Effect of discussion and deliberation on the public's views of priority setting in health care: focus group study.
OBJECTIVE: To investigate the extent to which people change their views about priority setting in health care as a result of discussion and deliberation. DESIGN: A random sample of patients from two urban general practices was invited to attend two focus group meetings, a fortnight apart. SETTING: North Yorkshire Health Authority. SUBJECTS: 60 randomly chosen patients meeting in 10 groups of five to seven people. MAIN OUTCOME MEASURES: Differences between people's views at the start of the first meeting and at the end of the second meeting, after they have had an opportunity for discussion and deliberation, measured by questionnaires at the start of the first meeting and the end of the second meeting. RESULTS: Respondents became more reticent about the role that their views should play in determining priorities and more sympathetic to the role that healthcare managers play. About a half of respondents initially wanted to give lower priority to smokers, heavy drinkers, and illegal drug users, but after discussion many no longer wished to discriminate against these people. CONCLUSION: The public's views about setting priorities in health care are systematically different when they have been given an opportunity to discuss the issues. If the considered opinions of the general public are required, surveys that do not allow respondents time or opportunity for reflection may be of doubtful value. (+info)
Diabetes care: who are the experts?
OBJECTIVES: To identify issues that patients and professionals consider important in diabetes care and differences in their priorities for care and to determine patients' and professionals' judgements of the relative importance of their chosen priorities. DESIGN: Structured group interviews using the nominal group technique. SETTING: Five district health authorities on Tyneside. SUBJECTS: Five nominal groups: expert (seven), non-expert (seven) health care professionals; insulin dependent (four), non-insulin dependent patients (eight); and carers of diabetic patients (eight). MAIN MEASURES: Items important in diabetes care to each nominal group (themes of care), ranked into a series of "top 10" items for each group, and allocated a score according to relative importance to individual members; scores were standardised by individual weighting and group weighting for comparison within and between groups. RESULTS: Patients and professionals agreed that information given to patients, interaction between professionals and patients, patient autonomy, and access were important for good diabetes care, but the importance assigned to each differed. Thus the professionals emphasised empathy and aspects of good communication and patients the desire to know enough to live a "normal" life. Differences were also found within the patient groups; these related to changes in patients' needs at specific points in the development of their illness and in their orientations to care. CONCLUSION: Patients differ from professionals in their orientation to diabetes care, and they can, and should, be involved in setting priorities for care. Since these priorities are dynamic further work is needed to explore the nature of patient satisfaction with diabetes care. (+info)
Policy priorities in diabetes care: a Delphi study.
OBJECTIVES: To produce policy priorities for improving care of diabetes based on the findings of original research into patient and professional opinions of diabetes care in South Tyneside. To judge the feasibility of implementing these priorities as policy. DESIGN: A two round Delphi survey with a panel of 28 inverted question markexperts. inverted question mark In the first round each respondent produced a list of recommendations based on the findings of a report of patients' and professionals' opinions of diabetes care. 20 respondents produced a total of 180 recommendations, reviewed by a monitoring panel to produce a summary list of 28 recommendations. In the second round respondents rated each recommendation on two 5 point Likert scales. SETTING: Mainly Tyneside but also other parts of England. SUBJECTS: 28 healthcare professionals, including patients and patients' representatives. MAIN MEASURES: Voting by experts on how important each recommendation was to improving diabetes care service, and how likely the recommendation was to be implemented in the next five years. RESULTS: There was a high degree of consensus among respondents about recommendations considered important and likely to be implemented--namely, those concerned with improving communications between doctors in hospital and in general practice, and improving communications with patients. Respondents were more pessimistic about the prospects of implementing the recommendations than about their importance. Respondents thought that standards were important for improving care, and half would stop payments to general practice diabetic clinics that did not keep to district standards for diabetes care. For two recommendations a mismatch occurred between the importance of the recommendations and likelihood of implementation. This may reflect the practical problems of implementing recommendations. 18 of the 22 respondents thought that the study was useful in generating recommendations. CONCLUSIONS: The Delphi technique is a useful method for determining priorities for diabetes care and in assessing the feasibility of implementing recommendations. (+info)
Breastfeeding promotion and priority setting in health.
