Public Health

Ethics and equity: Choice or compulsion?

F. Sim, P. Mackie — 2012-02-01

Public health and ethics are so closely intertwined that many would contend that the public health department is rationally considered to be the conscience of the organisation. A function that has, at its heart, always to consider what is in the best interests of the population as a whole – not necessarily the interests of individual patients or members of the public, not care providers or carers, nor healthcare systems, but the population in its entirety – is bound by powerful ethical principles, with a strong utilitarian leaning. So it is no surprise that this month, we have some papers that reflect this fascinating relationship between ethics and public health.

Using outreach to involve the hard-to-reach in a health check: What difference does it make?

A. Sinclair, H.A. Alexander — 2011-12-29

Summary: Objectives: Mortality from coronary heart disease remains higher in Scotland than the European average. Primary prevention programmes, such as Keep Well, aim to tackle the associated risk factors within deprived communities. In Lanarkshire, the problem of non-attendance amongst ‘hard-to-reach’ groups was addressed by an outreach team, but there was a need to understand the methods employed to achieve health screening attendance.Study design: Qualitative interviews with a typical sample of those who initially failed to attend for health screening but were subsequently appointed after outreach intervention.Methods: Semi-structured interviews (n = 30) were conducted following clinic attendance. Transcripts were subjected to a form of content analysis and concepts were arranged into themes.Results: The group often referred to as ‘hard-to-reach’ are more accurately defined as either ‘hard-to-contact’ or ‘hard-to-engage’. Non-attenders reported that outreach staff were effective in engaging them partly because of their personalities, but also because some of the contacts occurred at an opportune time.Conclusions: Not all non-attenders for screening appointments are negatively disposed towards health screening, and defining them all as ‘hard-to-reach’ does them a disservice. The majority appeared to need outreach staff to convert them into attenders, but the costs of this need to be balanced against the benefits realized.

Glasgow smiles better: An examination of adolescent mental well-being and the ‘Glasgow effect’

K.A. Levin — 2011-12-22

Summary: Background: The existence of a negative ‘Glasgow effect’ on health has been much disputed. Previously, Glasgow’s poor health was believed to be due to high levels of poverty. However, more recent studies investigating adult health outcomes have shown an effect over and above that of deprivation.Objectives: To examine the existence of a ‘Glasgow effect’ on mental well-being and subjective health of an adolescent sample.Study design: Data from the 2006 Health Behaviour in School-Aged Children cross-sectional survey were analyzed.Methods: Data were modelled using multilevel logistic and linear modelling for the following outcomes: happiness, confidence, feeling left out, self-rated health, multiple health complaints (MHC), life satisfaction and health-related quality of life (KIDSCREEN-10). The models were further adjusted for family affluence and family status, as proxy measures of socio-economic status.Results: The proportions of pupils that reported being very happy, always confident and never left out were greater among pupils in Glasgow compared with pupils in the rest of Scotland, as were mean life satisfaction and KIDSCREEN scores. Frequencies of MHC and subjective health were not significantly different in Glasgow compared with the rest of Scotland. Similar results were observed following the modelling procedures, adjusting for age, sex, grade and school type (state or independent), for all outcomes other than life satisfaction, and effect sizes increased further after adjustment for family affluence and family status. The odds of a pupil in Glasgow being very happy, for example, were 1.48 [credible interval (CI) 1.19–1.83] those of a pupil outside Glasgow. After adjustment for family affluence and family status, the odds were 1.59 (CI 1.28–1.98). An interaction term between Glasgow and grade was not significant for all mental well-being outcomes, although there was some suggestion that a negative Glasgow effect on self-rated health is emerging by Secondary 4.Conclusions: The Glasgow effect may not be all bad. The findings suggest that mental well-being is more prevalent in Glasgow compared with the rest of Scotland during adolescence. Further research is recommended to investigate the Glasgow effect during this life stage.

