, Norway and Sweden). It is argued that the structural position including social class/employment status and material living standards are determinants of men's health, but additional determinants of women's health include family roles. Employment patterns are similar for men in all 4 countries and for Finnish women, but differ for women in the other 3 countries where women take part-time jobs or, particularly in Britain, where more women are full-time housewives. Prevalence data from comparable surveys in the 4 countries are presented and further analysed by means of logistic regression analysis. Associations with limiting long-standing illness are examined by age, social class, material living standards and family roles. Contrary to expectations inequalities in health are more pronounced for both employed men and employed women in the Nordic countries than in Britain. For men in all 4 countries and for Finnish and Swedish women, age and social class are strongly associated with ill-health. For Norwegian women the evidence remains unclear. Employment participation among British women is lower than in the other 3 countries and in the examination of their ill-health a role framework complements the structural one: in addition to age and social class, marital status and parental status are associated with their ill-health.

How far does research influence policy

Abstract: This paper argues that there are ways of making research more amenable to the needs of policy makers and policy makers more sympathetic to the needs of researchers by investing in greater analysis of the links between research and policy. It shows how many in public health hold contradictory conceptual pictures of the research process, assuming a rational ratherthan enlightenment model of the policy process. By acknowledging the barriers to research affecting policy it becomes easier to build strategies around the dissemination of research so that it becomes more accessible to policy makers. Thus, researchers need to take into account the extent to which politics may affect how much notice policy makers take of research findings, they need to consider how far scientific uncertainty leads to distortion or inaction in policy making and they need to consider issues around timing and communication of research results, recognizing policy makers' short-term horizons and the need for clear presentation of scientific findings. The paper ends by arguing that those in public health need to pay far more attention to the policy environment, looking not just at policy content, but also at the processes of policy. By using a policy analysis framework it is possible to identify and overcome the barriers to research influencing policy.

Twelve year follow-up of a school-based health education programmeThe Oslo Youth Study

Abstract: The Oslo Youth Study (1979–1981) was designed to evaluate the impact of a school-based health education programme targeting students' eating patterns, physical activity levels and cigarette smoking. The study was implemented with participants from 6 combined elementary and junior high schools, half of whom received the educational programme. In the autumn of 1991, students enrolled as part of the Oslo Youth Study grade cohorts in 1981 were invited to participate in a follow-up study. The purpose of this study was to investigate the potential long-term impact of the Oslo Youth Study health education programme. A total of 711 subjects completed a questionnaire in 1991 (an overall participation rate of 75.1%). Analysing the cross-sectional data obtained in 1991, we observed no overall long-term positive impact of either the smoking, nutrition or physical education programmes. Among the 1979–1991 cohort participants, we found that subjects exposed to the educational programme reported a significantly higher prevalence of regular vigorous exercise than did subjects from comparison schools (49 versus 40%; p=0.01). No similar effect was seen with smoking or eating behaviour. The results from this 12 year follow-up study seem to confirm findings from previous studies indicating that school-based education can have a positive short-term impact on health-related behaviours, but that these effects tend to disappear over time.

A conceptual overview of recent health care reforms

Abstract: Health systems in many developed countries are undergoing major structural reform. While some changes remain regulatory in character, a new feature is the large number of reforms that rely upon market-derived instruments to improve the performance of health care institutions. The shift toward incentive-oriented reforms is particularly pronounced in publicly operated health systems. Current reforms can be analysed in terms of 2 conceptual frameworks: the policy objectives governments seek to attain, and the changes introduced within each of 3 basic building block components of a health system. Viewed through these lenses, the current reform process has emphasized market-derived approaches in the pursuit of micro-economic efficiency on the production side of health systems and in the allocative mechanism that links finance to production. Conversely, market-style instruments appear to have little to offer on the finance side of systems. Adequate evaluation has yet to be conducted to determine the impact of specific market-derived reforms on equity or on health-related effectiveness.

