Alcohol mortality in Russia: a historical perspective

OBJECTIVE

To examine major changes in the supply of alcohol in Russia and its impact on health in late-tsarist and early-Soviet society.

STUDY DESIGN AND METHODS

Statistical data on acute forms of alcohol mortality were drawn from official publications and medical literature published in the period 1860-1930 that covered the 50 provinces of European Russia and some of the major cities in the Russian Empire. These data were examined for across-time changes in alcohol mortality in relation to changes in the availability of alcohol products, both in terms of increased and decreased levels of supply.

RESULTS

Rapid changes in the supply of alcoholic products in earlier periods of Russian history resulted in quick and marked changes in the levels of acute alcohol mortality. However, while restrictions on the availability of spirits have sometimes been effective in reducing alcohol mortality, there has often been a rapid recourse to alternative forms of alcohol, i.e. alcohol surrogates.

CONCLUSION

The lesson of history suggests that any attempt to deal with the problem of hazardous drinking in Russia must deal with all sources of alcohol, both legal and illegal, as individuals have demonstrated a high degree of ingenuity in identifying alternative sources of alcohol, both in the past and the present.

Public attitudes towards smoking and tobacco control policy in Russia

BACKGROUND

Since the political transition in 1991, Russia has been targeted intensively by the transnational tobacco industry. Already high smoking rates among men have increased further; traditionally low rates among women have more than doubled. The tobacco companies have so far faced little opposition as they shape the discourse on smoking in Russia. This paper asks what ordinary Russians really think about possible actions to reduce smoking.

METHODS

A representative sample of the Russian population (1600 respondents) was interviewed face to face in November 2007.

RESULTS

Only 14% of respondents considered tobacco control in Russia adequate, while 37% thought that nothing was being done at all. There was support for prices keeping pace with or even exceeding inflation. Over 70% of all respondents favoured a ban on sales from street kiosks, while 56% believed that existing health warnings (currently 4% of front and back of packs) were inadequate. The current policy of designating a few tables in bars and restaurants as non-smoking was supported by less than 10% of respondents, while almost a third supported a total ban, with 44% supporting provision of equal space for smokers and non-smokers. Older age, non-smoking status and living in a smaller town all emerged as significantly associated with the propensity to support antismoking measures. The tobacco companies were generally viewed as behaving like most other companies in Russia, with three-quarters of respondents believing that these companies definitely or maybe bribe politicians. Knowledge of impact of smoking on health was limited with significant underestimation of dangers and addictive qualities of tobacco. A third believed that light cigarettes are safer than normal cigarettes.

CONCLUSION

The majority of the Russian population would support considerable strengthening of tobacco control policies but there is also a need for effective public education campaigns.

Sex differences in use of interventional cardiology persist after risk adjustment

Background:

Studies from several countries have documented gender disparities in the management of coronary artery disease. Whether such gender disparities are seen in Italy and, if so, whether they can be explained by factors such as age and severity of illness were investigated.

Methods:

77 974 Piedmontese patients, admitted between 1999 and 2002, with a primary diagnosis of myocardial infarction (ICD 410), angina (ICD 413), chronic ischaemia (ICD 414) and chest pain (ICD 786.5) were studied. The number of men and women undergoing surgical treatment was extracted and the male–female odds ratios calculated. Several risk factors and a risk adjustment technique (APR-DRG) were used to control for possible confounders. Backward stepwise multiple logistic regression was used to adjust for significant covariates.

Results:

Crude analysis demonstrated that gender is a discriminating factor in the probability of surgery (OR 2.11, 95% CI 2.04 to 2.19), with similar findings among those with each main diagnosis. The odds ratios decreased after adjustment for age, co-morbidity and disease severity but remained significant.

Conclusions:

Men and women admitted to hospitals in a region of northern Italy with a diagnosis of cardiovascular disease are treated differently and this cannot be explained by age or severity of disease.

Healthy Israel 2020: a visionary national health targeting initiative

This article describes the development of a national health targeting initiative entitled 'Healthy Israel 2020' which was created to enhance the health and wellbeing of Israelis through a variety of health promotion and disease prevention interventions. This initiative builds upon the experience of two major worldwide targeting efforts, "Health People 2010" of the US and the World Health Organization's Health21', as well as lessons learned from other countries. Important philosophical underpinnings are highlighted, particularly the evidence-based nature of the process. Real-world organizational and policy challenges and creative solutions are presented. It is hoped that this report will be of value to others in Israel and elsewhere who are interested in improving the health of their nations.

