How policy informs the evidence

Bridging the gap between research evidence and its implementation in public health practice: case studies of embedded research model

AIM

To investigate the potential of embedded research in bridging the gap between research evidence and its implementation in public health practice.

METHODS

Using a case study methodology, semi-structured interviews were conducted with 4 embedded researchers, 9 public health practitioners, and 4 other stakeholders (2 teachers and 2 students) across four case study sites. Sites and individuals were purposively selected. Sites included two local authorities, one secondary school, and one sports organisation. Thematic data analysis was adopted to analyse the qualitative data.

RESULTS

Four themes were identified: (1) building and maintaining relationships, (2) working with stakeholders, (3) informing practice, and (4) critical reflection.

CONCLUSIONS

Embedded researchers build and maintain relationships with practitioners and other stakeholders to produce research. Evidence from the co-produced research informs future practice and research to improve service and delivery rendered to the public. Thus, embedded researchers use their role to bridge the research evidence - implementation gap in public health practice.

Are Research-Practice Partnerships Responsive to Partners' Needs? Exploring Research Activities During the COVID-19 Pandemic

Despite everyone's best intentions, RPP-produced research may still fall short of being responsive to the needs of practice partners. The COVID-19 pandemic arguably magnified the demand for research to help education leaders make informed decisions in unprecedented ways. Were RPPs able to be responsive to practice-side partners in their time of need? We draw upon data collected as part of the 2019, 2020, and 2021 National Network of Education Research-Practice Partnerships' (NNERPP) annual reports to explore this question. Our findings suggest an increase in design-based projects, in addition to increases in quick-turnaround research syntheses in order to accommodate partner needs.

The dark side of coproduction: do the costs outweigh the benefits for health research?

Background

Coproduction, a collaborative model of research that includes stakeholders in the research process, has been widely advocated as a means of facilitating research use and impact. We summarise the arguments in favour of coproduction, the different approaches to establishing coproductive work and their costs, and offer some advice as to when and how to consider coproduction.

Debate

Despite the multiplicity of reasons and incentives to coproduce, there is little consensus about what coproduction is, why we do it, what effects we are trying to achieve, or the best coproduction techniques to achieve policy, practice or population health change. Furthermore, coproduction is not free risk or cost. Tensions can arise throughout coproduced research processes between the different interests involved. We identify five types of costs associated with coproduced research affecting the research itself, the research process, professional risks for researchers and stakeholders, personal risks for researchers and stakeholders, and risks to the wider cause of scholarship. Yet, these costs are rarely referred to in the literature, which generally calls for greater inclusion of stakeholders in research processes, focusing exclusively on potential positives. There are few tools to help researchers avoid or alleviate risks to themselves and their stakeholders.

Conclusions

First, we recommend identifying specific motivations for coproduction and clarifying exactly which outcomes are required for whom for any particular piece of research. Second, we suggest selecting strategies specifically designed to enable these outcomes to be achieved, and properly evaluated. Finally, in the absence of strong evidence about the impact and process of coproduction, we advise a cautious approach to coproduction. This would involve conscious and reflective research practice, evaluation of how coproduced research practices change outcomes, and exploration of the costs and benefits of coproduction. We propose some preliminary advice to help decide when coproduction is likely to be more or less useful.

The tale wagged by the DAG: broadening the scope of causal inference and explanation for epidemiology

'Causal inference', in 21st century epidemiology, has notably come to stand for a specific approach, one focused primarily on counterfactual and potential outcome reasoning and using particular representations, such as directed acyclic graphs (DAGs) and Bayesian causal nets. In this essay, we suggest that in epidemiology no one causal approach should drive the questions asked or delimit what counts as useful evidence. Robust causal inference instead comprises a complex narrative, created by scientists appraising, from diverse perspectives, different strands of evidence produced by myriad methods. DAGs can of course be useful, but should not alone wag the causal tale. To make our case, we first address key conceptual issues, after which we offer several concrete examples illustrating how the newly favoured methods, despite their strengths, can also: (i) limit who and what may be deemed a 'cause', thereby narrowing the scope of the field; and (ii) lead to erroneous causal inference, especially if key biological and social assumptions about parameters are poorly conceived, thereby potentially causing harm. As an alternative, we propose that the field of epidemiology consider judicious use of the broad and flexible framework of 'inference to the best explanation', an approach perhaps best developed by Peter Lipton, a philosopher of science who frequently employed epidemiologically relevant examples. This stance requires not only that we be open to being pluralists about both causation and evidence but also that we rise to the challenge of forging explanations that, in Lipton's words, aspire to 'scope, precision, mechanism, unification and simplicity'.

