MPH Master pieces

Setting priorities

The Oregon Health Plan was a famous attempt in the early 1990s to ration health care - money was limited so a list of 696 treatments was put in priority order. The budget available stretched as far as the top 565. There were many critiques of the method but it was certainly bold and explicit. Anyone involved in planning or funding health services should know something about it.

Here is an interesting commentary almost 15 years on which gives the political background and an update on where Oregon is now.

Up close and personal

One of the problems of public health is that we tend to see everything remotely, through a table of statistics. So it's good every now and then to remind ourselves of the human reality behind the numbers: this testimony is well worth reading.

Mind and matter

Another report from the group in New Zealand which is measuring the effect of improving housing conditions e.g. by installing heating. Think I've mentioned them before.

This one documents the effect on asthma in children. Research on damp housing has been dogged by the problem of subjective versus objective improvement - people say they feel better when you attend to their housing problems, but is that because their lung function has improved or because, having been offered help and attention, they don't mind so much. And of course in children the problem is compounded by the fact that you are relying on reports from the parent not the child.

As you will see this study shows plenty of subjective, but no objective, improvement. The authors put a brave face on this result but to my mind go too far in their conclusions. 

Honey I shrunk the inequality!

I've often said that the only way to reduce inequality is to change the environment - fluoridate the water supply, build a crash barrier etc. Received wisdom and plenty of observations shows that the powerful in society (well educated with many resources to call upon) will be the first to take advantage of any health-enhancing measure, thus increasing inequality even if overall health improves. There are one or two exceptions over the years. My favourite counter is disease eradication - polio, smallpox, pellagra. THere was a reduction in social class inequality in post-neonatal mortality in the UK in the 1970s and 80s.

Here is an excellent article which suggests that the GP incentive scheme usually known as the QoF framework may have done the trick. There's a wonderful graph showing the inequities shrinking and being pulled up over time. The key question is whether QoF success is a measure of anything important - most of the items are about stuff (blood pressure, smoking habit etc) being recorded rather than anything being done about it. One or two exceptions (and they attract high scores) such as actual blood pressure, glycosylated haemogolbin in diabetics.

Anyway, well worth a read!

Lay health advisors

The UK Department of Health is keen to promote 'health trainers'. Here is a study which sought to tackle smoking, diet and exercise in an African American community in North Carolina using lay health advisors.

The 15 - 18 advisors were required to have 80 hours of classes and workshops, and were paid $12 per hour for a maximum of 10 hours per week. They were supervised by a full time co-ordinator with support from a dietician, nurse, smoking cessation specialist and a fitness specialist. 

Advisors were nominated as being 'outgoing', interested in the project and well known and trusted in the local community. Most were over 50. 

The study design involved regular surveys in the study area and comparison against concurrent state-wide survey: not quite ideal but probably the best that was available.

All of this cost more than $7m, lasted 7 years and was directed at a population of only 20,000. I imagine that the British effort on health trainers will involve considerably shorter training, less time and little or no specialist back-up. Likely to succeed?

Funnel plots, outliers and smoking

I don't often blog the Journal of Public Health but a paper in the latest issue caught my eye - almost literally: there is an interesting graph of death rates from cancer in the 100 or so PCTs of England. The data are displayed as a funnel plot with age-standardised death rate on the 'y' axis and number of deaths on the 'x' axis. Doing it this way allows you to put a statistical outlier funnel on the map which narrows as the numbers get bigger.

In the first graph there is a group of PCTs which are outliers. Now comes the clever bit - if you take out lung cancer none of them are outliers. So these high death rate PCTs owe their unenviable position to smoking. The picture is somewhat different in females.

You could have done all of this with tables of data but it's the graphic which makes the story compelling.

While on the subject of images, here is a sorry tale. A coffee creamer, for reasons not entirely clear, uses on its packaging a graphic of a bear nursing a baby bear. All very cuddly but the effect of the picture is that 18% of women in Laos have used it as infant food. Analysis of images is known as semiotics, an important discipline because as this and other examples show, images often override words. (Which means you should go back to those cancer graphs and make sure the underlying analysis is fully rigorous.)