Social and ethnic inequalities in the offer and uptake of prenatal screening and diagnosis in the UK: a systematic review

OBJECTIVE

To review studies addressing the question of whether there are social inequalities in either the offer or the uptake of prenatal testing in the UK.

METHOD

Systematic review of studies assessing the offer or uptake of prenatal screening or diagnosis according to social class or ethnic origin. Electronic databases were searched using a strategy developed for a review of inequalities in access to maternity care supplemented with terms specific to prenatal testing. Further papers were identified from reference lists, citation searches and key organizations.

RESULTS

From over 600 identified papers, 41 were potentially relevant. Twenty met the inclusion criteria. The studies included covered screening and/or diagnosis for Down's syndrome, neural tube defects, haemoglobin disorders and HIV. Many studies were limited by small numbers or poor reporting of data and analysis. Six studies reported data on prenatal testing according to women's social class or educational level. None found any significant social inequalities in testing. Some studies suggested that women of South Asian origin might be up to 70% less likely to receive prenatal testing for haemoglobin disorders and Down's syndrome than White women. A small number of studies suggested that South Asian women might be less likely to be offered testing.

CONCLUSIONS

This review provides some evidence of ethnic inequalities in access to prenatal testing. Further research is required to improve our understanding of why testing may not be offered, the reasons for failure to take up testing when offered, and to identify whether there are other social inequalities in access to prenatal testing.

Economic costs of post-natal depression in a high-risk British cohort

BACKGROUND

Post-natal depression is a common condition that can result in distress for the mother and deleterious effects on the development of the infant.

AIMS

To estimate the economic costs of post-natal depression in a geographically defined cohort of women at high risk of developing the condition.

METHOD

Unit costs were applied to estimates of health and social care resource use made by 206 women recruited from antenatal clinics and their infants. Net costs per mother-infant dyad over the first 18 months post-partum were estimated.

RESULTS

Mean mother-infant dyad costs were estimated at pound 2419.00 for women with post-natal depression and pound 2026.90 for women without post-natal depression, a mean cost difference of pound 392.10 (P=0.17). The mean cost differences between women with and without post-natal depression reached statistical significance for community care services (P=0.01), but not for other categories of service. Economic costs were higher for women with extended experiences of the condition.

CONCLUSIONS

The results of this study should be used to facilitate the effective planning of services by different agencies.

Economic implications of assisted reproductive techniques: a systematic review

BACKGROUND

Approximately one in six couples experiences problems with their fertility at some point in their reproductive lives. The economic implications of the use of assisted reproductive techniques require consideration. Herein, the health economics research in this area are critically appraised.

METHODS

Multiple strategies were used to identify relevant studies. Each title and abstract was independently reviewed by two members of the study team and categorized according to perceived relevance. The selected papers were then assessed for quality and data were extracted, converted to UK pounds sterling at 1999/2000 prices, tabulated and critically appraised.

RESULTS

A total of 2547 papers was identified through the searches; this resulted in 30 economic evaluations, 22 cost studies and five economic benefit studies that met the selection criteria. The quality of these studies was mixed; many failed to disaggregate costs, discount future costs or conduct sensitivity analyses. Consistent findings included the following: initiating treatment with intrauterine insemination appeared to be more cost-effective than IVF; vasectomy reversal appeared to be more cost-effective than ICSI; factors associated with poor prognosis decreased the cost-effectiveness of interventions.

CONCLUSIONS

The cost-effectiveness of different interventions should be considered when making decisions about treatment. Future economic appraisals of assisted reproductive techniques would benefit from more robust methodology than is evident in much of the published literature to date.

The accuracy of self-reported healthcare resource utilization in health economic studies

OBJECTIVE

Individuals' recollections of the number and type of health service encounters are frequently required for health economic studies. We sought to establish whether the accuracy of self-reported healthcare resource utilization is a function of the duration of the recall period and the saliency of the health service encounter.