Community-wide cardiovascular disease prevention in young people: Long-term outcomes of the Class of 1989 Study

Abstract: The Class of 1989 Study, as part of the Minnesota Heart Health Program, examines 2 cohorts of adolescents in 2 communities in northcentral US. The goal of the study was to reduce the risk of cardiovascular disease among young people in one of the cohorts through changes in smoking, eating patterns and physical activity levels. Because of its importance as a health behaviour, alcohol use was also addressed, even though it was not a specific target of the Minnesota Heart Health Program. The behaviour patterns of both cohorts were surveyed annually in schools from 1983 to 1989. One cohort additionally was exposed to 5 years of behavioural health education in their schools, peer leadership and a community-wide programme for adults. The behaviour health education curricula focused on skills, competencies, role models and norms for healthier behaviour. Students in the educated cohort demonstrated significant reductions in smoking from 1984 to 1989. Females in the educated cohort also consistently reported significantly healthier eating habits and physical activity patterns than the reference cohort. Short-term changes in alcohol use were also noted among both males and females, consistent with the results of other research studies of school-based programmes. Results for eating patterns and physical activity patterns with males were not as robust as with females. Nevertheless, behavioural health programmes in schools coordinated with community-wide education and campaigns with adults appears promising.

Incidence of and reasons for disability pension in a Swedish cohort of middle-aged men

Abstract: The prevalence of disability pensions was investigated among 5 birthyear cohorts (1926–30) of male residents in Malmo, Sweden (N=7,697) They were invited to a screening programme in the mid-1970s Disability pension and mortality data were identified from national computerized databases At the end of follow-up (the calendar year of their 58th birthday), 1,391 (18%) had been granted a disability pension and 655 (9%) had died The most frequent causes for disability pension, accounting for 74% of the cases, were musculoskeletal diseases, mental disorders (including alcohol dependence) and diseases of the circulatory system Alcohol dependence was more common among those who refrained from participating in the screening programme, while musculoskeletal and neurological diseases were more common among those who did participate Mental disorders (including alcohol dependence) predominated in younger and musculoskeletal diseases in older age groups Both alcohol dependence and non-participation in health screening were related to the risk of a disability pension To be used for identifying subjects at risk for disability pension, health screenings should be designed to reach as many of the usual non-participants as possible and should be targeted at men in younger ages

Excess winter mortality from ischaemic heart disease and stroke during colder and warmer years in Israel: An evaluation and review of the role of environmental temperature

Abstract: Most data on winter excess mortality from cardiovascular disease have been reported from countries with large seasonal temperature variations. In this study, the contribution of environmental temperature to ischaemic heart disease (IHD) and stroke mortality was evaluated in a country with relatively small variations in seasonal temperature. The association between monthly temperature and cause-specific monthly proportion of annual mortality was studied in the population of Israel aged 45 years and over for the period 1976–85. Population size in this group averaged nearly 1 million people during the study period, and about 40% of all deaths were due to IHD or stroke. For men, IHD mortality was 51% higher and stroke mortality 48% higher in mid-winter than in mid-summer; for women the respective figures were 48% and 40%. In cosinor analysis for months above and below the median minimum temperature, it was shown that excess mortality in winter was greater in years below the median minimum temperature in almost all age-sex categories. In partial correlation analysis, most of the variation in IHD and stroke mortality was explained by variation in minimum monthly temperature. These findings strongly support the role of environmental temperature in excess winter mortality from cardiovascular disease over a wide age range, and efforts should be directed at identifying intervention measures which could significantly reduce the incidence of premature mortality.

Love or money? Social support, class inequality and the health of women and children

Abstract: Recent evidence on the relationships between people's social support resources and their health shows the general importance of social support as an environmental factor promoting good personal and public health. The literature on social support is less equivocal in this sense than that on health-service use, where some evidence suggests that, even controlling for previous health status, use of the health services is not health promoting. However, it is not clear just what aspects of social support may be relevant to different measures of health status. The relationships between class inequality, social support and health-service use also require illumination. This paper uses longitudinal data from a study of socially disadvantaged households to explore these issues in relation to the health of women and young children. Analysis of these data shows that the social support resources of mothers generally decline over the first year following birth. Both quantitative and qualitative indicators of support are significant predictors of good health, though qualitative indicators (how support is experienced) have stronger relationships with health outcomes than quantitative indicators (the extent of social contact). The psychological well-being of mothers is more closely linked than either their physical health or that of their babies to their support resources. Support from mothers, friends and a research-provided midwife support intervention is particularly important. Health-service use and social support are not related to each other and, indeed, appear to function in opposite ways in relation to health outcomes; while health-service use is associated with poorer health (controlling for social deprivation, stress, and previous health status), the social support resources of mothers are associated with improved health outcomes.