Maximizing the contribution of the public health workforce: the English experience

In the United Kingdom, until the 1990s, specialist practice of public health was dominated by the medical profession. During the past decade, the contributions to specialist public health practice of people from diverse disciplines have become recognized, respected and valued. In parallel to this paradigm shift in culture in the specialist workforce, recognition is growing of the importance to health improvement of the routine activities of people in other jobs, whose daily work can have a significant impact on population health. These people include public health practitioners, such as environmental health officials, but also others in a very wide range of occupations, from local government chief executive officers to catering assistants, who, although their actions can have a substantial influence on public health, would not traditionally have been viewed as part of the public health workforce. Transforming opportunities for training and professional development to meet the diverse needs of these different groups within the public health workforce for them to recognize and fulfil their potential for health improvement is an important challenge, if we are to achieve continuing improvements in public health. Presenting England's attempts to address the challenges of recruiting and training the range of people needed to deliver effective intersectoral public health may offer insights for those facing similar challenges in other countries.

Children with hearing loss and increased risk of injury

PURPOSE

Few studies have tested the hypothesis that children with sensory disabilities such as deafness may be at increased risk of injuries. To test this hypothesis, this study compared rates of emergency department or hospital treatment for injury among Medicaid-insured South Carolina children with and without a diagnosis of hearing loss.

METHODS

Medicaid billing data for 2002-2003 were obtained from the South Carolina Office of Research and Statistics. International Classification of Diseases, Ninth Revision, Clinical Modification billing codes were used to identify children with and without hearing loss, and episodes of injury-related emergency department or hospital treatment were compared for the 2 groups.

RESULTS

Rates of injury treatment in children with hearing loss were more than twice that of the control group (17.72 vs 8.58 per 100, respectively). The relative rate (RR) remained significantly higher (RR = 1.51, 95% confidence interval, 1.30-1.75) after adjusting for age, race, sex, and the number of hospital or emergency department encounters for treatment of non-injury-related conditions. Children with hearing loss had significantly higher treatment rates for every injury type, bodily location, and external cause, with a cell size sufficient for valid comparison.

CONCLUSIONS

Children with hearing loss may be at increased risk of injury. Additional study is needed to determine whether children with hearing loss are at increased risk (as opposed to simply seeking hospital care for injuries more often). If so, targeted injury prevention efforts for these children and their families would be warranted.

Tobacco policies in Austria during the Third Reich

BACKGROUND

The anti-smoking stance taken by Adolf Hitler, coupled with Nazi support for research on smoking and lung cancer and campaigns to discourage smoking, have encouraged pro-smoking groups to equate tobacco control activities with totalitarianism. Previous work has described the situation in Germany.

OBJECTIVE

To examine the situation in Austria, also part of the Reich after 1938.

DESIGN

Iterative analysis of documents and reports about the situation in Austria in the 1930s and 1940s, supplemented by a review of Reich legal ordinances, party newspapers, health behaviour guidelines issued by Nazi party organisations and interviews with expert informants.

RESULTS

In contrast to the situation in Germany where, albeit to a much lesser degree than is commonly believed, some anti-smoking policies were adopted, the Nazi authorities in Austria made almost no attempt to discourage smoking and the Austrian tobacco company worked closely with the Nazi authorities to ensure that supplies were maintained.

CONCLUSION

Especially when looked at in the Austrian context, the much-cited link between anti-smoking policies and Nazism is a gross over-simplification. This purported link should not be used to justify the continued failure to act effectively against smoking in Germany and Austria.

The impact of private-sector provision on equitable utilisation of coronary revascularisation in London

OBJECTIVE

To investigate the impact of including private-sector data on assessments of equity of coronary revascularisation provision using NHS data only.

DESIGN

Analyses of hospital episodes statistics and private-sector data by age, sex and primary care trust (PCT) of residence. For each PCT, the share of London's total population and revascularisations (all admissions, NHS-funded, and privately-funded admissions) were calculated. Gini coefficients were derived to provide an index of inequality across subpopulations, with parametric bootstrapping to estimate confidence intervals.

SETTING

London.

PARTICIPANTS

London residents undergoing coronary revascularisation April 2001-December 2003.

INTERVENTION

Coronary artery bypass graft or angioplasty.

