Showing papers in "Journal of Public Health in 2009"

Nurse-patient interaction and communication: A systematic literature review

Abstract: The purpose of this review is to describe the use and definitions of the concepts of nurse-patient interaction and nurse-patient communication in nursing literature. Furthermore, empirical findings of nurse-patient communication research will be presented, and applied theories will be shown. An integrative literature search was executed. The total number of relevant citations found was 97. The search results were reviewed, and key points were extracted in a standardized form. Extracts were then qualitatively summarized according to relevant aspects and categories for the review. The relation of interaction and communication is not clearly defined in nursing literature. Often the terms are used interchangeably or synonymously, and a clear theoretical definition is avoided or rather implicit. Symbolic interactionism and classic sender-receiver models were by far the most referred to models. Compared to the use of theories of adjacent sciences, the use of original nursing theories related to communication is rather infrequent. The articles that try to clarify the relation of both concepts see communication as a special or subtype of interaction. The main intention of communication and interaction in the health setting is to influence the patient’s health status or state of well-being. Identified important structural factors of communication were: role allocation, different use of language and registers, and the nursing setting. The process of communication is often described with a phase model; communication often happens during other interventions and tasks. In general, influencing factors can be organized into the categories of provider variables, patient variables, environmental and situational variables. The included citations all conclude that communication skills can be learned to a certain degree. Involvement of patients and their role in communication often is neglected by authors. Considering the mutual nature of communication, patients’ share in conversation should be taken more into consideration than it has been until now. Nursing science has to integrate its own theories of nursing care with theories of communication and interaction from other scientific disciplines like sociology.

The impact of cigarette package design on perceptions of risk

Abstract: Background More than 40 countries have laws prohibiting misleading information from tobacco packages, including the words ‘light’, ‘mild’ and ‘low-tar’. Little is known about the extent to which other words and package designs prove misleading to consumers. Methods A mall-intercept study was conducted with adult smokers (n ¼ 312) and non-smokers (n ¼ 291) in Ontario, Canada. Participants viewed pairs of cigarette packages that differed along a single attribute and completed ratings of perceived taste, tar delivery and health risk. Results Respondents were significantly more likely to rate packages with the terms ‘light’, ‘mild’, ‘smooth’ and ‘silver’ as having a smoother taste, delivering less tar and lower health risk compared with ‘regular’ and ‘full flavor’ brands. Respondents also rated packages with lighter colors and a picture of a filter as significantly more likely to taste smooth, deliver less tar and lower risk. Smokers were significantly more likely than nonsmokers to perceive brands as having a lower health risk, while smokers of light and mild cigarettes were significantly more likely than other smokers to perceive brands as smoother and reducing risk. Perceptions of taste were significantly associated with perceptions of tar level and risk.

Partners in health? A systematic review of the impact of organizational partnerships on public health outcomes in England between 1997 and 2008

Abstract: Objective To systematically review the available evidence on the impact of organizational partnerships on public health outcomes (health improvement and/or a reduction in health inequalities) in England between 1997 and 2008. Design Systematic review of quantitative (longitudinal before and after) and qualitative studies (1997–2008) reporting on the health (and health inequalities) effects of public health partnerships in England. Data sources Eighteen electronic databases (medical, social science and economic), websites, bibliographies and expert contacts. Results Only 15 studies, relating to six different interventions, met the review criteria and most of these studies were not designed specifically to assess the impact of partnership working on public health outcomes. Of the studies reviewed, only four included a quantitative element and they produced a mixed picture in terms of the impacts of partnership working. Qualitative studies suggested that some partnerships increased the profile of health inequalities on local policy agendas. Both the design of partnership interventions and of the studies evaluating them meant it was difficult to assess the extent to which identifiable successes and failures were attributable to partnership working. Conclusion This systematic review suggests that there is not yet any clear evidence of the effects of public health partnerships on health outcomes. More appropriately designed and timed studies are required to establish whether, and how, partnerships are effective.

Licence to be active: parental concerns and 10-11-year-old children's ability to be independently physically active.