Urbanization and prevalence of depression in diabetes

C.H. Lin, Y.Y. Lee, C.C. Liu, H.F. Chen, M.C. Ko, C.Y. Li — 2011-12-19

Summary: Objectives: To depict recent secular trend (2001–2005) in prevalence of depression among diabetic population in Taiwan, and to explore the influences of urbanization on the prevalence of depression.Study design: A descriptive correlation study design relating urbanization and prevalence of depression.Methods: Annual prevalence of depression was calculated as the ratio of number of individuals with depression (ICD-9-CM: 296, 309, or 311) to the size of diabetic population (ICD-9-CM: 250), which were ascertained from ambulatory care claim data of Taiwan’s National Health Insurance between 2001 and 2005. Multivariate Poisson regression analysis was used to assess the secular trend in the prevalence of comorbid depression, and to appraise the influence of urbanization on prevalence of depression in diabetic patients.Results: The prevalence of depression among diabetic population increased annually from 22.6/103 in 2001 to 27.0/103 in 2005 with a significantly and linearly rising trend (β = 0.0461, p < 0.0001). Diabetic population living in urban areas showed the largest increase in prevalence (6.3/103), followed by those from rural areas (5.6/103). Compared to the diabetic patients residing in rural areas, those living in urban areas (RR = 1.28, 95% CI = 1.25–1.31) and those from satellite towns (RR = 1.22, 95% CI = 1.19–1.25) both had significantly increased adjusted RR.Conclusions: There is a significant increasing trend in prevalence of depression among diabetic population in recent years in Taiwan. Diabetic patients from urban areas not only had the greatest prevalence of depression but also showed the largest increase in prevalence during the study period, which highlights a need for managing depression in urban diabetes.

Using Trust databases to identify predictors of late booking for antenatal care within the UK

E.C. Baker, D. Rajasingam — 2011-12-02

Summary: Objectives: To identify predictors of late booking for antenatal care using routinely collected data.Study design: Retrospective cohort study.Methods: Variables were selected with reference to comprehensive literature review. Data were extracted from a London hospital case-note database, and predictors of late booking were identified using logistic regression.Results: In total, 5629 women were included in the study. Median gestation at booking was 14 weeks, and 31% of women booked after 18 weeks of gestation. Variables with insufficient data recorded included language abilities, nationality and social risk. Women aged between 15 and 19 years, women with more than four children, and women belonging to the ethnic group ‘other’ were all significantly more likely to book late. Women with a body mass index ≥30kg/m2 were 1.5 times more likely to book late (not significant).Conclusion: Case-note databases are a potentially easy and effective way to analyse access to care and provider compliance with quality standards. Current deficits in routine data collection need to be addressed urgently in order to make this possible.

Recommended or mandatory pertussis vaccination policy in developed countries: Does the choice matter?

Dorota Zdanowska Girard — 2012-01-09

Summary: Objectives: To compare universal recommended and compulsory pertussis vaccination strategies in developed countries, and to discuss their effectiveness in terms of the proportion of infants and children who complete their primary course of pertussis vaccine.Study design: Retrospective analysis.Method: National pertussis surveillance and vaccination coverage data, official pertussis vaccination recommendations, and medical and epidemiological sources related to the use, safety and efficacy of whole-cell and acellular vaccines were analysed.Results: Similar vaccine coverage rates among children (above 94%) can be achieved at national level regardless of the type of vaccination legislation in place. Mandatory and recommended vaccination strategies appear to be equally effective.Conclusions: The choice of vaccination strategy is based on the national history of pertussis infection, the safety of available whole-cell vaccines and the willingness of health authorities to introduce acellular vaccines into routine use. The strategies adopted in the UK and the USA are two contrasting examples of immunization policies developed on the basis of different epidemiological backgrounds. They attest to the various associations between the type of pertussis vaccine and the type of universal vaccination strategies that can be undertaken for successful pertussis control. The introduction of a mandatory policy generally takes place during a period of low vaccination coverage, and is vindicated by the need for a rapid increase in immunization uptake. Countries that have already succeeded in implementing sustainable and high rates of uptake with a voluntary approach are expected to recommend pertussis vaccination, considering this to be the most justifiable policy.

Identifying infants at risk of becoming obese: Can we and should we?

R.S. Levine, D.L. Dahly, M.C.J. Rudolf — 2011-12-19

Summary: Objectives: Increased understanding of the risk factors for childhood obesity has raised the possibility of identifying infants who are at risk of becoming overweight or obese, enabling early intervention for infants at high risk. This paper considers the known risk factors, describes statistical work aimed at identifying risk, and considers the ethical and practical issues of such a development.Study design and methods: An overview of the published evidence for risk factors in the early development of overweight and obesity, and a statistical assessment of the practicality of developing a simple obesity risk assessment tool (ORT) for use in the primary care setting.Results: Analysis of data from two currently available UK birth cohort studies suggests that an ORT based on these data does not provide acceptable levels of specificity and sensitivity for use in a primary care setting.Conclusion: Further development of an ORT using additional data and enhanced statistical analysis may lead to a practical tool. However the practical, ethical and legal issues involved in its use, and the public health policy considerations that follow must be resolved.