METHODS

Patient recollections of a range of community services (general practitioner visits, community midwifery visits) and hospital services (accident and emergency attendances, hospital outpatient attendances, inpatient admissions) over 4-month and 8-month time periods were obtained from women participating in a randomized controlled trial. Comparisons were made with healthcare resource utilization data extracted from medical records. Where significant differences were identified between the self-reported and medically recorded data, a multivariate linear regression model was constructed to identify the factors associated with underreporting and overreporting of healthcare resource utilization.

RESULTS

The study revealed a tendency to underreport community service utilization, which appears to be exacerbated when the recall period is extended. A number of sociodemographic and clinical factors significantly associated with this tendency to underreport community service utilization were identified. The self-reporting of hospital service utilization over varying periods of recall was found to be more accurate.

CONCLUSION

It is important that economic analysts establish optimal methods for estimating resource utilization quantities within health economic analytical designs. In particular, greater emphasis should be placed on extracting information on community service utilization from medical records or routine health service information systems.

Should health professionals screen women for domestic violence? Systematic review

OBJECTIVE

To assess the evidence for the acceptability and effectiveness of screening women for domestic violence in healthcare settings.

DESIGN

Systematic review of published quantitative studies. SESRCH STRATEGY: Three electronic databases (Medline, Embase, and CINAHL) were searched for articles published in the English language up to February 2001.

INCLUDED STUDIES

Surveys that elicited the attitudes of women and health professionals on the screening of women in health settings; comparative studies conducted in healthcare settings that measured rates of identification of domestic violence in the presence and absence of screening; studies measuring outcomes of interventions for women identified in health settings who experience abuse from a male partner or ex-partner compared with abused women not receiving an intervention.

RESULTS

20 papers met the inclusion criteria. In four surveys, 43-85% of women respondents found screening in healthcare settings acceptable. Two surveys of health professionals' views found that two thirds of physicians and almost half of emergency department nurses were not in favour of screening. In nine studies of screening compared with no screening, most detected a greater proportion of abused women identified by healthcare professionals. Six studies of interventions used weak study designs and gave inconsistent results. Other than increased referral to outside agencies, little evidence exists for changes in important outcomes such as decreased exposure to violence. No studies measured quality of life, mental health outcomes, or potential harm to women from screening programmes.

CONCLUSION

Although domestic violence is a common problem with major health consequences for women, implementation of screening programmes in healthcare settings cannot be justified. Evidence of the benefit of specific interventions and lack of harm from screening is needed.

Admissions for critically ill children: where and why?

INTRODUCTION

Planning services for critically ill children requires identification of overall critical care activity as well as an assessment of population needs. METHOD AND OBJECTIVES: This prospective needs assessment took a census approach to estimating population-based admission rates for paediatric critical care irrespective of where care was provided. A survey form was completed for every child in the study population for all of their admissions.

CRITERIA

The need for tracheal intubation was used as a proxy for defining need for intensive care in this study. Critical illness was defined by clinical criteria adapted from the Advanced Paediatric Life Support Guidelines.

STUDY POPULATION

All children under 17 years resident in south-east England (Thames regions) who required care for a critical illness in any inpatient setting between 1 December 1996 and 30 November 1997. Critical illness was the presence of acute body-system or multi-system failure.

RESULTS

A wide variation in the rates of critical care admission to different types of care settings was reported ranging from 1.2 admissions per 1000 resident children per year for PIC units (general and cardiothoracic units) to 0.02 admissions per 1000 children per year for children admitted from the community to neonatal units. The age of children and their rates of admission were directly related to the type of ward or unit where children received care. Tracheal intubation occurred in all care settings. The proportion of intubated children transferred to paediatric intensive care units (PICUs) or paediatric cardiothoracic intensive care units (PCICUs) varied according to the type of referring unit. The proportion of episodes involving tracheal intubation where the child was not transferred to a PICU or PCICU was 52% for children in stand-alone neurosurgical units, 41% for those in adult intensive care units (AICUs), and 4% for those in children's wards.