Birth weight related to social indicators in Norway

Abstract: The relationship between parental social position and birth weight is being studied. A total population of 102,638 single born, first-born infants was included in the study. Census information from 1980 was linked to the Medical Birth Registry for the years 1978-1982. Children of parents with a high education (more than 15 years) had the highest birth weight. The association was distinct and linear between low birth weight and education. The same tendency appeared for paternal socio-economic status, but differences were comparatively small. When examining income the pattern was different. The highest maternal income group had the highest proportion of low birth weight offspring. When examining parental education jointly, it was found that the mothers' education had the greatest impact on birth weight. By adjusting for female smoking, using survey data, the association between maternal education and birth weight was weakened. However, assuming that birth weight is decreased by 200 g from smoking, the effect was still significant.

A comparison of approaches to health service quality in the UK, USA & Sweden and of the use of organizational audit frameworks

Abstract: Health care reforms in the UK, USA and Sweden are leading health providers and purchasers to pay more attention to quality. This paper considers different approaches to proving and improving quality before and after 1990 in these three countries. The second part of the paper describes different frameworks for auditing health service quality, such as the ISO 9000 and US Malcum Baldridge award. It considers how purchasers can use these frameworks in purchasing services, and how providers can use the frameworks to assess and improve their own service quality.

Social reproduction of physical activity

Abstract: Using a health promotion perspective, nationwide surveys on health behaviours and life-styles were carried out in 11 countries in 1985–1986. The surveys were part of the study 'Health Behaviour in School-aged Children (HBSC), a World Health Organization cross-national survey'. The analyses of these survey data from 13 and 15 year olds in Austria, Norway and Wales indicated that high levels of participation in physical activity by adolescents are associated with the physical activity levels of their parents and best friends, finding it easy to make new friends and liking school. Intervention aimed at increasing the number of adolescents who adopt and maintain participation in leisure-time physical activities is likely to be more successful if a greater number of strategies in several different settings are applied. The findings are explained as being a result of the social reproduction process and it is suggested that awareness about how this process affects the development of health behaviour and life-styles is vital in establishing realistic goals when planning and evaluating youth health promotion efforts.

Determinants of selected unhealthy eating behaviours among male and female adults

Abstract: In this exploratory study we have examined determinants of unhealthy eating behaviours in a sample of 500 middle aged adults from a city community in Scotland. Effects of sociodemographic characteristics and behavioural factors on the number of unhealthy eating habits were estimated. Findings from regression analyses show strong effects of male gender, lower occupational status, and smoking status on poor eating habits. A significant interaction effect between gender and alcohol consumption indicates a considerable gender difference in links between nutrition and drinking habits. The present findings indicate the complicated nature of determinants of unhealthy eating behaviours and call for more complex methods in studying patterns of eating behaviour.

Stability in physical activity levels in young adolescents

Abstract: There is a need for a descriptive epidemiology of stability and change in physical activity levels through childhood and adolescent years. The purpose of this study was to assess tracking (degree of stability) of 4 broad categories of self-reported physical activities in a sample of young adolescents over a period of 2 years. A representative sample of seventh graders (n=861) (478 boys and 383 girls, mean age at baseline 13.3 ± 0.3 years) in Hordaland county of Western Norway was first examined in 1990 and then again 2 years later in 1992. Both genders significantly reduced most activities while remaining stable in overall leisure-time physical activity as measured in hours per week. A substantial proportion of the sample, 69–90%, reported no or small deviations in the second year compared to baseline reports. Pearson's γ coefficients between corresponding measures at baseline and the second year were weak to moderate, varying between 0.25 and 0.51. Thus, the results do not indicate a conclusive pattern of tracking of physical activity. Mean levels were higher for boys than for girls at both time points on most measures. The data indicate that young adolescents become less physically active and their physical activity occurs in longer sessions. Further, a polarization between active and less active students seems to take place as the associations between the various measures were consistently stronger in the second year compared to the baseline year. This may reflect the beginning of a process leading to the existing polarization between the physically active and inactive sections of the adult population.

