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Blood safety is a global public health priority. However, the degree to which blood is, or is not free of infection risk varies greatly around the world. The major determinants of this variation in risk are the availability of resources to support blood safety measures such as testing and the qualitative and quantitative epidemiological patterns of blood-borne infections. These factors are outlined and examples are presented.
Prevention of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) among adolescents is increasingly recognized as an important public health priority. Sexual risk acts associated with HIV/AIDS transmission (unprotected sexual intercourse with multiple partners of unknown serostatus) are typically initiated by late adolescence, with many youths engaging in sexual relations earlier. Despite being well informed about HIV/AIDS and having positive attitudes toward HIV/AIDS prevention, adolescents have not changed their behavior in response to the pandemic. AIDS-prevention programs must be tailored to consider stereotypic sex roles, gay youths' sexual orientation, and substance abuse. Intensive prevention programs focusing on helping youths perceive HIV as a problem, motivate them to act safely, and implement safe acts by acquiring coping skills, access to condoms and health care, and identifying individual barriers to implementing safe acts have successfully reduced adolescents' risk acts. However, avenues for broad-scale dissemination of such programs or alternative models to change youths' behaviors must be identified.
Performance priorities for high quality care, multiprofessional team care and deinstitutionalization of patients among mental health services in England and West Germany were found to be significantly influenced by management practices fostering goal congruence, peer review and staff participation in decision making.
OBJECTIVE: To explore stakeholders' acceptance of criteria for setting priorities for the health care system in Uganda. METHODS: A self-administered questionnaire was used. It was distributed to health workers, planners and administrators working in all levels of the Ugandan health care system. It was also distributed to members of the public. Participants were asked how strongly they agreed or disagreed with 18 criteria that could be used to set priorities for allocating health care. A total of 408 people took part. Data were entered and analysed using SPSS statistical software. Predetermined cut-off points were used to rank the criteria into three different categories: high weight (>66% of respondents agreed), average weight (33-66% of respondents agreed) and low weight (<33% of respondents agreed). We also tested for associations between respondents' characteristics and their degree of agreement with the criteria. FINDINGS: High-weight criteria included severity of disease, benefit of the intervention, cost of the intervention, cost-effectiveness of the intervention, quality of the data on effectiveness, the patients age, place of residence, lifestyle, importance of providing equity of access to health care and the community's views. The average-weight criteria included the patient's social status, mental features, physical capabilities, political views, responsibilities for others and gender. Low-weight criteria included the patient's religion, and power and influence. There were few associations between respondents' characteristics and their preferences. CONCLUSION: There was a high degree of acceptance for commonly used disease-related and society-related criteria. There was less agreement about the patient-related criteria. We propose that average-weight criteria should be debated in Uganda and other countries facing the challenge of distributing scarce health care resources.
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BACKGROUND: Over 90 per cent of local housing authorities in England allocate medical priority for rehousing (MPR) to applicants with medical or care needs but very few studies have been undertaken to investigate the health effects of this practice. This longitudinal study compares the change in health status of adult applicants for MPR who were rehoused with applicants who were not rehoused. METHODS: A total of 566 households applying for MPR were interviewed before any rehousing, and of these 253 households were re-interviewed between 9 and 12 months later. Data from initial and follow-up interviews were analysed for 227 adults, of whom 104 were rehoused. The rehoused and not rehoused groups were not significantly different in terms of health status, gender, education, income or housing conditions, but participants who were not rehoused were more likely to report mobility problems and to be aged over 50. Health data were collected by interview using the Short Form 36 (SF-36) questionnaire. Questions were also asked about housing conditions and the local neighbourhood, instrumental activities of daily living (IADL) and health-related behaviour. RESULTS: The health status of adult applicants for MPR was very poor. Those who were not rehoused experienced a slight improvement in five dimensions of the SF-36 whereas those who were rehoused experienced much larger improvements in six dimensions. For those who were rehoused, significant net improvements occurred in reports of tiredness, feeling depressed, sleeplessness, use of prescribed medication, use of medical services and problems with IADL. No changes occurred in reports of respiratory problems, longstanding illness or disability, use of antidepressants, sleeping pills or tranquillizers, smoking or social support. CONCLUSIONS: MPR was associated with improvements in mental health status and mobility, and among respondents aged 50 years or under with a reduced use of prescribed medication and medical services. Whereas most applicants applied for MPR because of mobility problems, they were less likely than other applicants to be rehoused. The health improvements that appeared to occur should be qualified by the extent of unmet need for appropriately adapted housing and the high level of ill-health that persisted even among adults who were rehoused.