Abstract: Background Physical activity independent of adult supervision is an important component of youth physical activity. This study examined parental attitudes to independent activity, factors that limit licence to be independently active and parental strategies to facilitate independent activity. Methods In-depth phone interviews were conducted with 24 parents (4 males) of 10–11-year-old children recruited from six primary schools in Bristol. Results Parents perceived that a lack of appropriate spaces in which to be active, safety, traffic, the proximity of friends and older children affected children’s ability to be independently physically active. The final year of primary school was perceived as a period when children should be afforded increased licence. Parents managed physical activity licence by placing time limits on activity, restricting activity to close to home, only allowing activity in groups or under adult supervision. Conclusions Strategies are needed to build children’s licence to be independently active; this could be achieved by developing parental selfefficacy to allow children to be active and developing structures such as safe routes to parks and safer play areas. Future programmes could make use of traffic-calming programmes as catalysts for safe independent physical activity.

Improving access to smoking cessation services for disadvantaged groups: a systematic review

Abstract: Background Smoking is a main contributor to health inequalities. Identifying strategies to find and support smokers from disadvantaged groups is, therefore, of key importance. Methods A systematic review was carried out of studies identifying and supporting smokers from disadvantaged groups for smoking cessation, and providing and improving their access to smoking-cessation services. A wide range of electronic databases were searched and unpublished reports were identified from the national research register and key experts. Results Over 7500 studies were screened and 48 were included. Some papers were of poor quality, most were observational studies and many did not report findings for disadvantaged smokers. Nevertheless, several methods of recruiting smokers, including proactively targeting patients on General Physician’s registers, routine screening or other hospital appointments, were identified. Barriers to service use for disadvantaged groups were identified and providing cessation services in different settings appeared to improve access. We found preliminary evidence of the effectiveness of some interventions in increasing quitting behaviour in disadvantaged groups.

Selective decrease in consultations and antibiotic prescribing for acute respiratory tract infections in UK primary care up to 2006.

Abstract: Background The aim of this study was to estimate trends in primary care consultations and antibiotic prescribing for acute respiratory tract infections (RTIs) in the UK from 1997 to 2006. Methods Data were analysed for 100 000 subjects registered with 78 family practices in the UK General Practice Research Database; the numbers of consultations for RTI and associated antibiotic prescriptions were enumerated. Results The consultation rate for RTI declined in females from 442.2 per 1000 registered patients in 1997 to 330.9 in 2006, and in males from 318.5 to 249.0. The rate of consultations for colds, rhinitis and upper respiratory tract infection (URTI) declined by 4.2 (95% CI 2.3–6.1) per 1000 per year in females and by 3.6 (2.3–4.8) in males. The rate of antibiotic prescribing for RTI was higher in females and declined by 8.5 (2.0–15.1) per 1000 in females and 6.7 (2.7–10.8) in males. For colds, rhinitis and URTI, the proportion of consultations with antibiotics was prescribed declined by 1.7% per year in females and 1.8% in males. Conclusions Decreasing frequency of consultation and antibiotic prescription for colds, rhinitis and ‘URTI’ continues to drive a reduction in the

Factors associated with television viewing time in toddlers and preschoolers in Greece: the GENESIS study.

Abstract: Background The aim of this work was to describe the television (TV) viewing time of preschoolers and to examine factors that may be associated with it. Methods A representative sample of 2374 Greek children aged 1–5 years was examined (GENESIS study). Several anthropometric, sociodemographic and lifestyle characteristics were recorded. Results The mean value of children’s TV viewing time was 1.32 h/day. Twenty six percent of participants spent � 2 h/day in TV viewing. The percentage of children whose TV viewing time was longer than 2 h/day was higher in children aged 3–5 years (32.2%) than in those aged 1–2 years (11.1%). Multiple logistic regression revealed that the time parents spent viewing TV and the region of residence were significantly associated with child’s TV viewing time among children aged 3–5 years. Among children aged 1–2 years, the maternal educational status, the region of residence and the maternal TV viewing time were found to be related to child’s TV viewing time. Conclusions The current findings suggest that almost one third of Greek preschoolers exceed the limit of 2 h/day TV viewing and that parental TV