Life stress, support and class inequality

Abstract: This paper examines the relationships between stress, social support, class, health and health-service use in a sample of mothers and children from a predominantly socially disadvantaged population. The initial sample size was 509; the sample was drawn from 4 cities, 2 in the south of England and 2 in the Midlands. Stress, measured using a standard life-events inventory, was found to be more common amongst the most disadvantaged women; the women who reported the most stress during pregnancy also reported the most stress 1 year after the birth. There were few direct relationships between stress and social support; those that did exist were in the direction of more life events being associated with less support. The occurrence of life events was strongly related to the mothers' psychological and physical health; there were also relationships with the babies' health, especially at 1 year. Events of particular importance were those relating to money, problems with partners and paid work. Women who reported life events were more likely to use the health services both for themselves and for their babies. A model is proposed for understanding the processes linking the material and cultural circumstances associated with class and health outcomes. In this model, social support and health-service use occupy contrasting roles as factors mediating these relationships. While health-service use is associated with an increased risk of adverse health outcomes, social support is health-promoting.

Psychosocial factors and psychosomatic complaints among postal workers

Abstract: The aim with this cross-sectional study of postal workers in 7 different occupations was to evaluate the correlations between some psychosocial factors and psychosomatic complaints. A sample of 105 men and 38 women were given self-administered questionnaires. The questionnaires inquired about gastrointestinal complaints, sleep quality, psychological work demands, decision latitude, and social support at the workplace. The data were analysed by variance analysis (Anova), χ2-test and stepwise multiple regression. In the group with the lowest psychological work demands, the highest decision latitude, and the best social support, there were few symptoms in comparison with the other groups. The findings are consistent with the hypothesis that a poor psychosocial work situation results in a higher report of psychosomatic complaints. Therefore, it is important to elucidate the causes of high frequency of certain symptoms. This would be an important task for the occupational health service, since psychosomatic symptoms might be an early indicator of work related problems.

Health promotion in general practice: On meanings and aims in interaction

Abstract: The enterprise of health promotion in medicine involves a responsibility of distinguishing between the concepts of health and absence of disease and of reflecting on the notions of illness and sickness. In this paper the importance of human dialogue is stressed both as a means and end of the doctor-patient relationship and as the main means of genuine health promotion. The outcome of health work is proposed to depend mainly on the way the patients are encountered. Their efforts to make themselves seen as being sick should not on all occasions be diagnosed and treated. By means of a reflected, dialogic practice patients may be listened to and inspired to reconstruct their symbol-based relationship to the world of meaning. The conception of health primarily includes man's relationship to himself. Illness is looked upon as the subject's experience of illhealth, whereas disease is understood as a functional imbalance of bodily organs. There is a tacit meaning in being ill (and found sick) that can be realized and attended to best in close relationship with the patient. Physicians – preferably general practitioners – involved in health promotion should, it is concluded, both assist the patients to give up their sick role and continually elaborate their own professional competence to see and successfully encounter the manifold specifically human issues underlying their patients' presented symptoms.

Cost of diseases in international perspective

Abstract: This study compares the health care costs of The Netherlands with the United States and Sweden and estimates the impact of demographic change on costs. Total health care costs were allocated to disease, age, sex and specific subsectors. For The Netherlands 75% of the costs in 1988 were assigned to specific diseases. Costs of mental disorders and other chronic non-fatal diseases dominate, followed by cardiovascular diseases. The effect of age is strong from age 70 years onwards. The effect of sex, adjusting for age, is small, except for elderly women, who are more expensive. Both total and disease-specific costs are similar in The Netherlands and Sweden, but differ from those in the US. The available data suggest that the differences in medical practice and health care systems may explain a substantial part of the divergent results; demographic or epidemiologic aspects seem less important. Ageing induces, in the Dutch case, a modest 0.7% annual increase in costs. The contribution of other forces in the increase of costs is probably more important. A structural upward pressure on costs also prevails in The Netherlands and Sweden, but it is more prominent in the US, due to a large amount of expensive surgery and high administration costs.