The role of the Sheffield model on the minimum unit pricing of alcohol debate: the importance of a rhetorical perspective

The minimum unit pricing (MUP) alcohol policy debate has been informed by the Sheffield model, a study which predicts impacts of different alcohol pricing policies. This paper explores the Sheffield model's influences on the policy debate by drawing on 36 semi-structured interviews with policy actors who were involved in the policy debate. Although commissioned by policy makers, the model's influence has been far broader than suggested by views of 'rational' policy making. While findings from the Sheffield model have been used in instrumental ways, they have arguably been more important in helping debate competing values underpinning policy goals.

What is Good Qualitative Research?

Qualitative research has an enormous amount to contribute to the fields of health, medicine and public health but readers and reviewers from these fields have little understanding of how to judge its quality. Work to date accurately reflects the complexity of the theoretical debate required but may not meet the needs of practitioners attempting to apply qualitative work in reviews of evidence. This article describes a simple, practitioner-focused framework for assessing the rigour of qualitative research that attempts to be inclusive of a range of epistemological and ontological standpoints. An extensive review of the literature, contributions from expert groups and practitioners themselves lead to the generation of two core principles of quality: transparency and systematicity, elaborated to summarize the range of techniques commonly used, mirroring the flow of the research process. The complexities discovered are only summarized here. Finally, outstanding issues such as ‘how much transparency is enough?’, are flagged up.

Researching Health Inequities among African Americans: The Imperative to Understand Social Class

Racial and ethnic inequities in health abound in many disease categories. African-American communities suffer from an increased burden of illness, with higher incidence and mortality rates and more severe morbidity in cerebrovascular disease, heart disease, several cancers, diabetes, and many other ailments. Healthy People 2010, the federal government's health plan, calls for eliminating health disparities by race, ethnicity, gender, education, income, disability, geographic location, or sexual orientation. Research aimed at increasing our understanding of these health disparities and designing and evaluating interventions to improve African-American health is hampered by a liberal, classless approach. The authors argue for a theoretical framework in this research that recognizes that class exploitation sets the stage for and interacts with racial discrimination to determine racial inequities in health.

Systematic review of interventions to reduce illicit drug use in female drug-dependent street sex workers

OBJECTIVES

Most female street-based sex workers (SSWs) are drug users and this group experience particularly poor outcomes in achieving and maintaining abstinence. In 2010 the UK adopted a recovery-orientated Drug Strategy. This strategy did not specifically highlight the complex drug treatment needs of SSWs. Therefore we sought to synthesise and critically appraise existing evidence of interventions to reduce illicit drug use in this group, in order to guide service change toward better provision for the drug treatment needs of SSWs.

METHODS

A systematic review of evidence on the effectiveness of interventions to reduce illicit drug use in female SSWs. Following the PRISMA guidelines, a structured search strategy was used. Searches included databases, organisational and government websites to identify published and grey literature, as well as contacting experts in the field, and hand-searching reference lists and journals.

RESULTS

Six studies, one experimental and five observational, were identified which met review inclusion criteria. Intervention approaches evaluated included substitute prescribing, educational sessions and motivational interviewing. All studies reported a positive intervention effect but the five observational studies were all subject to a relatively high risk of bias. By contrast, the experimental study provided little or no evidence of positive effect (OR for reduction of illicit drug in intervention compared to controls 1.17 95%CI 0.84-1.66 at 3 months and 1.14 (95% CI 0.8 to 1.61) at 6 months follow-up). All six studies described challenges and solutions to study recruitment, retention and follow-up, which were influenced by issues affecting SSWs' health and social stability.

CONCLUSIONS

There is currently no strong evidence for effectiveness of interventions to reduce illicit drug use in female SSWs with problematic drug use. Thus, the development and robust evaluation of effective interventions should be a priority if recovery-orientated goals are to become more achievable for this group.

New directions in evidence-based policy research: a critical analysis of the literature

