Health Equity: 03/20/09

Friday, March 20, 2009

[EQ] Challenges in measuring changes in health and social indicators over time

Challenges in measuring changes in health and social indicators over time

Robert W Platt¹, Jennifer Zeitlin²
¹ Departments of Epidemiology, Biostatistics and Occupational Health and of Pediatrics, McGill University, Westmount, Canada
² INSERM, UMR, Epidemiological Research Unit on Perinatal Health and Women's and Children's Health, , Paris, France

Journal of Epidemiology and Community Health 2009 - April 2009 (Volume 63, Number 4).

Website: http://jech.bmj.com/cgi/content/full/63/4/267

“……The paper by Mortensen et al¹ raises important questions inthe study of time trends in fetal growth and other exposuresand outcomes.

Fetal growth is usually measured by birthweight for gestational age, and small for gestational age (SGA), typically defined using a percentile cut-off point of the weight for gestational age distribution, is a commonly used outcome in perinatal epidemiology studies.2 SGA is also considered an important risk factor3 4 in studies of perinatal exposures on child and adult outcomes, and therefore implicitly an important intermediate between prenatal exposures and morbidity and mortality. Defining SGA requires reference to a population standard to identify the percentiles. Ignoring the potential for bias that arises using a live birth standard,5 there are several choices of population standards that may have an effect on the study.

The primary choice is whether to select an absolute or a relative reference. An absolute reference, where all births are compared with the same reference population (either internal or external), implies that SGA is a fixed construct, and that every baby of the same weight and gestational age has the same level of risk regardless of the population to which they belong. A relative reference, where the reference population is different for different groups, conversely, implies that SGA is only relevant relative to other members of a defined population…..”

Time is on whose side?
Time trends in the association between maternal social disadvantage and offspring fetal growth.
A study of 1 409 339 births in Denmark, 1981–2004

L H Mortensen¹, F Diderichsen², G Davey Smith³, A M Nybo Andersen^1,4

¹ National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
² Department of Social Medicine, Institute of Public Health Science, University of Copenhagen, Centre for Health and Society, Copenhagen, Denmark
³ Department of Social Medicine, University of Bristol, Bristol, UK
⁴ Epidemiology, University of Southern Denmark, Odense, Denmark

Abstract: http://jech.bmj.com/cgi/content/abstract/63/4/281

Background: Fetal growth is highly socially patterned and is related tohealth across the life course, but how the social patterns offetal growth change over time remains understudied. The timetrends in maternal social disadvantage in relation to fetalgrowth were examined in the context of a universal welfare stateunder changing macroeconomic conditions over a 24-year period.

Methods: All births in Denmark from 1981 to 2004 were included, and theassociation between maternal social disadvantage and birthweightwas examined for gestational age z-scores over time using linearregression.

Results: All measures of social disadvantage were associated with decreasedfetal growth (p<0.001), but with considerable differencesin the magnitude of the associations. The association was strongestfor non-Western ethnicity (–0.28 z-score), low education(–0.19), teenage motherhood (–0.14), single motherhood(–0.13) and poverty (–0.12) and weakest for unemployment(–0.04). The deficit in fetal growth increased over timefor all associations except for unemployment. Also, the measuresof social adversity increasingly clustered within individualsover time.

Conclusion: Maternal social disadvantage is associated with decreased fetalgrowth in a welfare state. Social disadvantage is increasinglyclustered so that fewer pregnancies are exposed, but those exposedsuffer a greater disadvantage in fetal growth. The economicupturn in the last decade did not appear to weaken the associationbetween maternal social disadvantage and decreased fetal growth.

* * *

This message from the Pan American Health Organization, PAHO/WHO, is part of an effort to disseminate
information Related to: Equity; Health inequality; Socioeconomic inequality in health; Socioeconomic
health differentials; Gender; Violence; Poverty; Health Economics; Health Legislation; Ethnicity; Ethics;
Information Technology - Virtual libraries; Research & Science issues. [DD/ KMC Area]

“Materials provided in this electronic list are provided "as is". Unless expressly stated otherwise, the findings
and interpretations included in the Materials are those of the authors and not necessarily of The Pan American
Health Organization PAHO/WHO or its country members”.
------------------------------------------------------------------------------------
PAHO/WHO Website
Equity List - Archives - Join/remove: http://listserv.paho.org/Archives/equidad.html

    IMPORTANT: This transmission is for use by the intended recipient and it may contain privileged, proprietary or confidential information. If you are not the intended recipient or a person responsible for delivering this transmission to the intended recipient, you may not disclose, copy or distribute this transmission or take any action in reliance on it. If you received this transmission in error, please notify us immediately by email to infosec@paho.org, and please dispose of and delete this transmission. Thank you.