The burden of alcohol-related ill health in the United Kingdom

Abstract: Background Although moderate alcohol consumption has been shown to confer a protective effect for specific diseases, current societal patterns of alcohol use impose a huge health and economic burden on modern society. This study presents a method for estimating the health and economic burden of alcohol consumption to the UK National Health Service (NHS). Methods Previous estimates of NHS costs attributable to alcohol consumption were identified by systematic literature review. The mortality and morbidity due to alcohol consumption was calculated using information from the World Health Organization Global Burden of Disease Project and routinely collected mortality data. Direct health-care costs were derived using information on population attributable fractions for conditions related to alcohol consumption and NHS cost data. Results We estimate that alcohol consumption was responsible for 31 000 deaths in the UK in 2005 and that alcohol consumption cost the UK NHS £3.0 billion in 2005‐06. Alcohol consumption was responsible for 10% of all disability adjusted life years in 2002 (male: 15%; female: 4%) in the UK. Conclusions Alcohol consumption is a considerable public health burden in the UK. The comparison of the health and economic burden of

Functional health literacy among primary health-care patients: data from the Belgrade pilot study

Abstract: Background Over the last decade, health literacy has become a vibrant area of research. Our objective was to evaluate health literacy and its association with socio-demographic variables, self-perception of health and the presence of chronic conditions in primary health-care patients. Methods A cross-sectional study among 120 patients was conducted in two primary health-care centers. The test of functional health literacy in adults, a 50-item reading comprehension and 17-item numerical ability test (score, 0–100) were administered. Chi-square test and logistic regression analyses were applied. Results Inadequate and marginal health literacy existed in 43 participants (41.0%), and adequate health literacy was present in 62 participants (59.0%). Functional health literacy was significantly different by location, gender, age, marital status, employment, education, material status, selfperception of health and presence of chronic conditions. Based on the multivariate analysis, health literacy was significantly associated with the participant’s age (odds ratio [OR], 4.86; 95% confidence interval [CI], 2.41–9.80; P ¼ 0.000), level of education (OR, 4.48; 95% CI, 1.73–11.57; P ¼ 0.002) and chronic conditions (OR, 1.90; 95% CI, 1.16–3.11; P ¼ 0.010). Conclusion These results provide evidence that limitations in functional health literacy are widespread among primary health-care patients and encourage efforts for further monitoring. Low health literacy may impair a patient’s understanding of health messages and limit their ability to attend to their medical problems.

Residential Anonymous Linking Fields (RALFs): a novel information infrastructure to study the interaction between the environment and individuals' health

Abstract: Background The necessity of aggregating health data over areas can impede our understanding of health determinants. Methods We demonstrate the possibility of creating anonymous links between individual residences and the local environment using digital map data and a data linkage system. Results Digital map data were used successfully to anonymously link 1.3 million addresses to the local environment. The data linkage system allows detailed environment data surrounding each residence to be linked both to each resident therein and to their medical records. Conclusions Local environment data specific to each house can be effectively and anonymously linked to the population registered with the National Health Service. Our integrated approach potentially enables flexible fine-scale, large-area observational studies of communities and health.

Leading for Health and Wellbeing: the need for a new paradigm

Abstract: Much of the government’s health policy in recent years has focused on improving health and wellbeing. There have been numerous strategies, targets, reviews of progress and calls for further efforts to tackle what are widely perceived to be persistent, stubborn, deep-seated and intractable problems. Such problems are sometimes called ‘wicked issues’ in the sense that they defy easy or single bullet solutions—if, indeed, there are any solutions at all or ones of a lasting nature. Wicked issues have complex causes and require complex solutions. They share a number of features most of which are strikingly evident in the public health challenges societies face, including tackling obesity, alcohol misuse, poor mental health, environmental degradation and so on. Unlike ‘tame’ problems which can be readily defined and solutions identified, wicked problems cannot be resolved through traditional linear, analytical approaches. Wicked problems:

Predictors of work ability in occupations with psychological stress

Abstract: This study aimed to detect health- and work-related predictors of poor and good work ability in teachers (TE) and office workers (OW). Work ability and its influence factors were analyzed in 100 female TE and 60 female OW aged between 25 and 60 years. The work ability was evaluated with the work ability index questionnaire and the health status with the vitality measurement system®. In addition, cardiac risk factors, burnout risk, as well as the working demands and effort-reward ratio were taken into account. Predictors of work ability were analyzed by using a CHAID analysis. The number of complaints represents the best predictor to divide both occupational groups into subgroups with different work abilities (criterion variable). Poor work ability is caused by many complaints and cardiovascular risk factors. By contrast, excellent work ability is associated with few complaints, the occupation “office workers,” a younger vital functional age, and the absence of burnout symptoms, which means in comparison with OW, TE have a 1.6 times higher risk for impaired work ability. Furthermore, the absence of burnout symptoms is a resource of TE, whereas OWs tend to have a younger vital functional age compared to their calendrical age. Although this analysis is able to explain 61.2% of the influence on impaired work ability, research for further causes must be undertaken. The results reflect the positive effect of a high educational level and a challenging job on the preservation of good work ability. Moreover, they draw the attention to the psychological and psychosocial strains of TE. TEs are exposed more frequently to feeling overstrained; this probably effects a higher retirement rate due to illness.

Geographical variation in the provision of elective primary hip and knee replacement: the role of socio-demographic, hospital and distance variables

Abstract: Background To explore inequalities in the provision of hip/knee replacement surgery and produce small-area estimates of provision to inform local health planning. Methods Hospital Episode Statistics were used to explore inequalities in the provision of primary hip/knee operations in English NHS hospitals in 2002. Multilevel Poisson regression modelling was used to estimate rates of surgical provision by socio-demographic, hospital and distance variables. GIS software was used to estimate road travel times and create hospital catchment areas. Results Rates of joint replacement increased with age before falling in those aged 80þ. Women received more operations than men. People living in the most deprived areas obtained fewer hip, but more knee operations. Those in urban areas received less hip surgery, but there was no association for knee replacement. Controlling for hospital and distance measures did not attenuate the effects. Geographical variation across districts was observed with some districts showing inequality in socio-demographic factors, whereas others showed none at all. Conclusions This study found evidence of inequalities in the provision of joint replacement surgery. However, before we can conclude that there is inequity in receipts of healthcare, future research must consider whether these patterns are explained by variations in need across sociodemographic groups.

Assessing IDU prevalence and health consequences (HCV, overdose and drug-related mortality) in a primary care trust: implications for public health action

Abstract: Background We report on an exercise to estimate the prevalence of injecting drug use (IDU) and associated harms in a single primary care trust. Methods Covariate capture–recapture methods to estimate (i) IDU prevalence; respondent driven sampling to measure (ii) prevalence of HCV and HIV and record linkage to measure (iii) mortality risk. Results (i) The overall estimated number of IDU was 5540 (95% confidence interval, CI: 4710–6780) for all cases and 3280 (95% CI: 1940– 4610) for cases matched to primary care register, i.e. a prevalence of 2.2 and 1.3% aged 15–54, respectively. (ii) The prevalence of HCV, hepatitis B and HIV was: 53, 32 and 0.7%. Over 70% of IDU in Bristol reported having at least one vaccination for HBV; more than half of those who were HCV positive were undiagnosed. (iii) The all-cause and overdose mortality rates for IDU were 0.75 and 0.4% respectively; and the standardized mortality ratio was 7.8 (95% CI: 5.4–10.8). Conclusion Locally specific and useful intelligence on injecting and its health consequence can be generated to inform local public health action, and may contribute information to validate national prevalence estimates.

Is there equity of service delivery and intermediate outcomes in South Asians with type 2 diabetes? Analysis of DARTS database and summary of UK publications.

