The respiratory health effects of nitrogen dioxide in children with asthma

There is growing evidence that asthma symptoms can be aggravated or events triggered by exposure to indoor nitrogen dioxide (NO(2)) emitted from unflued gas heating. The impact of NO(2) on the respiratory health of children with asthma was explored as a secondary analysis of a randomised community trial, involving 409 households during the winter period in 2006 (June to September). Geometric mean indoor NO(2) levels were 11.4 μg · m(-3), while outdoor NO(2) levels were 7.4 μg · m(-3). Higher indoor NO(2) levels (per logged unit increase) were associated with greater daily reports of lower (mean ratio 14, 95% CI 1.12-1.16) and upper respiratory tract symptoms (mean ratio 1.03, 95% CI 1.00-1.05), more frequent cough and wheeze, and more frequent reliever use during the day, but had no effect on preventer use. Higher indoor NO(2) levels (per logged unit increase) were associated with a decrease in morning (-17.25 mL, 95% CI -27.63- -6.68) and evening (-13.21, 95% CI -26.03- -0.38) forced expiratory volume in 1 s readings. Outdoor NO(2) was not associated with respiratory tract symptoms, asthma symptoms, medication use or lung function measurements. These findings indicate that reducing NO(2) exposure indoors is important in improving the respiratory health of children with asthma.

Retrofitting houses with insulation: a cost-benefit analysis of a randomised community trial

BACKGROUND

Housing is an important environmental influence on population health, and there is growing evidence of health effects from indoor environment characteristics such as low indoor temperatures. However, there is relatively little research, and thus little firm guidance, on the cost-effectiveness of public policies to retrospectively improve the standards of houses. The purpose of this study was to value the health, energy and environmental benefits of retrofitting insulation, through assessing a number of forms of possible benefit: a reduced number of visits to GPs, hospitalisations, days off school, days off work, energy savings and CO(2) savings.

METHODS

All these metrics are used in a cluster randomised trial--the "Housing, Insulation and Health Study"--of retrofitting insulation in 1350 houses, in which at least one person had symptoms of respiratory disease, in predominantly low-income communities in New Zealand.

RESULTS

Valuing the health gains, and energy and CO(2) emissions savings, suggests that total benefits in "present value" (discounted) terms are one and a half to two times the magnitude of the cost of retrofitting insulation.

CONCLUSION

This study points to the need to consider as wide a range of benefits as possible, including health and environmental benefits, when assessing the value for money of an intervention to improve housing quality. From an environmental, energy and health perspective, the value for money of improving housing quality by retrofitting insulation is compelling.

More effective home heating reduces school absences for children with asthma

BACKGROUND

New Zealand homes are underheated by international standards, with average indoor temperatures below the WHO recommended minimum of 18 degrees C. Research has highlighted the connection between low indoor temperatures and adverse health outcomes, including social functioning and psychological well-being. Both health effects and social effects can impact on school absence rates. The aim of this study was to determine whether more effective home heating affects school absence for children with asthma.

METHODS

A single-blinded randomised controlled trial of heating intervention in 409 households containing an asthmatic child aged 6-12 years, where the previous heating was an open fire, plug-in electric heater or unflued gas heater. The intervention was the installation of a more effective heater of at least 6 kW before the winter of 2006 in half the houses. Demographic and health information was collected both before and after the intervention. Each child's school was contacted directly and term-by-term absence information for that child obtained for 2006 and previous years where available.

RESULTS

Complete absence data were obtained for 269 out of 409 children. Compared with the control group, children in households receiving the intervention experienced on average 21% (p=0.02) fewer days of absence after allowing for the effects of other factors.

CONCLUSION

More effective, non-indoor polluting heating reduces school absence for asthmatic children.

Tuberculosis associated with household crowding in a developed country

BACKGROUND

Tuberculosis (TB) remains an important infectious disease in New Zealand (NZ) and globally, but risk factors for transmission are still poorly understood. This research aimed to identify whether household crowding contributes to TB transmission in NZ.

METHODS

This ecological study used TB surveillance and census data to calculate TB incidence rates by census area unit (CAU). Census data were used to determine CAU characteristics including proportion of household crowding (a bedroom deficit of one or more), proportion of population who are migrants born in high-TB-incidence countries, median household income, and deprivation level. A negative binomial regression model was used to estimate the association between TB incidence and household crowding.