Despite 40 years of research into evidence-based policy (EBP) and a continued drive from both policymakers and researchers to increase research uptake in policy, barriers to the use of evidence are persistently identified in the literature. However, it is not clear what explains this persistence - whether they represent real factors, or if they are artefacts of approaches used to study EBP. Based on an updated review, this paper analyses this literature to explain persistent barriers and facilitators. We critically describe the literature in terms of its theoretical underpinnings, definitions of 'evidence', methods, and underlying assumptions of research in the field, and aim to illuminate the EBP discourse by comparison with approaches from other fields. Much of the research in this area is theoretically naive, focusing primarily on the uptake of research evidence as opposed to evidence defined more broadly, and privileging academics' research priorities over those of policymakers. Little empirical data analysing the processes or impact of evidence use in policy is available to inform researchers or decision-makers. EBP research often assumes that policymakers do not use evidence and that more evidence - meaning research evidence - use would benefit policymakers and populations. We argue that these assumptions are unsupported, biasing much of EBP research. The agenda of 'getting evidence into policy' has side-lined the empirical description and analysis of how research and policy actually interact in vivo. Rather than asking how research evidence can be made more influential, academics should aim to understand what influences and constitutes policy, and produce more critically and theoretically informed studies of decision-making. We question the main assumptions made by EBP researchers, explore the implications of doing so, and propose new directions for EBP research, and health policy.

More than "using research": the real challenges in promoting evidence-informed decision-making

OBJECTIVES AND METHODS

Seventeen focus groups and 53 semi-structured individual interviews involving 205 planners and decision-makers were conducted in all 11 Regional Health Authorities (RHAs) in the province of Manitoba, Canada. Objectives were to explore perspectives on the nature and use of "evidence," and barriers to evidence-informed decision-making (EIDM).

RESULTS

In spite of almost universal support in principle for using evidence in decision-making, there was little consensus among participants on what evidence is, what kind of evidence is most appropriate and how "using evidence" can best be demonstrated. Significant skepticism about EIDM was expressed. Issues related to workload, politicized decision-making and organizational factors dominated the discussion of decision-makers. Barriers to EIDM were commonly attributed to factors external to the RHAs.

CONCLUSION

Effective strategies to promote EIDM must address the multiple barriers experienced by decision-makers in a complex decision-making environment. Rather than simply focusing on issues of access to evidence or development of individual capacity, strategies must focus on changing decision-making processes to support appropriate use of evidence.

Systematic review of multidisciplinary teams in the management of lung cancer

BACKGROUND

In several countries, clinical practice guidelines for lung cancer recommend that multidisciplinary (MD) teams should be used to plan the management of all lung cancer patients. We conducted a systematic review to evaluate and critically appraise the effectiveness of multidisciplinary teams for lung cancer.

MATERIALS AND METHODS

Medline searches were carried out for the period 1984 to July 2007. We included any study that mentioned team working among specialists with diagnostic and curative therapeutic intent, where members of the team met at a specified time, either in person or by video or teleconferencing, to discuss the diagnosis and management of patients with suspected lung cancer. All study designs were included. We were particularly interested in whether multidisciplinary working improved survival but also considered other outcomes such as practice patterns and waiting times.

RESULTS

Sixteen studies met the criteria for inclusion. Statistical pooling was not possible due to clinical heterogeneity. Only two of the primary studies reported an improvement in survival. Both were before-and-after designs, providing weak evidence of a causal association. Evidence of the effect of MD teams was stronger for changing patient management than for affecting survival. Six of the studies reported an increase in the percentage of patients undergoing surgical resection or an increase in the percentage of patients undergoing chemotherapy or radiotherapy with curative intent.

CONCLUSION

This systematic review shows limited evidence linking MD teams with improved lung cancer survival. This does not mean that MD teams do not improve survival, merely that currently available evidence of this is limited. It seems intuitively obvious that MD teams should improve outcomes for lung cancer patients, but there are difficulties in conducting randomised trials to show this. The best way forward would be prospective evaluation of the effectiveness of MD teams as they are implemented, paying particular attention to collecting data on potential confounders.

Evaluating health effects of transport interventions methodologic case study

BACKGROUND

There is little evidence about the effects of environmental interventions on population levels of physical activity. Major transport projects may promote or discourage physical activity in the form of walking and cycling, but researching the health effects of such "natural experiments" in transport policy or infrastructure is challenging.

METHODS

Case study of attempts in 2004-2005 to evaluate the effects of two major transport projects in Scotland: an urban congestion charging scheme in Edinburgh, and a new urban motorway (freeway) in Glasgow.

RESULTS

These interventions are typical of many major transport projects. They are unique to their context. They cannot easily be separated from the other components of the wider policies within which they occur. When, where, and how they are implemented are political decisions over which researchers have no control. Baseline data collection required for longitudinal studies may need to be planned before the intervention is certain to take place. There is no simple way of defining a population or area exposed to the intervention or of defining control groups. Changes in quantitative measures of health-related behavior may be difficult to detect.

CONCLUSIONS

Major transport projects have clear potential to influence population health, but it is difficult to define the interventions, categorize exposure, or measure outcomes in ways that are likely to be seen as credible in the field of public health intervention research. A final study design is proposed in which multiple methods and spatial levels of analysis are combined in a longitudinal quasi-experimental study.