Abstract: Background There are doubts whether diabetes care is equitable across UK ethnic groups. We examined processes and outcomes in South Asians with diabetes and reviewed the UK literature. Methods We used name search methods to identify South Asians in a regional diabetes database. We compared prevalence rates, processes and outcomes of care between November 2003 and December 2004. We used standard literature search techniques. Results The prevalence of diabetes in South Asians was 3–4 times higher than non-South Asians. South Asians were 1.11 times (95% confidence interval 1.06, 1.16) more likely to have a structured review. South Asian women were 1.10 times more likely to have a record of body mass index (95% CI 1.04, 1.16). HbA1c levels were 1.03 times higher (95% CI 1.00, 1.06) among South Asians, retinopathy 1.36 times more common (95% CI 1.03, 1.78) and hypertension 0.71 times as common (95% CI 0.58, 0.87). Conclusions We found evidence of equity in many aspects of diabetes care for South Asians in Tayside. The finding of higher HbA1c and more retinopathy among South Asians needs explanation and a service response. These findings from a region with a small non-White population largely support the recent findings from other parts of the UK.

Mental health as a reason for claiming incapacity benefit--a comparison of national and local trends

Abstract: Background Getting incapacity benefit (IB) claimants into work has become a focus for policy makers. Strategies to help this group depend on an understanding of the reasons for claiming benefit at a local level where variations from a national strategy may be needed. Methods Data supplied by the Department for Work and Pensions (DWP) was analysed to establish reasons for claiming benefit in Scotland and Glasgow between 2000 and 2007. Results There has been a continuing rise in mental health diagnosis and a corresponding fall in musculoskeletal diagnosis during this period. More people were claiming because of mental health problems in Glasgow than in Scotland. Also those with a poor employment history (creditsonly claimants) are more likely to claim IB because of a mental health problem. This study has shown a breakdown into 25 categories those claiming IB because of a mental health problem. Conclusion DWP data can be used to provide important insights into the trends in reasons for claiming IB, in particular those claiming because of mental health problems. This study also highlighted the growing importance of problems caused by alcohol and drug-abuse claimants, a subset of the mental health category. DWP data should be used at a local as well as a national level to guide and evaluate interventions to help this vulnerable group.

The complex interrelationship between ethnic and socio-economic inequalities in health.

Abstract: Ethnicity matters in medicine and public health. Health professionals, both in public health and medicine, should be aware of the influence of ethnicity on health (care) and target health (care) services accordingly. In his paper, Bhopal discusses some of the issues that are relevant to health professionals who want to get familiar with this issue. These include the classification of ethnic groups, the use of ethnicity versus race as a basis for classification of groups and the use of absolute versus relative risks to describe inequalities in health. Bhopal also discusses some of the factors that produce ethnic inequalities in health. If health (care) policy is to respond effectively to these inequalities, we need to have a clear understanding of the factors that account for these inequalities, e.g. the higher burden of diabetes mellitus in immigrant populations with a South Asian background can only effectively be prevented if we have a detailed insight into the factors that are responsible for the increased risks of these groups. Currently, there is a paucity of evidence on these factors and mechanisms, and further research into these issues is warranted. An explanation that gets very little attention in Bhopal’s paper is that from socio-economic factors. Ethnic minority groups, in general, do have a lower socio-economic status than the ‘majority’ population in the host country. Given the well-known association between socio-economic status and health, it is not surprising that ethnic inequalities in health are, to at least some extent, socio-economic in nature. Many empirical studies support this hypothesis. As a general rule, explanation of ethnic inequalities in health should recognize that these inequalities are rooted in socio-economic factors. This is not to say, however, that ethnic inequalities in health can simply be understood by generalizing insights in socio-economic inequalities in health in the ‘majority’ population towards immigrant populations. Instead, we should aim to understand the complex way in which ethnic inequalities are linked up with socio-economic inequalities. The first point to realize is that socio-economic position is a multidimensional concept. It includes key components such as educational level and occupational class, but also employment status, income level and other indicators for material welfare. Different types of socio-economic determinants may be relevant to ethnic minority groups as compared with the majority population. For example, first-generation migrants may be disproportionally affected by lack of formal education. The lack of formal education, together with migrants’ problems of acculturation and integration, may particularly affect their later socio-economic career, including occupational positions, wealth accumulation and residential career. Thus, a ‘false start’ early in the socioeconomic career may affect migrant groups in particular. This implies that, if ethnic inequalities are to be addressed by policies on socio-economic determinants of health, particular emphasis may need to be placed on the root socioeconomic factors shaped in the early life of migrants. Second, the pervading relationship between socioeconomic factors and health (care) may take different forms in different ethnic groups. Recent studies showed that socioeconomic inequalities in health within ethnic minority groups often were smaller (or sometimes larger) than in the total national population. Illustrations for this were provided for example in recent Dutch studies on mortality by cause of death, metabolic syndrome prevalence and hospitalization rates. Such an effect modification has been found to be

Health and social care responses to the Department of Health Heatwave Plan.