MAIN OUTCOME MEASURES

Directly standardised revascularisation rates, Gini coefficients.

RESULTS

NHS-funded age-standardised revascularisation rates varied from 95.2 to 193.9 per 100,000 and privately funded procedures from 7.6 to 57.6. Although the age distribution did not vary by funding, the proportion of revascularisations among women that were privately funded (11.0%) was lower than among men (17.0%). Privately funded rates were highest in PCTs with the lowest death rates (p = 0.053). NHS-funded admission rates were not related to deprivation nor age-standardised deaths rates from coronary heart disease. Privately funded admission rates were lower in more deprived PCTs. NHS provision was significantly more egalitarian (Gini coefficient 0.12) than the private sector (0.35). Including all procedures was significantly less equal (0.13) than NHS-funded care alone.

CONCLUSION

Private provision exacerbates geographical inequalities. Those responsible for commissioning care for defined populations must have access to consistent data on provision of treatment wherever it takes place.

Consultants’ attitudes to clinical governance: Barriers and incentives to engagement

OBJECTIVE

To explore medical specialists' attitudes to clinical governance in acute hospitals and factors influencing these attitudes.

METHODS

A semi-structured interview study with a purposeful sample of 24 medical specialists from two contrasting hospitals. Hospital A had a low level of consultant involvement in quality improvement initiatives and Hospital B had higher levels of engagement.

RESULTS

Specialists from both hospitals acknowledged that quality improvement was a major part of their role. Among specialists from Hospital A, the lack of a commonly held focus on quality-improvement, poor inter-professional relationships and little clinical engagement in management were the main factors generating negative attitudes towards clinical governance. Effective communication of the hospital's goal of continuous quality improvement to all staff groups, a sense of being able to get issues affecting the quality of care heard by senior management, and a perception that there were clear structures and processes to support clinical governance, were factors that resulted in a more positive attitude to clinical governance among specialists in Hospital B. Specialists from both hospitals identified lack of time across all professional groups and availability of accurate data as barriers to involvement in clinical governance activities.

CONCLUSION

The cultural context, level of technical support available, ability to communicate clear goals and strategies and the presence of structures to support delivery, all contribute to shaping specialists' attitudes to clinical governance and in turn influence levels of engagement and ultimately the success of quality improvement initiatives.

Understanding differences in the receipt of chemotherapy between African-American (AA) and white (W) patients with stage III colon cancer

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Background: Even when stage is controlled for, AA are more likely to die from colon cancer than are W. Previous research suggests that AA are less likely to receive adjuvant chemotherapy for Stage III colon cancer than W. This study examines the differences in the receipt of chemotherapy for stage III colon cancer and the reasons behind those differences. Methods: The records of patients diagnosed with and/or receiving their first-course of treatment for Stage III colon cancer at the University of Chicago between 1995–2004 were examined. Specifically, patient charts were audited to determine whether the patients had received chemotherapy, and if not, the documented reasons for the non-receipt of therapy. In the case of incomplete records, the patients’ outside physicians were contacted to ascertain the chemotherapy history. Chemotherapy information was unavailable for only 13 patients (5 AA and 8 W). Results: A total of 186 patients (110 AA and 76 W) were diagnosed with stage III colon cancer at the University of Chicago between 1995–2004. No significant differences were seen with respect to age, sex or tumor location between AA and W. In total, 65% of AA versus 82% of W received chemotherapy (OR 0.43; 95% CI: 0.20–0.86). AA were more likely to not undergo chemotherapy because of comorbidities (OR 3.80; 95%CI 1.35–10.50). Those pts not receiving therapy because of comorbidities had a poorer overall survival than those who received therapy (HR 5.9; 95%CI 3.4–10.3). This effect held for both AA and W pts (p=0.65 for race and comorbidity interaction). Among the 146 pts (86AA, 63W) for whom it is known that chemotherapy was recommended, AA were over 9 times as likely to have a documented refusal (OR 9.5; 95% CI 1.19–75.4). These findings were robust to adjustments for age, sex, insurance status and marital status. Conclusions: AA were significantly less likely than W to receive chemotherapy for stage III colon cancer. The reasons for the difference include both refusal of therapy and the presence of comorbidities that the treating physicians felt were a contraindication to therapy. Future research should be directed at better understanding the reasons behind the higher refusal rates for AA patients.

No significant financial relationships to disclose.