The obesity pandemic: Implementing the evidence for children in Scottish families

A.D. Millard — 2011-12-29

Summary: Background: Increasing obesity levels arise from multiple causes, which require understanding as a whole system. Co-ordinated action from heterogeneous groups with differing interests and perspectives is required to tackle rising obesity. To be effective, this must be targeted at identifying, agreeing and modifying the critical drivers.Objectives: To illustrate an application of an environmental health systems modelling approach (as adapted in Scotland) to a particularly important Scottish topic: the rising obesity levels in Scottish children.Discussion: The model was able to capture an integration of the closely coupled causal chains around excessive energy intake and physical inactivity in children in their domestic environment. The model was able to incorporate action at different strategic levels.Conclusions: Applying the Drivers, Pressures, State, Exposure, Effects, Actions (DPSEEA) model to the public health problem of child obesity allowed a clear view of a number of multiple causal chains involved in a particular environment. That clarity may be a necessary condition for co-ordinated action to create change.

Higher waist-to-height ratio and waist circumference are predictive of metabolic syndrome and elevated serum alanine aminotransferase in adolescents and young adults in mainland China

2011-12-16

Summary: Objectives: The prevalence of overweight and obesity continue to increase among children and adolescents worldwide. This study examined whether waist circumference (WC), waist-to-hip ratio (WHpR) and waist-to-height ratio (WHtR) are predictive of metabolic syndrome and elevated serum alanine aminotransferase (ALT) among adolescents and young adults in mainland China.Study design: Cross-sectional study.Methods: In total, 6997 students aged 12–24 years from nine Chinese cities participated in this study. Anthropometric and biochemical data were collected. A logistic regression model was performed to determine the association between anthropometric indicators and metabolic syndrome components and abnormal liver function.Results: This study found prevalence rates for the metabolic syndrome and elevated ALT of 1.4% and 3.1%, respectively, among adolescents and young adults in mainland China. A multivariate logistic regression model found that WHtR ≥0.50 was more strongly associated with metabolic syndrome components and elevated ALT than WC values at or above the 90th percentile (P90) or WHpR ≥P90. Odds ratios for elevated ALT were 2.03 [95% confidence interval (CI) 1.46–2.81], 4.56 (95% CI 3.07–6.78) and 13.43 (95% CI 7.67–23.51) in adolescents and young adults with one, two and three or more components of metabolic syndrome, respectively (P < 0.001 for all).Conclusions: Higher WC and WHtR were found to be predictive of metabolic syndrome components and elevated ALT among adolescents and young adults in mainland China, and the association was stronger for WHtR. Furthermore, adolescents and young adults with more metabolic syndrome components were more likely to suffer from elevated ALT.

Epidemiology of the metabolic syndrome in Hungary

2012-01-09

Summary: Objectives: Hungary has high cardiovascular mortality. Recent studies have revealed a high prevalence of several cardiovascular risk factors, including obesity, diabetes and hypertension. The objective of this study was to assess the prevalence of the metabolic syndrome in Hungary.Study design: Cross-sectional study.Methods: Within the framework of the Hungarian General Practitioners’ Morbidity Sentinel Stations Programme, a random sample of 2006 individuals aged 20–69 years was selected in 2006. Physical examinations, blood sampling and data collection were performed by general practitioners. Information on environmental factors was gathered using a questionnaire. The population prevalence was estimated based on the sample frequencies.Results: The overall response rate was 91%. The age-adjusted prevalence of the metabolic syndrome using the 2009 Harmonized definition was 38% [95% confidence interval (CI) 35–42%] in males and 30% (95% CI 28–33%) in females aged 20–69 years. There were no significant regional differences in the frequency figures.Conclusions: The high prevalence of the metabolic syndrome is a serious public health problem in Hungary, and remains a major determinant of the high burden of cardiovascular disease.

Identifying and verifying causes of death in Turkey: National verbal autopsy survey

S. Akgün, M. Çolak, C. Bakar — 2012-01-30

Summary: Objectives: The aim of this study was to identify the national, rural, and urban mortality rates, and to define the medical causes of death for the 0–28 days and 29 days-5 years age groups, as well as adult mortality in Turkey.Study design: A cross-sectional survey, which identified the causes of death using the verbal autopsy(VA) method, and a methodological study, which determined the validity of the verbal autopsy method was used in conjunction with each other.Methods: The verbal autopsy method, based on a representative sampling according to age and gender in Turkey, was used. A methodological study was additionally used, which determined the validity of the VA method.Results: The crude death rate calculated from the VA survey was 0.51% with rates of 0.60% in males, 0.42% in females, 0.48% in urban areas, and 0.56% in rural areas. Life expectancy at birth was 72.6 years for males and 77.2 years for females. The mean life expectancy at birth for both sexes together was 74.8 years. The VA form has a high degree of validity although no study or form can take the place of a records-based surveillance system with accurate information; the VA form is a useful tool for collecting data during certain periods or specific areas. However, healthcare providers must work towards establishing a well-designed, routine surveillance system in the long term.Conclusions: The mortality rates and life expectancies were consistent with other similar studies in the country and the Turkish VA method may be safely used to determine causes of death in countries with inadequate record and registry systems.