Dementia-free life expectancy in Belgium

Abstract: To monitor the influence of dementia on the health of the population the concept of Dementia-Free life Expectancy (DemFLE) was introduced. The DemFLE was estimated using Sullivan's method on the data of the ERDA study 1991 (Epidemiology Research on Dementia, Antwerp, Belgium). At the age of 65 years, elderly people in Belgium had a life expectancy of 16.4 years, a DemFLE of 15.3 years, and 1.1 years with at least moderate dementia. In absolute years the life expectancy with dementia remained constant beyond the age of 65: it was about 1.7 years for women, 0.7 years for men. The proportion of the remaining life that will be lived in a demented state increased with age: 4% and 9% in men and women at age 65, but 20% and 30% at the age of 85. The results confirm dementia as an important public health problem in the elderly.

Health consequences of unemployment in Barcelona

Abstract: Although Spain has had the highest unemployment rate in the European Community for over a decade, very little is known about the impact of unemployment on the health of the Spanish population. This paper analyses the health consequences of unemployment in Barcelona, the capital of Catalonia, using a sample of 4,119 respondents to the Health Survey of Barcelona in 1986. It is concluded that ill health is not caused by unemployment per se, but is better explained by a combination of individual and socio-economic stressors. Furthermore, for more than purely economic reasons, the availability of an unemployment subsidy appears to be the most important factor in ameliorating the stresses of unemployment.

Changing perceptions of general practitioner care

Abstract: One of the major aims of the recent UK government inspired changes in general practice based primary care was to enhance the quality of care provided for consumers. The aim of the study reported here was to see if these changes, specifically the implementation of the GP contract in 1990, has led to an improvement in the quality of general practitioner care, at least from the consumers point of view. Thus, a follow-up study was conducted to investigate whether changes had occurred in the attitudes of consumers towards primary care between 1988 and 1991. Baseline data was collected in 1988 from a random sample of adults in one health district in South East England, with the second study being carried out in the same area in September 1991. The results indicate that some changes in consumer satisfaction have taken place. In the area of access, for example, satisfaction increased with waiting times in the doctors' surgery (an important source of dissatisfaction in the 1988 study) and an improvement has also taken place with respect to the time taken to get an appointment for the treatment of an urgent condition. Similarly with regard to the doctor-patient relationship, satisfaction with the time available in the consultation and the amount of information given has significantly improved. However, the proportion of respondents who felt they could not discuss their personal problems with their GP remains fairly high (well over one-third) representing little change from 1988. Similarly, overall satisfaction with the GP remains high. Explanations for these changes are discussed.

Unemployment and health in SpainThe influence of socio-economic environment

Abstract: We present the results of a study on the association between unemployment and health and the use of health services, exploring the influence of the socio-economic environment on these relationships. With this aim, data from the Spanish National Health Survey (SNHS) were used. Health was measured by subjective health status, presence of chronic illnesses and psychological symptoms. The use of health services was measured by drug consumption (over the counter and/or prescribed drugs), doctor consultation, hospital admission and casualty attendance. A total of 13,344 individuals aged between 16 and 65 years were included. Results were analysed for all of Spain and for 3 regions with different socio-economic levels: Andalusia, Catalonia and the Basque Country. Although in Spain as a whole there was a relationship between unemployment, ill health and more use of health services, this relationship varied for the selected regions. Thus, in Catalonia and the Basque Country, where unemployment rates have dramatically increased in recent years, this relationship was maintained, while in Andalusia, where high unemployment rates have been a long-standing phenomenon, the relationship was less clear. It is suggested that the economic and social environment might be critical in determining the relationship between unemployment and health.

