Should equity in health be target number 1?

Policy measures to reduce socioeconomic health differences (SEHD) must be preceded by an analysis of the possibilities and desirability of a reduction. This paper argues that it is necessary to pursue equality in health, conceived as equal opportunities to achieve health. This principle is justified as part of the principle of maximizing individual freedom of choice, and requires that everyone has the opportunity to be as healthy as possible. By means of this principle a distinction can be made between unjust, unavoidable, and acceptable health inequalities. The determinants of SEHD which lead to inequalities considered unjust must be subject to policy. These are living conditions (physical and social environment and health care) and conditions of choice (e.g. the knowledge of an individual about the health risks of a certain behaviour). Even if SEHD are considered inequities, sometimes conflicting interests will make it difficult to propose a health policy to redress these inequities. These are partly the consequence of the intersectoral character of a policy aimed at equality of opportunities to attain health, in which the importance of health has to be weighed against other goals. Moreover the impact of such a policy on the individual free choice has to be critically weighed. Finally in the context of health care policy, conflicts between the principle of equality and maximizing health can be expected

The health benefits of prevention : a simulation approach

The goal of the Prevent project was to devise a tool for policy makers to use epidemiologic data on the relationship between risk factors and diseases, to estimate the effect on the health of a population of changes in risk factor prevalence, either autonomous or through interventions. These effect estimates can either be used directly in policy making for instance to set realistic targets, or serve as input for formal priority setting exercises such as cost effectiveness analyses

By how much would limiting TV food advertising reduce childhood obesity?

Background: There is evidence suggesting that food advertising causes childhood obesity. The strength of this effect is unclear. To inform decisions on whether to restrict advertising opportunities, we estimate how much of the childhood obesity prevalence is attributable to food advertising on television (TV). Methods: We constructed a mathematical simulation model to estimate the potential effects of reducing the exposure of 6- to 12-year-old US children to TV advertising for food on the prevalence of overweight and obesity. Model input was based on body measurements from NHANES 2003–04, the CDC-2000 cut-offs for weight categories, and literature that relates advertising to consumption levels and consumption to body mass. In an additional analysis we use a Delphi study to obtain experts’ estimates of the effect of advertising on consumption. Results: Based on literature findings, the model predicts that reducing the exposure to zero would decrease the average BMI by 0.38 kg/m−2 and lower the prevalence of obesity from 17.8 to 15.2% (95% uncertainty interval 14.8–15.6) for boys and from 15.9% to 13.5% (13.1–13.8) for girls. When estimates are based on expert opinion, these values are 11.0% (7.7–14.0) and 9.9% (7.2–12.4), respectively. Conclusion: This study suggests that from one in seven up to one in three obese children in the USA might not have been obese in the absence of advertising for unhealthy food on TV. Limiting the exposure of children to marketing of energy-dense food could be part of a broader effort to make children's diets healthier

"We're not short of people telling us what the problems are. We're short of people telling us what to do": An appraisal of public policy and mental health

Background: There is sustained interest in public health circles in assessing the effects of policies on health and health inequalities. We report on the theory, methods and findings of a project which involved an appraisal of current Scottish policy with respect to its potential impacts on mental health and wellbeing. Methods: We developed a method of assessing the degree of alignment between Government policies and the 'evidence base', involving: reviewing theoretical frameworks; analysis of policy documents, and nineteen in-depth interviews with policymakers which explored influences on, and barriers to cross-cutting policymaking and the use of research evidence in decisionmaking. Results: Most policy documents did not refer to mental health; however most referred indirectly to the determinants of mental health and well-being. Unsurprisingly research evidence was rarely cited; this was more common in health policy documents. The interviews highlighted the barriers to intersectoral policy making, and pointed to the relative value of qualitative and quantitative research, as well as to the imbalance of evidence between "what is known" and "what is to be done". Conclusion: Healthy public policy depends on effective intersectoral working between government departments, along with better use of research evidence to identify policy impacts. This study identified barriers to both these. We also demonstrated an approach to rapidly appraising the mental health effects of mainly non-health sector policies, drawing on theoretical understandings of mental health and its determinants, research evidence and policy documents. In the case of the social determinants of health, we conclude that an evidence-based approach to policymaking and to policy appraisal requires drawing strongly upon existing theoretical frameworks, as well as upon research evidence, but that there are significant practical barriers and disincentives

A stakeholder analysis of the perceived outcomes of developing and implementing England’s obesity strategy 2008–2011