This paper describes the implementation of a clinical guideline across three acute Trusts. A Clinical Effectiveness Steering Group identified prevention of venous thromboembolism as a health priority. A local guideline development group adapted the recommendations of an existing review and produced a local guideline. Then, a multidisciplinary implementation group developed the practical aspects of implementing guidelines into routine daily practice. They identified appropriate staff to carry out risk assessment and to administer appropriate prophylaxis, as necessary. They also produced a "guideline pack" containing a training resource manual and implementation aids. Following this a multiple strategy implementation programme was used to introduce the guidelines, and an evaluation was carried out eight to ten months after the introduction of the guidelines. The evaluation identified a number of areas for improving current practice. Guideline implementation is a complex, time-consuming process.
A series of slides on health priorities in Africa was shown to an audience of 123 people, of which 19 were not medical specialists. The authors of this experiment wanted to verify that the objectives set by the producers were met. The study, conducted in the form of a questionnaire, asked the people questioned to give their opinion on the objectives, the kind of public aimed at, the standard of the various subjects covered and the usefulness and cost-efficiency ratio of the type of audio-visual equipment used. Although the analysis of collected data reveals certain discrepancies as to the professional status of those questioned, the vast majority of participants considered this documentary support to be extremely worthwhile.
Every other year since 1995 the Public Health Laboratory Service has undertaken a consultation exercise to identify communicable diseases of high public health priority. The purpose of identifying disease priorities is to guide rational and transparent service planning and resource allocation. Also, the process aims to ensure a customer sensitive service. This paper presents the results of the priority setting exercise undertaken in 1999. A postal questionnaire was sent to 1130 key professionals involved in communicable disease control in the United Kingdom. Respondents were asked to assess the relative priority of 61 communicable diseases and to identify priority areas of work associated with these diseases. Five criteria were used to assess relative priority. The five criteria were; present burden of ill-health, social and economic impact, potential threat to health, health gain opportunity and public concern and confidence. For each disease, respondents were asked to score the importance of each criterion. Forty six percent of participants (518/1130) returned completed questionnaires. There was no significant difference in response rate by professional group. Based on the scores assigned to each of the five criteria, the relative priority of 61 communicable diseases has been established. The top ten diseases in descending order of priority are, HIV/AIDS, meningococcal diseases, Chlamydia trachomatis, influenza, tuberculosis, E. coli O157, Methicillin resistant Staphylococcus aureus, salmonellosis, transmissible spongiform encephalopathies and Helicobacter pylori. The opinion of a large number of health care professionals has been used to establish a priority rank for a wide range of communicable diseases. This work provides planners and policy makers with a synthesis of current professional opinion that can be used as a foundation for making decisions on service developments.
Since 1990, the priority-setting has become one of the key issues in making choices in health care. In 1991, the now famous Dunning Report was presented to the Dutch Cabinet. One of its main conclusions was that health services should satisfy four criteria: necessary care, effectiveness, efficiency, and individual responsibility. Priority-setting can be done either by excluding medical treatments from compulsory health insurance coverage and/or by the use of both protocols and guidelines, and the individual selection of patients by health professionals. The discussion on the introduction of in vitro fertilization into the basic health insurance package and the exclusion of dental care for adults have shown that, on the basis of the Dunning criteria, it is not easy to leave complete or parts of services out of the basic health insurance package. The second strategy - the application of the Committee's criteria by the use of protocols, guidelines, and budget restrictions - is even more difficult to realize. More patients assert their right to health care benefits before courts. The courts' decisions have shown that it is difficult for the patient's counsellor to prove that government is responsible for non-delivery due to force majeur. Courts attach much importance to the Dunning criteria; in particular the criterion of necessity.
An important consideration when establishing priorities in health care is the likely effects that alternative allocations of resources will have on health-related quality-of-life (HRQoL). This paper reports on a large-scale national study that elicited the relative valuations attached by the general public to different states of health (defined in HRQoL terms). Health state valuations were derived using the time trade-off (TTO) method. The data from 3395 respondents were highly consistent, suggesting that it is feasible to use the TTO method to elicit valuations from the general public. The paper shows that valuations for severe health states appear to be affected by the age and the sex of the respondent; those aged 18-59 have higher valuations than those aged 60 or over and men have higher valuations than women. These results contradict those reported elsewhere and suggest that the small samples used in other studies may be concealing real differences that exist between population sub-groups. This has important implications for public policy decisions.
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The state of Oregon has developed a unique method to set priorities for health services. The method is based on a cost-utility formula but also incorporates public attitudes and values. Using an explicit process, the Oregon Health Services Commission has completed the ranking of 714 condition-treatment pairs. The background, methods, and criticisms of the Oregon approach highlight key questions for managers and physicians in other health services when they allocate limited resources.