Abstract: Background The increasing risk of heatwaves in England poses a particular threat to the health of elderly people. A National Heatwave Plan has been produced to ensure that adaptation plans are established. The objective was to explore the perceptions of frontline statutory and voluntary sector staff on the feasibility of implementing the Heatwave Plan for elderly people in the community. Methods Semi-structured interviews and focus groups with 109 health, social care and voluntary staff from three London Boroughs. Results Few frontline staff were aware of the Plan. Most respondents did not perceive heatwaves to be a sufficiently frequent event to require prioritization within their routine summer workloads. They highlighted the complexities associated with defining vulnerability and identifying vulnerable individuals as well as barriers to implementation of the Plan. Respondents suggested a multi-faceted approach to interventions including a public health campaign, community engagement and increasing the responsiveness of statutory services. Conclusion The issues highlighted could hinder effective implementation of the Heatwave Plan. Ensuring continuity of care so that timely information can be recorded and disseminated may address the problems associated with shifting vulnerability. Best practice with respect to intersectoral collaboration should be identified and innovative multi-faceted interventions should be designed and evaluated.

How much do operational processes affect hospital inpatient discharge rates

Abstract: Background The objective of this study is to determine the effect of day of the week, holiday, team admission and rotation schedules, individual attending physicians and their length of coverage on daily team discharge rates. Methods We conducted a retrospective analysis of the General Internal Medicine (GIM) inpatient service at our institution for years 2005 and 2006, which included 5088 patients under GIM care. Results Weekend discharge rate was more than 50% lower compared with reference rates whereas Friday rates were 24% higher. Holiday Monday discharge rates were 65% lower than regular Mondays, with an increase in pre-holiday discharge rates. Teams that were on-call or that were on call the next day had 15% higher discharge rates compared with reference whereas teams that were post-call had 20% lower rates. Individual attending physicians and length of attending coverage contributed small variations in discharge rates. Resident scheduling was not a significant predictor of discharge rates. Conclusions Day of the week and holidays followed by team organization and scheduling are significant predictors of daily variation in discharge rates. Introducing greater holiday and weekend capacity as well as reorganizing internal processes such as admitting and attending schedules may potentially optimize discharge rates.

Assessing the efficiency of rural health centres in Burkina Faso: an application of Data Envelopment Analysis

Abstract: Effective health care provision benefits from the support of measurement techniques. Contrary to the situation in industrialised countries efficiency analyses in the health care sector in Africa are a very recent phenomenon. Hardly any of the existing studies was conducted at the level of primary care. The purpose of this study was twofold: (1) to evaluate the relative efficiency of health centres in rural Burkina Faso and (2) to investigate reasons for inefficient performance. Data Envelopment Analysis (DEA) was applied. To account for the situation in that country, the output-oriented approach was used in connection with different returns to scale assumptions. To identify the spatial effect of the catchment area on efficiency the Tobit model was applied. According to constant returns to scale, 14 health centres were relatively efficient. The DEA projections suggest that the inefficient units were too big to be efficient. Tobit regression showed that the relatively efficient health centres are located close to villages in their catchment area. For ethical reasons it is not appropriate to try to improve the efficiency of health centres by closing some of them. Their efficiency can be improved and lives can be saved if access to health centres is enhanced.