Background International recommendations urge governments to implement population-based strategies to reduce the burden of obesity. This study assesses the development and implementation of the obesity strategy in England 2008–2011, Healthy Weight, Healthy Lives (HWHL). The aim was to identify if stakeholders perceived HWHL to have made any difference to the action to address obesity in England, with the ultimate objective of identifying insights that could inform the development and implementation of future obesity strategies in England and elsewhere. Methods Qualitative study using semi-structured interviews and thematic framework analysis. 40 stakeholders involved in the development and implementation of the obesity strategy were interviewed. Results Evidence from this study suggests that HWHL was perceived to have made a positive difference to efforts to address obesity in England. It was credited with creating political buy-in, engaging more stakeholders, stimulating and facilitating action, enhancing knowledge and changing attitudes. But it was reported to have failed to fully catalyse action across all government departments and sectors, or to develop adequate mechanisms for learning about the effectiveness of the different elements and actions in the Strategy. Key elements of the Strategy contributing towards to the perceived positive differences included its multi-faceted, inclusive nature; governance structures; monitoring programme to assess progress against national and local targets; child-focus; and funding. The development of the Strategy was said to be stimulated and aided by the prior synthesis of a critical mass of scientific evidence. Conclusions The English experience of HWHL lends support to the recommendations to develop population-based obesity strategies. It indicates that in order to stimulate comprehensive, inter-sectoral action, obesity strategies need to take a population-based, multi-faceted approach, be implemented through a clear governance structure, follow a systematic process of aligning goals, objectives and agendas between government departments and sectors with a stake in obesity, and have a clear system of reporting changes in obesity rates against a target. In order to design effective policies and to build the case for continued investment, obesity strategies also need to incorporate a national framework for learning and evaluation from the outset

Coronary heart disease policy models: a systematic review

BACKGROUND: The prevention and treatment of coronary heart disease (CHD) is complex. A variety of models have therefore been developed to try and explain past trends and predict future possibilities. The aim of this systematic review was to evaluate the strengths and limitations of existing CHD policy models. METHODS: A search strategy was developed, piloted and run in MEDLINE and EMBASE electronic databases, supplemented by manually searching reference lists of relevant articles and reviews. Two reviewers independently checked the papers for inclusion and appraisal. All CHD modelling studies were included which addressed a defined population and reported on one or more key outcomes (deaths prevented, life years gained, mortality, incidence, prevalence, disability or cost of treatment). RESULTS: In total, 75 articles describing 42 models were included; 12 (29%) of the 42 models were micro-simulation, 8 (19%) cell-based, and 8 (19%) life table analyses, while 14 (33%) used other modelling methods. Outcomes most commonly reported were cost-effectiveness (36%), numbers of deaths prevented (33%), life-years gained (23%) or CHD incidence (23%). Among the 42 models, 29 (69%) included one or more risk factors for primary prevention, while 8 (19%) just considered CHD treatments. Only 5 (12%) were comprehensive, considering both risk factors and treatments. The six best-developed models are summarised in this paper, all are considered in detail in the appendices. CONCLUSION: Existing CHD policy models vary widely in their depth, breadth, quality, utility and versatility. Few models have been calibrated against observed data, replicated in different settings or adequately validated. Before being accepted as a policy aid, any CHD model should provide an explicit statement of its aims, assumptions, outputs, strengths and limitations

Methodologies used to estimate tobacco-attributable mortality: a review

<p>Abstract</p> <p>Background</p> <p>One of the most important measures for ascertaining the impact of tobacco on a population is the estimation of the mortality attributable to its use. To measure this, a number of indirect methods of quantification are available, yet there is no consensus as to which furnishes the best information. This study sought to provide a critical overview of the different methods of attribution of mortality due to tobacco consumption.</p> <p>Method</p> <p>A search was made in the Medline database until March 2005 in order to obtain papers that addressed the methodology employed for attributing mortality to tobacco use.</p> <p>Results</p> <p>Of the total of 7 methods obtained, the most widely used were the prevalence methods, followed by the approach proposed by Peto et al, with the remainder being used in a minority of studies.</p> <p>Conclusion</p> <p>Different methodologies are used to estimate tobacco attributable mortality, but their methodological foundations are quite similar in all. Mainly, they are based on the calculation of proportional attributable fractions. All methods show limitations of one type or another, sometimes common to all methods and sometimes specific.</p

A systematic review of the health, social and financial impacts of welfare rights advice delivered in healthcare settings

BACKGROUND: Socio-economic variations in health, including variations in health according to wealth and income, have been widely reported. A potential method of improving the health of the most deprived groups is to increase their income. State funded welfare programmes of financial benefits and benefits in kind are common in developed countries. However, there is evidence of widespread under claiming of welfare benefits by those eligible for them. One method of exploring the health effects of income supplementation is, therefore, to measure the health effects of welfare benefit maximisation programmes. We conducted a systematic review of the health, social and financial impacts of welfare rights advice delivered in healthcare settings. METHODS: Published and unpublished literature was accessed through searches of electronic databases, websites and an internet search engine; hand searches of journals; suggestions from experts; and reference lists of relevant publications. Data on the intervention delivered, evaluation performed, and outcome data on health, social and economic measures were abstracted and assessed by pairs of independent reviewers. Results are reported in narrative form. RESULTS: 55 studies were included in the review. Only seven studies included a comparison or control group. There was evidence that welfare rights advice delivered in healthcare settings results in financial benefits. There was little evidence that the advice resulted in measurable health or social benefits. This is primarily due to lack of good quality evidence, rather than evidence of an absence of effect. CONCLUSION: There are good theoretical reasons why income supplementation should improve health, but currently little evidence of adequate robustness and quality to indicate that the impact goes beyond increasing income