The rationale behind early prevention of cardiovascular disease in young people

Abstract: The rationale for primary prevention of cardiovascular disease (CVD) in young people is based on the applicability to youth of the causal aetiologic model of CVD among adults. Young people in developed countries exhibit early atherosclerotic lesions, as well as elevated physiological risk factors. Young people in the United States consume a higher fat diet than recommended, approximately half are physically active and nearly 1 in 5 graduate from high school as regular cigarette smokers. Not only are risk factors and risk behaviours evident in youth, but they appear to track through adolescence and into adulthood. This review suggests that early prevention efforts are prudent and may be critical.

Health care reforms and public health

Abstract: This article addresses the relationship between public health and the current health care reforms (HCRs) in Europe, an important topic because countries engaged in HCR also endorse the Health for All (HFA) strategy of the World Health Organization (WHO) in which a public health approach dominates. Bringing these together into one comprehensive health policy is problematic and thus far not very successful. This study investigates this problem. Four different approaches of HCR are discussed: humanistic, organizational, administrative/financial and the public health approach. Next a description of the highlights of the HFA strategy is given. The HCR and HFA policies of England and The Netherlands are compared according to the following criteria: equity and equal access to health services, the use of health status data, appropriateness and efficiency of cure and care, health promotion and disease prevention and the role and responsibility of the government and other actors. In England the prospects for the integration of HCR and public health are more favourable than in The Netherlands. The structure of the health care system – government dominated versus pluralistic–seems to be the most important factor. In England steps have been taken to integrate the health strategy into the existing health care system, the National Health Service, whereas in The Netherlands the health strategy and the health care system are almost completely separate. Nevertheless in these (and other) countries, there are opportunities for further integration. HCRs should have broader objectives, public health should tune in more to the current debate on HCR and the Maastricht Treaty offers new opportunities for the integration of the two.

‘Thinking aloud’ as a method of analysing the treatment decisions of physicians

Abstract: The feasibility of studying the decision-making process of physicians with the ‘thinking aloud’ method was tested in a study of 33 physicians. On 2 occasions 3 months apart the study subjects were asked for their management of 2 duplicate sets of 5 patients. On 1 occasion they either had to think aloud when making their decision, or they had to give a retrospective report of their decision-making process. The verbalized thoughts and retrospective reports were analysed to search for different decision-making strategies. In 2 relatively simple cases (women with urinary tract infections), the thinking aloud method showed a decision process with little deliberation about the treatment, suggesting the use of rules-of-thumb or routine behaviour. Thinking aloud during more complex cases (stomach and reflux complaints) showed more comparative and absolute evaluations of possible management and treatment options. This differentiation in strategies did not emerge from the retrospective reports. The inconsistency in the repeated treatment choices was about 27%. Thinking aloud did not significantly increase this inconsistency. It is concluded that thinking aloud is a useful method of analysing treatment decisions.

Values in European health care markets: values in European health care markets

Abstract: The discipline of public health has played an important role in showing that the health of populations depends on more than the amount and quality of the health services available. The relationship between health services and health status has been a traditional theme within the discipline. This paper proposes that public health has a part to play in current health reform debates and research, which have been dominated by attention to economic incentives and the technical operation of the systems. The focus has been on the inputs to and processes within health systems, with relatively little attention to the likely impact of these changes on outcomes and population health. The paper considers one aspect of health reforms which affects population health status: the part played by the social values of choice and equity. It gives an analysis of these concepts to help evaluate reforms, and as a basis for empirical research into the impact of reforms. It considers how the NHS reforms have affected choice and equity and how to increase patient choice and uphold certain types of equity which many health service staff and the public believe to be important. It shows how some types of choice conflict with some types of equity and that different groups in society benefit according to whether choice or equity is more prominent in health reform. The purpose of this paper is to help researchers, public health practitioners and policy makers consider, for a particular health reform, the following questions: i) will reforms increase the choices which are important to most people?, ii) what will the effect be on different types of equity?, iii) how will the changes affect population health?, iv) how should public health aims be pursued in systems with market competition?