Accounting for EBM: Notions of evidence in medicine

This paper takes as a focus of anthropological enquiry the set of techniques and practices for the appraisal and clinical application of research evidence that has become known as evidence-based medicine (EBM) (or, more recently, evidence-based health care). It first delineates and classifies the criticisms of EBM emerging from within the health professions. It then charts the evolution of EBM in responding to these criticisms and uncovers its character as a pedagogical innovation aimed at transforming clinical practice. It identifies EBM as an indeterminate and malleable range of techniques and practices characterised not by particular kinds of methodological rigour, but by the pursuit of a new approach to medical knowledge and authority. It situates this characterisation within a contemporaneous political and economic climate of declining trust and growing accountability. This analysis provides a basis from which to consider the notions of evidence implicit in EBM itself and also in the qualitative social sciences, including anthropology, which not only critique but also contribute to these notions themselves. Finally, the paper considers possible future trajectories for EBM with regard to the incorporation of cultural and structural dimensions of health and the inclusion of qualitative material in the evidence base.

Do urban regeneration programmes improve public health and reduce health inequalities? A synthesis of the evidence from UK policy and practice (1980-2004)

OBJECTIVES

To synthesise data on the impact on health and key socioeconomic determinants of health and health inequalities reported in evaluations of national UK regeneration programmes.

DATA SOURCES

Eight electronic databases were searched from 1980 to 2004 (IBSS, COPAC, HMIC, IDOX, INSIDE, Medline, Urbadisc/Accompline, Web of Knowledge). Bibliographies of located documents and relevant web sites were searched. Experts and government departmental libraries were also contacted.

REVIEW METHODS

Evaluations that reported achievements drawing on data from at least two target areas of a national urban regeneration programme in the UK were included. Process evaluations and evaluations reporting only business outcomes were excluded. All methods of evaluation were included. Impact data on direct health outcomes and direct measures of socioeconomic determinants of health were narratively synthesised.

RESULTS

19 evaluations reported impacts on health or socioeconomic determinants of health; data from 10 evaluations were synthesised. Three evaluations reported health impacts; in one evaluation three of four measures of self reported health deteriorated, typically by around 4%. Two other evaluations reported overall reductions in mortality rates. Most socioeconomic outcomes assessed showed an overall improvement after regeneration investment; however, the effect size was often similar to national trends. In addition, some evaluations reported adverse impacts.

CONCLUSION

There is little evidence of the impact of national urban regeneration investment on socioeconomic or health outcomes. Where impacts have been assessed, these are often small and positive but adverse impacts have also occurred. Impact data from future evaluations are required to inform healthy public policy; in the meantime work to exploit and synthesise "best available" data is required.

State of the art of guidelines

Guidelines have existed in medicine for many centuries. Galen's doctrine of laudable pus sent many to an early grave, but variance in treatment put the practitioner in a difficult position, especially if all did not go well. Currently, guidelines proliferate, allegedly based upon careful evaluation of evidence culled from a variety of sources. However, obedience to guidelines is variable internationally and nationally, thus raising questions about their enforceability. They are, of course, not legally enforceable, but courts may be influenced by them, and variation must be evidence-based. Guidelines cannot logically be regarded as being set in stone; if that were the case, then there could be no innovation and medicine would not advance.

Associations of socio-economic position and disability among older women in Britain and Jyväskylä, Finland

The aim was to compare the pattern of associations in measures of socio-economic position and disability among British and Finnish older women. In Britain data from the British Women's Heart and Health Study was used. Women from 23 towns took part in a nurse-assessed medical examination and postal questionnaire (n = 4286). In Finland, data from the Evergreen study was used. Eight hundred and four women from the city of Jyväskylä were interviewed at home. Socio-economic position was measured according to social class in childhood, education, use of a car, home ownership and previous occupation. Disability measures included questions on difficulties in washing/dressing and climbing stairs. Logistic regression analyses were conducted to examine the relationship between disability and socio-economic position. In the age-adjusted analysis of both samples increasing disability in washing/dressing and climbing stairs was associated with at least one of the measures of deprivation. The relationship between socio-economic position and disability was more distinct in the British than Finnish women. Despite adjustment for a range of confounders, the relationship between socio-economic position and disability was not much attenuated, particularly in the British women. The associations in the measures of socio-economic position and disability showed a slightly different pattern between the British and Finnish women.