Impact of antisocial lifestyle on health: chronic disability and death by middle age

Abstract: Background An antisocial lifestyle is associated with injury but also with less organic illness up to the age of 32. It is not known if these associations persist into the fifth decade. Methods Injury and illness data were collected prospectively in the longitudinal Cambridge study in delinquent development at age 43‐48. Hypotheses were that childhood predictors of antisocial behaviour and offending and antisocial behaviour at ages up to 32 would be associated with poorer health at age 48. Results Childhood and parental predictors of offending, self-reported delinquency at age 32 and convictions were significantly associated with death and disability by age 48. A model comprising three factors: any antisocial behaviour and any parental risk factor at age 8‐10 and any antisocial behaviour at age 27‐32 best discriminated death or disability. Two factors: conviction between ages 10‐18 and any antisocial behaviour at age 8‐10 discriminated almost as well. Conclusions Death and disability by age 48 were strongly associated with antisocial behaviour at ages 8‐10 and 27‐32, convictions and impulsivity during adolescence and parental predictors of offending at age 8‐10. Preventing childhood and adolescent antisocial behaviour and offending may also prolong life and prevent disability among those who would otherwise offend.

Economic evaluation of an intensive home visiting programme for vulnerable families: a cost-effectiveness analysis of a public health intervention

Abstract: The objective of the study was to evaluate the cost-effectiveness of an intensive home visiting programme directed at vulnerable families during the antenatal and post-natal periods in reducing the risk of abuse and neglect in the first year of life. The design was an economic evaluation alongside a multicentre randomized controlled trial, in which 131 eligible women were randomly allocated to receive 18 months of intensive home visiting (n = 67) or standard services (n = 64). A cost-effectiveness analysis of this public health intervention was undertaken from a societal perspective. The mean costs in the control and intervention arms were 3874 pounds and 7120 pounds, respectively, a difference of 3246 pounds (P Language: en

Medicine and public health in a multiethnic world.

Abstract: Achievement of medical and public health goals requires mutual understanding between professionals and the public, a challenge in diverse societies. Despite their massive diversity humans belong to one species, with race and ethnicity used to subgroup/classify humans and manage diversity. Classifications are contextual and vary by time, place and classifier. As classifications show major variations in health status, and risk factors, research using race and ethnicity has accelerated. Medical sciences, including epidemiology, are learning fast to extract value from such data. Among the debatable issues is the value of the relative risk versus absolute risk approaches (the latter is gaining ground), and how to assess ethnicity and race (self-assignment is favoured in the UK and North America, country of birth in continental Europe). Racial and ethnic variations in disease and risk factors are often large and usually unexplained. There is a compelling case for ethnic monitoring, despite its difficulties, for tackling inequalities and as a foundation for research. Medical and public health goals require good data collected in a racism-free social environment. Health professionals need to find the benefits of exploring differences while avoiding social division. Advances in health care, public health and medical science will follow.

What causes H5N1 avian influenza? Lay perceptions of H5N1 aetiology in South East and East Asia.

Abstract: Background Health education to reduce population poultry exposures has limited effect. Lay beliefs about H5N1 highly pathogenic avian influenza (HPAI) causes could provide insights helpful for improving public health interventions. Methods Qualitative interviews of poultry farmers, retailers, market stall holders and consumers in Hong Kong (n ¼ 20), Guangzhou (n ¼ 25), Vietnam (n ¼ 38) and Thailand (n ¼ 40) were conducted using purposive sampling and analysed using ethnographic principles. Results Each location produced three comparable themes: ‘viruses’: HPAI exemplified a periodic, natural, disease process therefore, deserving little concern. For some, science had ‘discovered’ something long known to farmers and lived with for generations. Others believe the virus to be new. Viral ecology was reasonably well understood among farmers, but less so by retailers and consumers; ‘husbandry practices’ included poor hygiene, overcrowding and industrial farming, modern commercial feed and veterinary drugs; ‘vulnerability factors’ included uncontrollable ‘external’ explanations involving the weather, seasonal changes, bird migrations and pollution. Conclusions Lay explanations were generally ecologically consistent. Nonetheless, beliefs that HPAI is a normal, recurrent process, external factors and roles of industrialized poultry rearing countered health worker claims of H5N1 seriousness for smallholders. These causal beliefs incorporate contemporary models of H5N1 ecology, but in a manner that contradicts public health efforts at control.