An increase in exclusive breastfeeding prevalence can substantially reduce mortality and morbidity among infants. In this paper, estimates of the costs and impacts of three breastfeeding promotion programmes, implemented through maternity services in Brazil, Honduras and Mexico, are used to develop cost-effectiveness measures and these are compared with other health interventions. The results show that breastfeeding promotion can be one of the most cost-effective health interventions for preventing cases of diarrhoea, preventing deaths from diarrhoea, and gaining disability-adjusted life years (DALYs). The benefits are substantial over a broad range of programme types. Programmes starting with the removal of formula and medications during delivery are likely to derive a high level of impact per unit of net incremental cost. Cost-effectiveness is lower (but still attractive relative to other interventions) if hospitals already have rooming-in and no bottle-feeds; and the cost-effectiveness improves as programmes become well-established. At an annual cost of about 30 to 40 US cents per birth, programmes starting with formula feeding in nurseries and maternity wards can reduce diarrhoea cases for approximately $0.65 to $1.10 per case prevented, diarrhoea deaths for $100 to $200 per death averted, and reduce the burden of disease for approximately $2 to $4 per DALY. Maternity services that have already eliminated formula can, by investing from $2 to $3 per birth, prevent diarrhoea cases and deaths for $3.50 to $6.75 per case, and $550 to $800 per death respectively, with DALYs gained at $12 to $19 each. (+info)
Promoting audit in primary care: roles and relationships of medical audit advisory groups and their managers.
OBJECTIVES: To investigate perceptions of family health service authorities and medical audit advisory groups of advisory groups' involvement in clinical audit and wider quality issues; communication with the authorities; and manager satisfaction. DESIGN: National postal questionnaire survey in 1994. SETTING: All family health services authority districts in England and Wales. SUBJECTS: Chief executives or other responsible authority officers and advisory group chairpersons in each district. MAIN MEASURES: Priorities of advisory group and authority for audit; involvement of advisory group in wider quality issues; communication of information to, and contacts with, the authority and its involvement in planning the future work of the advisory group; and authorities' satisfaction. RESULTS: Both groups' views about audit were similar and broadly consistent with current policy. Advisory group involvement in wider quality issues was extensive, and the majority of both groups thought this appropriate. Much of the information about their activities collected by advisory groups was not passed on to the authority. The most frequent contact between the two groups was the advisory group's annual report, but formal personal contact was the most valued. Most authority respondents thought their views had been recognised in the advisory group's planning of future work; only a small minority were not satisfied with their advisory groups. Dissatisfied respondents received less information from their advisory groups, had less contact with them, and thought they had less input into their plans. There was some evidence that advisory groups in the "dissatisfied districts" were less involved in clinical audit and with their authorities in wider quality issues. CONCLUSIONS: Most advisory groups are developing their activities in clinical audit and have expanded their scope of work. The quality and availability of information about progress with audit is a cause for concern to both groups. (+info)
Developing a plan for primary health care facilities in Soweto, South Africa. Part II: Applying locational criteria.
This article is the second of a two-part series describing the development of a ten-year plan for primary health care facility development in Soweto. The first article concentrated on the political problems and general methodological approach of the project. This second article describes how the technical problem of planning in the context of scanty information was overcome. The reasoning behind the various assumptions and criteria which were used to assist the planning of the location of facilities is explained, as well as the process by which they were applied. The merits and limitations of this planning approach are discussed, and it is suggested that the approach may be useful to other facility planners, particularly in the developing world. (+info)
Gender and equity in health sector reform programmes: a review.
This paper reviews current literature and debates about Health Sector Reform (HSR) in developing countries in the context of its possible implications for women's health and for gender equity. It points out that gender is a significant marker of social and economic vulnerability which is manifest in inequalities of access to health care and in women's and men's different positioning as users and producers of health care. Any analysis of equity must therefore include a consideration of gender issues. Two main approaches to thinking about gender issues in health care are distinguished--a 'women's health' approach, and a 'gender inequality' approach. The framework developed by Cassels (1995), highlighting six main components of HSR, is used to try to pinpoint the implications of HSR in relation to both of these approaches. This review makes no claim to sociological or geographical comprehensiveness. It attempts instead to provide an analysis of the gender and women's health issues most likely to be associated with each of the major elements of HSR and to outline an agenda for further research. It points out that there is a severe paucity of information on the actual impact of HSR from a gender point of view and in relation to substantive forms of vulnerability (e.g. particular categories of women, specific age groups). The use of generic categories, such as 'the poor' or 'very poor', leads to insufficient disaggregation of the impact of changes in the terms on which health care is provided. This suggests the need for more carefully focused data collection and empirical research. (+info)
Opening the debate on DALYs (disability-adjusted life years).
The 1993 World Development Report is proving to be an influential document for the development of the health sector policies in developing countries. One important aspect of the Report concerns its proposals for Disability Adjusted Life Years as a measure of health change and hence effectiveness of interventions. This article comments on the use of such measures in the health policy arena. (+info)