Developing an evidence base for policies and interventions to address health inequalities: the analysis of "public health regimes"

Systematic reviews have become an important methodology in the United Kingdom by which research informs health policy, and their use now extends beyond evidence-based medicine to evidence-based public health and, particularly, health inequalities policies. This article reviews the limitations of systematic reviews as stand-alone tools for this purpose and suggests a complementary approach to make better use of the evidence. That is, systematic reviews and other sources of evidence should be incorporated into a wider analytical framework, the public health regime (defined here as the specific legislative, social, political, and economic structures that have an impact on both public health and the appropriateness and effectiveness of public health interventions adopted). At the national level this approach would facilitate analysis at all levels of the policy framework, countering the current focus on individual interventions. It could also differentiate at the international level between those policies and interventions that are effective in different contexts and are therefore potentially generalizable and those that depend on particular conditions for success.

Social capital and mental health: an interdisciplinary review of primary evidence

An interdisciplinary interrogation of primary evidence linking social capital and mental health sought to establish: (1) 'quality of evidence' (assessed in terms of study design, methods used to address stated questions, rigor of data analysis, and logic and clarity of interpretation of results), and (2) applicability of the evidence to public health policy and practice with respect to mental health. It is found that social capital, a complex and compound construct, can be both an asset and a liability with respect to mental health of those in receipt of and those providing services and other interventions. The most meaningful assessment of social capital or components thereof may examine individual access to rather than possession of social capital, a property of groups, and therefore an ecological variable. Theoretical advances in research on social capital serve to identify mainly two types of social capital: bonding (between individuals in a group) and bridging (between groups). Each type of social capital has cognitive and/or structural component(s) and may operate at micro and/or macro level(s). Effective mental health policy and service provision may build or strengthen bridging social capital and benefit from both bonding and bridging social capital where either or both exist. Established indicators of social capital are amenable to quantitative and qualitative assessment, preferably in tandem. However studies that employ combined research design are rare or non-existent. Interdisciplinary multi-method investigations and analyses are called for in order to unravel mechanisms whereby social capital and mental health might be meaningfully associated.

The health-related quality of life of people with peripheral arterial disease in the community: the Edinburgh Artery Study

BACKGROUND

Previous studies investigating the health-related quality of life of those with peripheral arterial disease have focused on patients recruited from hospital clinics. The health-related quality of life of people with peripheral arterial disease in the general population is unknown.

AIMS

We aimed to determine the health-related quality of life of people with intermittent claudication and asymptomatic peripheral arterial disease in the general population and to compare it with those with angina and those with no peripheral arterial disease or angina.

DESIGN OF STUDY

Analysis of cross-sectional data from the 12-year follow-up of a population-based cohort.

SETTING

Edinburgh, Scotland.

METHOD

Data from the Edinburgh Artery Study cohort's 12-year follow-up was analysed. Participants' peripheral arterial disease status was measured using the World Health Organisation intermittent claudication questionnaire and the ankle brachial pressure index. Self-assessed health-related quality of life data was collected using the SF-36 generic questionnaire. Health-related quality of life scores were calculated and their associations with peripheral arterial disease status groups were tested.

RESULTS

Subjects with intermittent claudication had significantly worse median health-related quality of life scores than patients without claudication in all domains except social functioning and mental health. Patients with claudication had a significantly lower physical component summary score than those without claudication (P </= 0.001). This association remained after adjustment for age, sex, social class, body mass index, smoking, and angina. Those with angina and claudication had significantly worse physical component summary scores than those with no peripheral arterial disease or angina (P </= 0.001). No significant difference was found in health-related quality of life scores between those with asymptomatic peripheral arterial disease and those with no peripheral arterial disease even after multiple adjustment for confounding factors.

CONCLUSION

People with intermittent claudication in the community had impaired health-related quality of life related to reduced physical health, but asymptomatic peripheral arterial disease did not significantly affect health-related quality of life.

Psychological and social sequelae of cannabis and other illicit drug use by young people: a systematic review of longitudinal, general population studies

BACKGROUND

Use of illicit drugs, particularly cannabis, by young people is widespread and is associated with several types of psychological and social harm. These relations might not be causal. Causal relations would suggest that recreational drug use is a substantial public health problem. Non-causal relations would suggest that harm-reduction policy based on prevention of drug use is unlikely to produce improvements in public health. Cross-sectional evidence cannot clarify questions of causality; longitudinal or interventional evidence is needed. Past reviews have generally been non-systematic, have often included cross-sectional data, and have underappreciated the extent of methodological problems associated with interpretation.

METHODS

We did a systematic review of general population longitudinal studies reporting associations between illicit drug use by young people and psychosocial harm.