The provision of infertility services has always provoked controversy. On the one hand, patients' groups and clinicians involved with infertile couples have long campaigned against the 'postcode lottery'. On the other hand, commissioners have been reluctant to commit resources to what they see as a low priority in health care. The issue has been brought back into the news with the government's decision to ask the National Institute of Clinical Excellence to review the inequalities in provision of fertility services. This article sets out the evidence for viewing infertility as an illness that deserves public funding, and argues that assisted conception should be viewed in the same light as other chronic non-life-threatening conditions that are currently funded by the NHS.
In France, the entire population theoretically has access to health coverage, but in fact a section of the poorest population does not. Institutions have therefore been set up to provide medical care for the destitute. The objectives of this study were to describe the social characteristics of the HIV-positive destitute population attending an out-patient clinic providing free health care for the destitute in a Paris University Hospital, to compare their clinical-epidemiological characteristics with those of non-destitute HIV-positive patients, and to evaluate the quality of their care. We performed a historical prospective study wherein a cohort of 115 HIV-positive destitute patients (defined as having no health coverage at their first consultation) was compared with a control cohort of 183 HIV-positive non-destitute patients attending the same clinic. Ninety-five per cent of the destitute patients had no stable employment, 32% had no source of income, 75% had no permanent residence and 27% were i.v. drug abusers. Fifty-nine per cent were foreigners, most of whom had legal residence papers and had been in France for more than 3 years. When comparing the control and the destitute groups, the latter had a three times greater risk of developing tuberculosis (RH = 3.2, CI 95% = [1.1-9.4]). Medical compliance, access to antiretroviral treatment and hospitalization were identical in both groups. No difference was observed in terms of occurrence of a new AIDS-related disease during follow-up when full-blown AIDS before entry, CD4 count at entry and transmission group were taken into account in multivariate analysis. From the moment that destitute patients attended this adapted medico-social facility, their access to care was the same as, if not better than, that of the other patients. The development of out-patient medico-social facilities for HIV-positive destitute patients must be a public health priority even for those countries theoretically providing generalized health coverage.
The perspectives of families, and especially parents of children with special health care needs, need to be better understood by the government agencies, health care providers, associations, and information systems vendors that are integrating child health information systems. To date, research on children with special health care needs has not included the perspectives of parents on integrated child health information systems. Interviews were conducted with a limited number of parents of children with special health care needs and a young adult with special health care needs about their perspectives on integrated health information systems needs. The interviews revealed common themes: (1) parents have experienced the benefits of information technology for health care purposes, (2) parents believe integrated health information systems could help to coordinate their children's health care, (3) parents believe information technology can help improve accuracy and timeliness of information, (4) parents of children with special health care needs believe their children's health information should be available to those who need it, but safeguards must be in place, (5) parents believe health information systems can improve health care, but it is not the highest priority health care issue for them, and (6) parents believe that their involvement in issues related to children with special health care needs, including information technology, is critical. Parents of children with special health care needs hold strong opinions about their children's health care, including health information systems. Parents need to be central to discussions about development of integrated child health information systems if we are to develop information systems that serve the needs of children with special health care needs and their families.
The immediate, common sense answer to the question, "Who is the NHS for?" would obviously be, "The patients who use it". This may well be the fundamental purpose of the NHS, yet it would appear that differing views of how this is to be achieved contribute to a misreading between stakeholders of each others' remit. The different positions taken by the two most important NHS stakeholders, the professional clinicians and the administrative managers, affect their definitions of, and therefore their attitudes to their own contribution to the purpose of the NHS. Suggests that before priorities in health care can be considered and discussed, let along be set, consensual agreement needs to be reached concerning the views of professional clinicians and managers of ways of achieving their vision of who the NHS is for.
An analysis of the limited available data confirms that the health status of Australia's Aborigines remains much worse than that of non-Aboriginal Australians. Despite significant improvements over the past decade Aboriginal fetal and infant mortality is still approximately three times that of non-Aborigines. Aboriginal life expectancy remains at least twenty years less than that of the total Australian population. Levels of Aboriginal hospitalisation have declined markedly, but remain well in excess of overall levels, particularly for infants and children. For Aborigines, the reduced overall impact of the communicable diseases has been balanced by a worsening of the "lifestyle" diseases, particularly hypertension, coronary heart disease and diabetes mellitus. Alcohol abuse plays an important role in these diseases, and in the level of accidents and violence amongst Aborigines. The current patterns require a reassessment of Aboriginal health priorities, with more attention being directed at the health problems of Aboriginal adults. Special Aboriginal health programs need to be expanded, and integrated with broad wide-ranging programs aimed at alleviating Aboriginal social inequality.