Tobacco use among medical students in Europe: Results of a multicentre study using the Global Health Professions Student Survey

2011-12-19

Summary: Objective: To examine smoking prevalence, knowledge and attitudes, and tobacco cessation training among university students attending European medical schools using the Global Health Professional Students Survey approach.Methods: A cross-country, cross-sectional study was performed among 12 medical schools in four countries in Europe (Germany, Italy, Poland and Spain). The survey was performed during the second semester of the third year of study from March to May 2009.Results: In total, 2249 subjects entered the study (overall response rate 92%). The overall prevalence of smoking among medical students was 29.3% (95% confidence interval 28.1–34.7), with percentages ranging from 28% in Germany to 31.3% in Italy. This study found that more than two-thirds of medical students believe that health professionals are role models for patients, with different beliefs in Poland (89.6%) and Germany (77.7%) vs Italy and Spain (57.2% and 54.4%, respectively) (P < 0.001). Smoking cessation training at medical school was only reported by 16.5% of students (lowest proportion in Italy, 3.5%) (P < 0.001). In terms of smoking cessation methods, the vast majority (89.8%) of medical students were aware of nicotine patches and gum (highest prevalence in Spain, 96.3%), and 24.4% were aware of the use of antidepressants (highest prevalence in Germany, 33.6%).Conclusion: This European survey found that the prevalence of smoking was higher among medical students than the general population. There is a strong need to provide medical students with training in smoking cessation techniques.

How prepared are our future doctors for HIV/AIDS?

S.S. Lee, A. Lam, K.C.K. Lee — 2011-11-28

Summary: Three cohorts (n = 391) of final-year medical students in Hong Kong were evaluated on their preparedness to provide HIV care. Through a self-administered questionnaire, half (53%) were assessed to be better prepared and had a lower perceived risk of infection at work, though unwillingness to manage HIV patients was reported in a minority (4.6%). For a majority of medical students (72.8%), a specially-designed clinic attachment offered the only opportunity to come face-to-face with HIV patients for the first time. With continued improvement in treatment effectiveness, HIV/AIDS is evolving to become a new chronic disease in most societies. Curriculum development in HIV medicine remains a challenge in this HAART era.

Assessing the validity of health impact assessment predictions regarding a Japanese city’s transition to core city status: A monitoring review

M. Hoshiko, K. Hara, T. Ishitake — 2011-12-19

Summary: Background: The validity of health impact assessment (HIA) predictions has not been accurately assessed to date. In recent years, legislative attempts to promote decentralization have been progressing in Japan, and Kurume was designated as a core city in April 2008. An HIA into the transition of Kurume to a core city was conducted before the event, but the recommendations were not accepted by city officials.Objective: The aim of this study was to examine the validity of predictions made in the HIA on Kurume by conducting a monitoring review into the accuracy of the predictions.Method: Before Kurume was designated as a core city, the residents completed an online questionnaire and city officials were interviewed. The findings and recommendations were presented to the city administration. One year after the transition, a monitoring review was performed to clarify the accuracy of the HIA predictions by evaluating the correlation between the predictions and reality.Results: Many of the HIA predictions were found to conflict with reality in Kurume. Prediction validity was evaluated for two groups: residents of Kurume and city officials. For the residents, 17% (2/12 items) of the predictions were found to be compatible, 58% (7/12) were incompatible and 25% (3/12) were difficult to evaluate. For city officials, the analysis was divided into those whose department was directly involved in tasks transferred to them (transfer tasks) and those whose department was not. For the city officials in departments responsible for conducting core city transfer tasks, 33% (3/9 items) of the predictions were found to be compatible, 33% (3/9) were incompatible and 33% (3/9) were difficult to evaluate. However, for the city officials whose responsibilities were unrelated to core city transfer tasks, 11% (1/9) of predictions were found to be compatible, 78% (7/9) were incompatible and 11% (1/9) were difficult to evaluate.Conclusion: Although it was possible to validate some of the HIA predictions, the results of this monitoring review found substantial discrepancies between the predictions and reality 1 year after the transition of Kurume to a core city. This suggests that the accuracy of HIA predictions may be called into question. However, it should be noted that the review was conducted very soon after the transition and the steering group was very small, which may explain why the HIA predictions were inaccurate. Further, long-term studies may be needed to assess the accuracy of HIA predictions in similar contexts.