CONCLUSIONS

This baseline study shows a significant number of critically ill children who are never cared for in PIC units. With national changes in UK policy to regionalise care for these children, monitoring care in all locations by cause of admission remains important. While the data were collected in 1997, the findings from this study remain relevant and provide the basis for planning regional critical care services for children. Results are also relevant to other geographical areas in that measuring the use of services for critically ill children must go beyond documenting admission to ICUs for children and adults. All settings for critical care must be identified, the activity documented, and the use of services measured against existing resources. Clear clinical criteria are needed to identify children who can be cared for appropriately on high dependency units.

Improving communication between health professionals and women in maternity care: a structured review

OBJECTIVE

To review trials of the effectiveness of interventions aimed at improving communication between health professionals and women in maternity care.

SEARCH STRATEGY

The electronic databases Medline, PsycLit, The Cochrane Library, BIDS Science and Social Science Indexes, Cinahl and Embase were searched. Final searches were carried out in April 2000.

INCLUSION CRITERIA

Controlled trials of interventions explicitly aimed at improving communication between health professionals and women in maternity care were included. Other trials were included where two reviewers agreed that this was at least part of the aim.

DATA EXTRACTION AND SYNTHESIS

95 potentially eligible papers were identified, read by one reviewer and checked against the inclusion criteria. The 11 included trials were read, assessed for quality and summarized in a structured tabular form.

RESULTS

The included trials evaluated interventions to improve the presentation of information about antenatal testing, to promote informed choice in maternity care, woman-held maternity records and computer-based history taking. Four trials in which women were provided with extra information about antenatal testing in a variety of formats suggested that this was valued by women and may reduce anxiety. Communication skills training for midwives and doctors improved their information giving about antenatal tests. The three trials of woman-held maternity records suggested that these increase women's involvement in and control over their care.

CONCLUSIONS

The trials identified by this review addressed limited aspects of communication and focused solely on antenatal care. Further research is required in several areas, including trials of communication skills training for health professionals in maternity care and other interventions to improve communication during labour and in the postnatal period.

Training programs for healthcare professionals in domestic violence

Although women who experience domestic violence seek healthcare services frequently, screening and counseling rates remain low, and healthcare professionals report feeling inadequately trained to care for abused women. The English language literature from 1989 to 1999 was searched to identify and evaluate published assessments of the education of healthcare providers in domestic violence toward women. Major deficiencies in program evaluation were found. They included the use of a historical comparison group, lack of an experimental design, selection of nonstandardized outcomes without clinical performance measures, short-term follow-up, limited documentation of course content and theory, and lack of focus on the impact of programs on abused women. Educational programs generally consisted of a single session of limited duration (1-3 hours). Based on published reports, it appears that few rigorously designed evaluations have been conducted of training programs for healthcare providers in the detection and treatment of women affected by domestic violence.

Addressing domestic violence through maternity services: policy and practice

OBJECTIVE

to explore current policies and practices in maternity units that aim to identify, assess and support women experiencing domestic violence.

DESIGN AND SETTING

a postal survey, conducted between June and October 1999, of all NHS Trusts in England and Wales that provided maternity services.

PARTICIPANTS

Heads of Midwifery or the midwife with expertise or interest in domestic violence in each Trust.

MAIN OUTCOME MEASURES

use of written policies and agreed practices for identifying and referring women experiencing domestic violence, such as availability of information, routine questioning of all women and offering women an appointment without their partner.

RESULTS

87% (183) of the 211 NHS Trusts providing maternity care participated in the survey. Twelve per cent of units had written policies for identifying women experiencing domestic violence, and a further 30% had some form of agreed practice. Less than half of maternity units routinely offered women an appointment without their partner, and just over half displayed material about domestic violence in places where women receive maternity care. Only three units had undertaken audit on their domestic violence practices.

CONCLUSIONS

there is considerable variability around England and Wales in policies and practices related to domestic violence. It is evident that clear guidelines for identification and referral, training, audit and the integration of domestic violence policies with child protection and other policies are necessary to fully address the issues.

Does poor communication contribute to stillbirths and infant deaths? A review

BACKGROUND

Assessors from the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) have cited poor communication as a contributory factor in a proportion of such deaths. This review assesses what research evidence exists to support or explain this.