[EQ] How political epidemiology research can address why the millennium development goals have not been achieved: developing a research agenda

How political epidemiology research can address why
the millennium development goals have not been achieved: developing a research agenda

D Gil-González 1,2, M T Ruiz-Cantero 1,2,3, C Álvarez-Dardet 1,2,3

1 Preventive Medicine and Public Health Area, University of Alicante, Alicante, Spain

2 Observatory of Public Policies and Health, University of Alicante, Alicante, Spain

3 CIBERESP, University of Alicante, Alicante, Spain

Journal of Epidemiology and Community Health 2009 - April 2009 (Volume 63, Number 4)

Abstract: http://jech.bmj.com/cgi/content/full/63/4/278

“…..The Millennium Development Goals (MDG) progress targets have not been met. Nevertheless, the United Nations (UN) has not yet undertaken in-depth review in order to discover the reasons behind this lack of progress in achieving the MDG. From a political epidemiology perspective, the intention here is to identify the political elements affecting the social factors impeding MDG fulfilment and, at the same time, to suggest future public policies and appropriate proposals that are both more coherent and supported by broader, empirical knowledge of the relevant issues.

The 8 Millennium Development Goals (MDG) and 18 Millennium Targets (MT), with their respective technical indicators for measuring progress, aim to influence the international political agenda in order to achieve minimum levels of well-being and health worldwide by the year 2015.1 Those MDG dealing directly with reducing infant mortality, improving nutrition and maternal health and the fight against infectious diseases are influenced by all the other goals, such as the eradication of poverty, universal access to education, gender equality, environmental sustainability and global partnership for development.

In spite of initial political support and the fact that this is an agreement aimed at achieving minimum standards, halfway through the proposed timescale, the expected progress has not been achieved.2 3 Given this context, the construction of a Political Epidemiology Research Agenda4 could contribute towards a more objective approach to the situation, identifying those factors that are hindering MDG achievement while at the same time providing future policies and proposals with greater coherence and supported by a broader, empirical knowledge base.

Epidemiology has contributed to research on MDG through a description of health problems, and has also identified and analysed some of their causes and other barriers hindering MT achievement.5 It has also revealed methodological problems involved in measuring MDG progress, and in the evaluation of interventions carried out to this end.6 Concerned as it is with the study of all factors above populations (epi–demos–logos), epidemiology not only deals with individuals; social epidemiology, for example, also highlights social factors affecting health, such as poverty.7 Therefore, it is hoped that research results will raise awareness among decision-makers and their constituencies as regards the need to take social issues into account. From a political epidemiology perspective, the intention is to go even further, and to identify the political elements affecting the social factors that are impeding MDG fulfilment. This can be achieved simply by applying epidemiological methodology to the study of the effect that decisions (or lack of decisions) made by the institutions representing political power have on a population’s health.8 9

Public policies, and their relation to health, are still not part of mainstream epidemiology, which continues to consider health as apolitical, and applies a definition of health that is centred on the individual illness rather than on society health problems.10 As a result, health policies are equated to healthcare services policies, and inequalities in health distribution are considered to be the result of individual problems (chosen lifestyle) or of how healthcare is implemented. This perspective has the effect of directing political attention towards the most manageable variable, the healthcare services. However, health inequalities have a political basis.10 Information on health inequality is not sufficient in order to decide what is inevitable and what is unjust, and such a decision does not depend solely on logic and empirical research, but also on an assessment of politics and ideology….”

* * *

    IMPORTANT: This transmission is for use by the intended recipient and it may contain privileged, proprietary or confidential information. If you are not the intended recipient or a person responsible for delivering this transmission to the intended recipient, you may not disclose, copy or distribute this transmission or take any action in reliance on it. If you received this transmission in error, please notify us immediately by email to infosec@paho.org, and please dispose of and delete this transmission. Thank you.

[EQ] The Obama presidency: what may happen, what needs to happen in health policies in the USA

The Obama presidency: what may happen, what needs to happen in health policies in the USA

Barbara Starfield

Johns Hopkins University, Baltimore, Maryland, USA

Journal of Epidemiology and Community Health 2009;63:265-266; doi:10.1136/jech.2008.084822
April 2009 (Volume 63, Number 4).

Website: http://jech.bmj.com/cgi/content/full/63/4/265

“……Expectations are high for the Obama presidency. People worked hard on his campaign, more because of his perceived integrity than his platforms (which were not well defined). Is it realistic to expect Obama to make a real difference?

The primary health policy focus of the presidential campaign was on achieving universal coverage with health insurance. It is an international scandal that the USA has between 50 and 100 million people (between 15% and 30% of its population) without adequate coverage for their healthcare costs—the leading cause of bankruptcy in the country and a postulated major cause of excess deaths among the socially deprived. In the Democratic presidential primaries, there were only relatively minor differences having to do with methods of financing and whether obtaining insurance would be mandatory. No one asked whether universal insurance would measurably improve population health statistics or disparities in health (the US ranking has fallen to between 20th and 30th in the world on major health indicators, with increasing inequities)…..”

* * *

    IMPORTANT: This transmission is for use by the intended recipient and it may contain privileged, proprietary or confidential information. If you are not the intended recipient or a person responsible for delivering this transmission to the intended recipient, you may not disclose, copy or distribute this transmission or take any action in reliance on it. If you received this transmission in error, please notify us immediately by email to infosec@paho.org, and please dispose of and delete this transmission. Thank you.