FINDINGS

We identified 48 relevant studies, of which 16 were of higher quality and provided the most robust evidence. Fairly consistent associations were noted between cannabis use and both lower educational attainment and increased reported use of other illicit drugs. Less consistent associations were noted between cannabis use and both psychological health problems and problematic behaviour. All these associations seemed to be explicable in terms of non-causal mechanisms.

INTERPRETATION

Available evidence does not strongly support an important causal relation between cannabis use by young people and psychosocial harm, but cannot exclude the possibility that such a relation exists. The lack of evidence of robust causal relations prevents the attribution of public health detriments to illicit drug use. In view of the extent of illicit drug use, better evidence is needed.

Delivering equitable care: comparing preventive services in Manitoba

OBJECTIVES

This study examined preventive care delivered in Manitoba during the 1990s by 3 different methods -childhood immunizations (by physicians and public health nurses under a government program), screening mammography (through a government program introduced in 1995), and cervical cancer screening (no program).

METHODS

Longitudinal administrative data, an immunization monitoring system, and Canadian census databases were used.

RESULTS

Cervical cancer screening rates remained static and showed strong socioeconomic differences; childhood immunization rates remained high with small socioeconomic gradients. The introduction of the Manitoba Breast Screening Program resulted in rising rates of screening and vanishing socioeconomic gradients.

CONCLUSIONS

Manitoba government programs in childhood immunization and screening mammography actively helped the provision of preventive care. Organized programs that target population groups, recognize barriers to access, and facilitate self-evaluation are critical for equitable delivery.

Evidence-based medicine and women: do the principles and practice of EBM further women's health?

Clinicians and policy makers the world over are embracing evidence-based medicine (EBM). The promise of EBM is to use summaries of research evidence to determine which healthcare interventions are effective and which are not, so that patients may benefit from effective interventions and be protected from useless or harmful ones. EBM provides an ostensibly rational objective means of deciding whether or not an intervention should be provided on the basis of its effectiveness, in theory leading to fair and effective healthcare for all. In this paper I closely examine these claims from the perspective of healthcare for women, using relevant examples. I argue that the current processes of evidence-based medicine contain a number of biases against women. These biases occur in the production of research that informs evidence-based medicine, in the methods used to analyse and synthesise the evidence, and in the application of EBM through the use of guidelines. Finally, the biomedical model of health that underpins most of the medical research used by EBM ignores the social and political context which contributes so much to the ill-health of women.

Evolutionary perspectives on pregnancy: maternal age at menarche and infant birth weight

We present a novel evolutionary analysis of low birth weight (LBW). LBW is a well-known risk factor for increased infant morbidity and mortality. Its causes, however, remain obscure and there is a vital need for new approaches. Life history theory, the most dynamic branch of evolutionary ecology, provides important insights into the potential role of LBW in human reproductive strategies. Life history theory's primary rationale for LBW is the trade-off between current and future reproduction. This trade-off underlies the prediction that under conditions of environmental risk and uncertainty (experienced subjectively as psychosocial stress) it can be evolutionarily adaptive to reproduce at a young age. One component of early reproduction is early menarche. Early reproduction tends to maximise offspring quantity, but parental investment theory's assumption of a quantity-quality trade-off holds that maximizing offspring quantity reduces quality, of which LBW may be the major component. We therefore predict that women who experienced early psychosocial stress and had early menarche are more likely to produce LBW babies. Furthermore, the extension of parent-offspring conflict theory in utero suggests that the fetus will attempt to resist its mother's efforts to reduce its resources, allocating more of what it does receive to the placenta in order to extract more maternal resources to increase its own quality. We propose that LBW babies born to mothers who experience early psychosocial stress and have early menarche are more likely to have a higher placental/fetal weight ratio. We review evidence in support of these hypotheses and discuss the implications for public health.

Socio-economic inequalities in diabetes complications, control, attitudes and health service use: a cross-sectional study

AIMS

To investigate socio-economic inequalities in diabetes complications, and to examine factors that may explain these differences.

METHODS

Cross-sectional questionnaire survey of 770 individuals with diabetes among 40 general practices in Avon and Somerset. General practice, optometrist and eye hospital records over time (median 7 years) were analysed. Slope indices of inequality, odds ratios and incidence rate ratios were calculated to estimate the magnitude of inequality between the most and least educated, and the highest and lowest earning patients, adjusted for age, sex and type of diabetes, and clustering of outcomes within practices.