METHODS

A structured review was carried out, including all studies of sub-optimal care in stillbirth or infant death and studies of litigation in perinatal care. The following databases were searched: MEDLINE, PsycLIT, The Cochrane Library, BIDS Science and Social Science Citation Indexes, Cinahl and Embase. For included studies, information was extracted on the type of study, the selection criteria and number of cases studied, other methods used and results relevant to the question.

RESULTS

One hundred and four studies of potential relevance to the review were identified. Of these, 52 did not meet the inclusion criteria and were excluded. Of the remaining 52 studies, 11 considered communication failure explicitly as a factor in sub-optimal care leading to stillbirth or infant death. In three out of the four studies that presented their findings in terms of numbers of cases, communication failure was noted in between 24 and 29 per cent of cases. There was some consistency across different types of study in the types of communication problems noted.

CONCLUSION

Poor communication may contribute to a proportion of stillbirths and infant deaths. However, given the small number of papers that looked explicitly at poor communication as a factor in sub-optimal care and the lack of comparative information on communication in cases that do not end in poor outcome, caution is needed in drawing conclusions based on the findings of these papers.

Prenatal and postnatal risk factors for mental retardation among children in Bangladesh

This study evaluated the contribution of prenatal, perinatal, neonatal, and postnatal factors to the prevalence of cognitive disabilities among children aged 2-9 years in Bangladesh. A two-phase survey was implemented in 1987-1988 in which 10,299 children were screened for disability. In multivariate analyses, significant independent predictors of serious mental retardation in rural and urban areas included maternal goiter (rural odds ratio (OR) = 5.14, 95% confidence interval (CI): 1.23, 21.57; urban OR = 4.82, 95% CI: 2.73, 8.50) and postnatal brain infections (rural OR = 29.24, 95% CI: 7.17, 119.18; urban OR = 13.65, 95% CI: 4.69, 39.76). In rural areas, consanguinity (OR = 15.13, 95% CI: 3.08, 74.30) and landless agriculture (OR = 6.02, 95% CI: 1.16, 31.19) were also independently associated with the prevalence of serious mental retardation. In both rural and urban areas, independent risk factors for mild cognitive disabilities included maternal illiteracy (OR = 2.48, 95% CI: 0.86, 7.12), landlessness (OR = 4.27, 95% CI: 1.77, 10.29), maternal history of pregnancy loss (OR = 2.61, 95% CI: 0.95, 7.12), and small for gestational age at birth (OR = 3.86, 95% CI: 1.56, 9.55). Interventions likely to have the greatest impact on preventing cognitive disabilities among children in Bangladesh include expansion of existing iodine supplementation, maternal literacy, and poverty alleviation programs as well as prevention of intracranial infections and their consequences. Further population-based studies are needed to confirm and understand the association between consanguinity and serious cognitive disability.

Economic issues in the follow-up of neonates

Children with conditions requiring neonatal intensive care impose a financial burden on health services, on families and carers, and on society generally. A systematic review of the literature identified 81 studies that conducted primary research on the cost of services as a result of conditions requiring neonatal intensive care. The majority of studies estimated costs incurred during the initial hospital stay. Relatively few studies considered health service costs following discharge from the neonatal intensive care unit, costs to other sectors of the economy or costs to families and carers. It is important that these costs are considered more fully.

Evaluating child disability programmes: the role of commissioners

The paper briefly reviews the role of a health care commissioner in planning and evaluating children's disability services, an area with a strong statutory framework but a paucity of guidance. It also explores how different aspects of evaluation apply to commissioning.

Rates of, and the factors affecting, cycle helmet use among secondary schoolchildren in East Sussex and Kent

OBJECTIVES

To assess the level of cycle helmet wearing among young people in two counties in the South East of England in 1994, and to identify the factors associated with helmet wearing.

DESIGN

Cross sectional survey in a convenience sample.

SETTING

Secondary schools in East Sussex and Kent.