Towards a framework for outcome assessment of health intervention : Conceptual and methodological considerations

Abstract: This study addresses health policy and public health in the field of cardiovascular disease (CVD) on the local level in Sweden. The overall aim is to contribute to the assessment of structural and social conditions within public health by analysing participation processes and outcome patterns in a local health programme. The northern Swedish MONICA study served as a reference area. The research strategy has been to integrate quantitative and qualitative methodologies and, thereby, focus on different aspects of the health programme under study.The mortality rate was excessive in the study area of Norsjo relative to both provincial and national figures over a period of more than 10 years. This finding formed the basis for a tenyear comprehensive and community-based health programme towards the prevention of CVD and diabetes.Even in this seemingly homogeneous area it was found that socio-economic circumstances were associated with the public health. Almost half of the study population had hypercholesterolaemia (;>6.5 mmol/1), 19% of men and 25% of women were smokers and 30% and 29%, respectively, had high blood pressure. Age had a strong impact on all outcome measures. After adjustments for age and social factors it was found that the relative risk of having hypercholesterolaemia dropped significantly in both sexes during the six years of intervention. The probability of being a smoker was significantly reduced only in highly educated groups. No statistically significant change over time could be found for the risk of suffering high blood pressure. In the reference area of northern Sweden there were no changes over time for any of the selected risk factors. The likelihood of self-assessed good health decreased with increasing risk factor load, with the exception of hypercholesterolaemia , in all social strata.The authorities, including the health and medical staff, were the main actors on the mediastage. Men in manual occupations were least affected by the media coverage. The actors and the public as well as the media viewed the health programme as orientated towards individual lifestyles. Community participation was mainly defined by the actors based on the medical and health planning approach. Differences in interpretations, social interests, personal conflicts and ideological constraints among the actors at local level were observed. Some critical attitudes towards the organization and management of the health programme were also noted among the citizens. However, a majority of the public wanted the health programme to continue. The present study underlines the importance of considering age, gender and social differences in the planning and evaluation of CVD preventive programmes.

Mortality in childhood, youth and early adulthood: Social inequality in a Swedish city

Abstract: In 1971-1985 statistically significant social differences in mortality in youth and early adulthood were found in the city of Goteborg, when divided into 3 socio-economic area groups according to income. This applied to total mortality, to major biological causes of death and external causes of death, i.e. intentional injuries (mainly suicide) as well as accidents. The differences increased from 1971-1975 to 1981-1985. A similar pattern, which was not statistically significant, was found in childhood mortality. A comparison of the social differences in mortality in childhood, youth and early adulthood showed an increasing level of difference by age group. A political and administrative decentralization was implemented in Sweden in the 1980s. Local area research thus has relevance for policy, planning and provision of services. The results can be used in targeting for health and as a basis for planning of health and social services based on local needs. It gives an indication of the possible gains in public health if the socio-economic differences can be reduced. Further studies should focus upon the uneven distribution of possibly preventable risk factors behind the obseived inequality in mortality. Although further studies are needed as a basis for prevention, the social inequality in mortality rates and causes of death can be used in targeting for health and as a basis for the allocation of resources in health services.

Social acceptance of smoking regulations in the workplace: A study from southern Germany

Abstract: Smoking regulations in the workplace are increasingly employed to protect non-smokers against passive smoking. Nevertheless, concern about their social acceptance hinders their implementation in many instances. Social acceptance of worksite smoking regulations was assessed in a cross-sectional study, which was conducted in 1992 among 930 employees of a Southern German telephone company. A minority of 16.5% among employees who smoked felt discriminated against. Perceived discrimination of smokers was strongly associated with the number of cigarettes smoked per day, but not with existing smoking regulations. Most smokers (79.2%) and non-smokers (94.9%) were in favour of some type of smoking restrictions; proportions were even higher in workplaces where smoking restrictions were already in effect. Among current smokers, a preference for smoking restrictions was positively associated with a desire to stop or reduce smoking. These results suggest that smoking regulations in the workplace can be accepted by smokers and non-smokers and are perceived as an aid to stop or reduce smoking rather than a discriminating measure among current smokers.