Inequalities in breast cancer stage at diagnosis in the Trent region, and implications for the NHS Breast Screening Programme

Abstract: Background This study investigates risk factors for diagnosis with late-stage breast cancer in order to identify inequalities and inform the understanding of barriers affecting access to mammography screening. Methods Data from the Trent Cancer Registry were used to identify all women with invasive breast cancer, diagnosed in 1998–2006. Risk of diagnosis with late-stage breast cancer was calculated to quantify strength of association between exposure and outcome. Results Women outside the age group for routine screening were approximately 30% [,50 years, relative risk (RR) ¼ 1.34 (95% confidence interval, CI: 1.26–1.43) and .70 years, RR ¼ 1.27 (95% CI: 1.19–1.36)] more likely to be diagnosed with late-stage breast cancer; the most deprived women were 37% [RR ¼ 1.37 (95% CI: 1.01–2.56)] more likely to be diagnosed with Stage IV breast cancer; ethnic minority women were 15% [RR ¼ 1.15 (95% CI: 1.09–1.22)] more likely to be diagnosed with late-stage breast cancer and women resident in 5 of 11 Trent Primary Care Trusts (PCT) had a greater than 30% increased risk of diagnosis with late-stage breast cancer than those in Nottingham City PCT. Conclusion These findings highlight the need for appropriate targeted interventions to address compositional and contextual inequalities that are

Impact of socioeconomic, behavioral and clinical risk factors on mortality

Abstract: This study investigates the relative contributions of socioeconomic status (SES), behavioral and clinical risk factors on mortality. The Third National Health and Nutrition Survey Linked Mortality File was used to examine the association of SES (race, insurance, education, income), behavioral (smoking, obesity, physical activity), and clinical (elevated blood pressure, triglyceride level, lipid levels, C-reactive protein (CRP)) risk factors with 6-12-year all-cause mortality. Respondents were stratified by known chronic diseases into one of the following categories: no chronic disease, non-cardiovascular chronic disease, cardiovascular disease, and diabetes. The overall weighted mortality rate was 9.5% with the highest mortality rate among diabetics. Race, insurance coverage, income, smoking status, inadequate physical activity, elevated blood pressure and elevated CRP were independently associated with mortality in the overall population. When stratified by chronic disease, SES factors remained associated with mortality, most strongly in the healthy population. Current smoking and inadequate physical activity were also associated with mortality across disease groups while clinical risk factors were less consistent. SES factors, health behaviors and clinical risk factors were all associated with mortality even when baseline health status and chronic diseases are taken into account. Efforts to reduce mortality will require a multi-faceted approach incorporating healthy behaviors and accessible health care systems in addition to clinical advances.

The statewide burden of obesity, smoking, low income and chronic diseases in the United States.

Abstract: Background We developed an estimation equation of EuroQol EQ-5D index scores from the Healthy Days measures of the Centers for Disease Control and Prevention for use in burden of disease and cost-effectiveness studies in population subgroups. This study estimated EQ-5D scores, quality-adjusted life years (QALYs) and quality-adjusted life expectancy (QALE) for the USA and the individual states. Methods We estimated the EQ-5D scores for respondents from the 2000–2003 Behavioral Risk Factor Surveillance System. We calculated QALYs and QALE lost to morbidity due to obesity/overweight, smoking, low income and chronic diseases. Results The mean EQ-5D score for US adults was 0.870. The mean scores ranged from 0.826 (West Virginia) to 0.902 (Hawaii). Smoking contributed from 5.6 (Utah) to 12.3 (Kentucky) percent, obesity/overweight 5.4 (South Dakota) to 13.8 (Louisiana) percent, low income 16.6 (Hawaii) to 39.9 (South Carolina) percent and chronic diseases 8.7 (Minnesota) to 22.9 (Tennessee) percent of explainable QALYs lost. These risks contributed the greatest proportion of explainable QALYs and QALE lost in Kentucky, Tennessee and South Carolina. Conclusions We estimated the burden of disease contributed by selected risk factors. Currently, such data are unavailable but are needed to set