SUBJECTS

Students in year 7 (aged 10-12 years) and year 11 (aged 14-16 years). Main outcome measures--Self reported "always wears a helmet".

RESULTS

Among those who ride a bicycle, 32% of boys and 29% of girls aged 10-12 years, and 14% of boys and 10% of girls aged 14-16, reported that they always wear helmets. The variables that were most consistently associated with helmet wearing (that is significantly associated with helmet wearing in at least five of the six age, sex, and county subgroups) were: "parental encouragement to wear a helmet" "closest friend wears a helmet", "belief that laws that make children wear helmets are good", and "sometimes rides off-road".

CONCLUSIONS

The self reported rates of always wearing a cycle helmet in East Sussex and Kent are consistent with overseas findings for populations who had not been exposed to intensive helmet promotion. The evidence suggests that parental encouragement has a favourable effect on rates of cycle helmet use among secondary schoolchildren, which is separate from and additional to peer influences. When designing a helmet promotion programme, therefore, it will have added impact if both parents and children are addressed.

Epidemiology and prevention of severe assault and gun injuries to children in an urban community

OBJECTIVES

To describe the epidemiology of severe assault and gun injuries to children in an urban population and consider the impact of a comprehensive injury prevention program.

MATERIALS AND METHODS

Pediatric injury deaths and hospital admissions for Northern Manhattan (1983-1992) were linked to census counts to compute incidence. Poisson regression was used to compare trends in incidence of assault and gun injuries before and during a community-wide pediatric injury prevention program in Central Harlem.

MAIN RESULTS

The incidence of severe nonfatal assault injury was 60.94/100,000/year, 10 times the fatality rate. The incidence of all gun injuries was 31.13. In adolescence, guns were the leading cause of both fatal and severe nonfatal assault injury, and were the most lethal method of assault (case-fatality = 18.5% for gun vs. 1.2% for all non-gun assault injury). Rates of assault and gun injuries declined by nearly 50% in the intervention community, while they increased in a neighboring community.

CONCLUSIONS

Comprehensive interventions may be effective in curbing the incidence of severe assault injuries to urban youth. Further controlled evaluations are needed to confirm the effectiveness of programs such as this and to better understand the prevention of violent injuries.

Evaluating a ten questions screen for childhood disability: reliability and internal structure in different cultures

This paper uses five strategies to evaluate the reliability and other measurement qualities of the Ten Questions screen for childhood disability. The screen was administered for 22,125 children, aged 2-9 years, in Bangladesh, Jamaica and Pakistan. The test-retest approach involving small sub-samples was useful for assessing reliability of overall screening results, but not of individual items with low prevalence. Alternative strategies focus on the internal consistency and structure of the screen as well as item analyses. They provide evidence of similar and comparable qualities of measurement in the three culturally divergent populations, indicating that the screen is likely to produce comparable data across cultures. One of the questions, however, correlates with the other questions differently in Jamaica, where it appears to "over-identify" children as seriously disabled. The methods and findings reported here have general applications for the design and evaluation of questionnaires for epidemiologic research, particularly when the goal is to gather comparable data in geographically and culturally diverse settings.

Use of Poisson regression and time series analysis for detecting changes over time in rates of child injury following a prevention program

The use of two statistical methods to quantify time trends (Poisson regression and time series analysis) is illustrated in analyses of changes in child injury incidence after implementation of a community-based injury prevention program in Central Harlem, New York City. The two analytical methods are used to quantify changes in the rate of injury following the program, while taking into account the underlying annual and seasonal trends. Rates of severe injury during the period from 1983 to 1991 among children under the age of 17 years living in Central Harlem and in the neighboring community of Washington Heights are analyzed. The two methods provide similar point estimates of the effect of the intervention and have a good fit to the data. Although time series analysis has been promoted as the method of choice in analysis of sequential observations over long periods of time, this illustration suggests that Poisson regression is an attractive and viable alternative. Poisson regression provides a versatile analytical method for quantifying the time trends of relatively rare discrete outcomes, such as severe injuries, and provides a useful tool for epidemiologists involved with program evaluation.