RESULTS

The least educated patients were more likely than the most educated patients to have diabetic retinopathy [adjusted odds ratio (OR) 4.3; 95% confidence interval 0.8, 23.7] and heart disease (adjusted OR 3.6; 1.1, 11.8), had higher HbA1c levels (adjusted slope index of inequality 0.9; 0.3, 1.5), felt that diabetes more adversely affected their social and personal lives (adjusted slope index of inequality 0.8; 0.5, 1.1 Diabetes Care Profile units), were more likely to be recorded as non-compliant by their health professionals, and had lower rates of hospital attendance (adjusted rate ratio 0.43; 0.26, 0.71). However, they did not see themselves as less compliant, and had higher general practice attendance rates (adjusted rate ratio 1.5; 1.1, 2.2).

CONCLUSIONS

Less educated and lower earning individuals with diabetes bear a larger burden of morbidity but use hospital care less. Health service resource allocation should reflect the distribution of chronic illness.

Assessing health impact assessment: multidisciplinary and international perspectives

Health impact assessment (HIA) seeks to expand evaluation of policy and programmes in all sectors, both private and public, to include their impact on population health. While the idea that the public's health is affected by a broad array of social and economic policies is not new and dates back well over two centuries, what is new is the notion-increasingly adopted by major health institutions, such as the World Health Organisation (WHO) and the United Kingdom National Health Services (NHS)-that health should be an explicit consideration when evaluating all public policies. In this article, it is argued that while HIA has the potential to enhance recognition of societal determinants of health and of intersectoral responsibility for health, its pitfalls warrant critical attention. Greater clarity is required regarding criteria for initiating, conducting, and completing HIA, including rules pertaining to decision making, enforcement, compliance, plus paying for their conduct. Critical debate over the promise, process, and pitfalls of HIA needs to be informed by multiple disciplines and perspectives from diverse people and regions of the world.

Psychosocial factors and public health: a suitable case for treatment?

Adverse psychosocial exposure or "misery" is associated with physical disease. This association may not be causal. Rather it may reflect issues of reverse causation, reporting bias, and confounding by aspects of the material environment typically associated with misery. A non-causal relation will not form the basis of effective public health interventions. This may be why psychosocial interventions have, so far, showed little effect on objective physical health outcomes. This paper reviews evidence for the "psychosocial hypothesis" and suggests strategies for clarifying these issues. It concludes that, although misery is clearly a bad thing as it erodes people's quality of life, there is little evidence that psychosocial factors cause physical disease. In the absence of better evidence, suggestions that psychosocial interventions are needed to improve population physical health, in both absolute and relative terms, seem premature.

Screening for prostate cancer

Epidemiologically, screening is justified by the importance of the disease and the lack of prospects for primary prevention, but evidence from natural history is unhelpful since men are more likely to die with, rather than from, prostate cancer. The available screening tests do not always detect men whose lesions could result in future morbidity or mortality. Evidence is limited for the benefits of treatment for localised cancers detected through screening, whereas the evidence for harm is clear. Observational evidence for the effect of population screening programmes is mixed, with no clear association between intensity of screening and reduced prostate cancer mortality. Screening for prostate cancer cannot be justified in low-risk populations, but the balance of benefit and harm will be more favourable after risk stratification. Prostate cancer screening can be justified only in research programmes designed to assess its effectiveness and help identify the groups who may benefit.

The World Health Report 2000: World Health Organization health policy steering off course-changed values, poor evidence, and lack of accountability

The World Health Report 2000 on health systems has raised concerns about its political biases, its methods and indicators, and its lack of reliable data. Tracing the origins of the Report, this article argues that it counteracts many of the concerns that gave rise to preparation of the Report in the first place. The mutually agreed-upon value-base, expressed in the Health for All strategy, has been largely abandoned. The Report includes contradictory messages, and many of its recommendations are not evidence-based. Furthermore, the ranking of countries according to their health systems' performance is not useful for health-policy-making, even if the methods and data could be improved. Because the member states and governing bodies of the WHO were not consulted during the production of the Report, the WHO secretariat has not received a mandate to change the value-base of the WHO's health policy or the aims of the Report. The WHO should return to its mandate as a normative intergovernmental U.N. agency on health.

Putting the public back into public health. Part II. How can public health be accountable to the public?

The practice of public health involves the application of evidence to improving population health, and should be accountable to the public. Accountability to the public can be considered either at the individual doctor-patient interface or through population-level policy making. The public, at both patient and population levels, should join the professionals at each stage of the 'population health evidence cycle'-in asking for, collecting, understanding and using evidence. A greater appreciation of the non-professional, public perspective would represent a substantial commitment to transforming our understanding and needs for different kinds of evidence required to improve the health of the population.

Social determinants of disability pension: a 10-year follow-up of 62 000 people in a Norwegian county population

BACKGROUND

Non-medical factors may be important determinants for granting disability pension (DP) even though disability is medically defined, as in Norway. The aim of this analysis was to identify determinants of DP in a total county population in a 10-year follow-up study.

METHODS

Participants were people without DP, 20- to 66-years-old in 1984-1986. The baseline data were obtained in the Nord-Trøndelag Health Study (HUNT): 90 000 people were invited to answer questionnaires on health, disease, social, psychological, occupational, and lifestyle factors. Information on those who later received DP was obtained from the National Insurance Administration database in 1995. Data analyses were performed using Cox regression analyses.

RESULTS

The incidence of DP showed great variation with regards to age and gender, accounting for an overall increase in the follow-up period. Low level of education, low self-perceived health, occupation-related factors and any long-standing health problem were found to be the strongest independent determinants of DP. Low level of education and socioeconomic factors contributed more to younger people's risk compared to those over 50 years. For people under 50 years of age with a low level of education compared to those with a high level of education, the age-adjusted relative risk for DP was 6.35 for men and 6.95 for women. The multivariate-adjusted relative risk was 2.91 and 4.77, respectively.

CONCLUSIONS

Even for a medically based DP, low socioeconomic status, low level of education and occupational factors might be strong determinants when compared to medical factors alone. These non-medical determinants are usually not addressed by individual based health or rehabilitation programmes.

Are inequalities in height underestimated by adult social position? Effects of changing social structure and height selection in a cohort study

OBJECTIVES

To investigate whether changing social structure and social mobility related to height generate (inflate) inequalities in height.

DESIGN

Longitudinal 1958 British birth cohort study.

SETTING

England, Scotland, and Wales.

PARTICIPANTS

10 176 people born 3-9 March 1958 for whom data were available at age 33 years.

MAIN OUTCOME MEASURES

Adult height and social class at age 33 years; class of origin (father's occupation when participant was 7 years old).

RESULTS

Adult height showed a social gradient with class at age 7 years and age 33 years. The difference in mean height between extreme groups was greater for class of origin than for adult class, reducing from 2.21 cm to 1.62 cm for men and from 2.18 cm to 1.74 cm for women. This narrowing inequality was due mainly to a decrease in mean height in classes I and II. This was because of the pattern of height related social mobility in which, for example, men moving into classes I and II were taller (mean 177.2 cm) than men remaining in class III manual (mean 176.1 cm) yet shorter than men with class I and II origins (mean 178.3 cm) and the relatively large number of individuals moving into classes I and II. Changes in the structure of society, seen here with the general trend of upward social mobility, have acted to diminish inequalities in adult height.

CONCLUSIONS

The combination of changing social structure and height related mobility constrains, rather than inflates, inequalities in height and may lead to an underestimation of the role of childhood socioeconomic factors in the development of inequalities in adult disease.

Evidence-based medicine: an introduction for psychiatrists

Evidence-based medicine (EBM) has been defined by Sackett as "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients." Practicing evidence-based medicine requires the ability to apply a knowledge of medical informatics and clinical epidemiology to the treatment of individual patients. This article provides an introduction to the history, philosophy, and methods of evidence-based medicine for psychiatrists and other mental health professionals. The article focuses on a systematic approach to efficiently finding the best evidence to answer clinical questions. Particular emphasis is given to a method for critically appraising papers that emphasizes validity, importance, and clinical applicability. Resources for further learning are provided.

Citizens advice in primary care for families with young children

BACKGROUND

Citizens advice can help clients avoid the worst consequences of poverty and hence has the potential to reduce inequalities in health. Previous studies of providing citizens advice from primary care have concentrated largely on older clients.

AIM

To measure the benefits obtained by families with young children from a citizens advice service in primary care.

METHOD

An advice worker was placed in three practices. Eligible families had a child less than 1 year of age. Quantitative analysis of data on benefits obtained by all families using the service was performed. Qualitative analysis of interviews with five users and five non-users of the service was undertaken.

RESULTS

Out of 107 families recruited, 23 used the CAB service, seeking advice on 49 different problems and obtaining benefit on 32 of these, most frequently on welfare benefits, debt management and housing. One-off financial benefits totalled pound sterlings 17 857 with annual recurring payments of pound sterlings 6480. The interviews raised five general themes: (1) the stresses surrounding the birth of a child; (2) factors associated with uptake of the service; (3) the content and value of the advice received; (4) the benefits to their health of the advice; and (5) their perception of the links between health and financial adversity.

CONCLUSIONS

Citizens advice offers considerable benefits to families with young children. It may have positive effects on maternal and child health. An advice service is a useful component of primary health care for young families.