RESULTS

The analysis included 1898 notified TB cases for the 2000-4 period. Univariate analysis showed TB incidence at the CAU level was associated with household crowding, for the total population and for all ethnic and age groups. After adjusting for the covariates of household income, existing TB burden, and proportion of migrants from high-TB-incidence countries, multivariate analysis showed statistically significant associations between TB incidence and household crowding. The incidence rate ratio (IRR) was 1.05 (95% CI 1.02 to 1.08) in the total population and 1.08 (95% CI 1.04 to 1.12) for NZ-born people <40 years.

CONCLUSION

At the CAU level, TB incidence in NZ is associated with household crowding. An individual-based study (e.g. case-control) in recently infected cases (detected by molecular epidemiology techniques) is suggested to complement these findings. Reducing or eliminating household crowding could decrease TB incidence in NZ and globally.

Sources of nitrogen dioxide (NO2) in New Zealand homes: findings from a community randomized controlled trial of heater substitutions

Houses in New Zealand have inadequate space heating and a third of households use unflued gas heaters. As part of a large community intervention trial to improve space heating, we replaced ineffective heaters with more effective, non-polluting heaters. This paper assesses the contribution of heating and household factors to indoor NO2 in almost 350 homes and reports on the reduction in NO2 levels due to heater replacement. Homes using unflued gas heaters had more than three times the level of NO2 in living rooms [geometric mean ratio (GMR) = 3.35, 95% CI: 2.83-3.96, P < 0.001] than homes without unflued gas heaters, whereas homes using gas stove-tops had significantly elevated living room NO2 levels (GMR = 1.42, 95% CI: 1.05-1.93, P = 0.02). Homes with heat pumps, flued gas heating, or enclosed wood burners had significantly lower levels of NO2 in living areas and bedrooms. In homes that used unflued gas heaters as their main form of heating at baseline, the intervention was associated with a two-third (67%) reduction in NO2 levels in living rooms, when compared with homes that continued to use unflued gas heaters. Reducing the use of unflued gas heating would substantially lower NO2 exposure in New Zealand homes.

PRACTICAL IMPLICATIONS

Understanding the factors influencing indoor NO2 levels is critical for the assessment and control of indoor air pollution. This study found that homes that used unflued gas combustion appliances for heating and cooking had higher NO2 levels compared with homes where other fuels were used. These findings require institutional incentives to increase the use of more effective, less polluting fuels, particularly in the home environment.

Could mainstream anti-smoking programs increase inequalities in tobacco use? New Zealand data from 1981-96

OBJECTIVE

To examine changes in the socio-economic and ethnic distribution of smoking in the New Zealand population from 1981 to 1996, and to consider the implication of these data for policies aimed at reducing tobacco consumption.

METHODS

Cross-sectional data were taken from 4.7 million respondents to the 1981 and 1996 New Zealand Censuses and 4,619 participants in a 1989 national survey, aged 15 to 79 years. Smoking prevalence rates were calculated by socio-economic position and ethnicity.

RESULTS

Smoking prevalence fell in the period 1981-96 in every population group. However, socio-economic and ethnic differences in smoking increased in relative terms. Smoking prevalence ratios comparing the least advantaged with the most advantaged groups increased in men from 1.20 to 1.53 by income, 1.54 to 1.85 by education, and 1.49 to 1.67 by ethnicity. In women, prevalence ratios increased from 1.17 to 1.51 by income, 1.55 to 2.02 by education, and 1.85 to 2.20 by ethnicity. The greatest increase in socio-economic differences may have occurred during the 1980s, the period of greatest overall decline in total population smoking.

CONCLUSIONS

Socio-economic and ethnic disparities in New Zealanders' smoking patterns increased during the 1980s and '90s, a period of significant decline in overall smoking prevalence.

IMPLICATIONS

Public health programs aimed at reducing tobacco use should pay particular attention to disadvantaged, Indigenous and ethnic minority groups in order to avoid widening relative inequalities in smoking and smoking-related health outcomes.

Risk factors for mold in housing: a national survey

A national random telephone survey was undertaken to determine the prevalence of reported mold in New Zealand houses and the risk factors for it. A total of 613 households provided responses. Mold in one or more rooms was reported by 35.1% of respondents in the sample. House design and construction factors that were independently associated with reported mold in the multivariate analysis included: poorer house condition, older house age (>22 years), relative lack of sun exposure, and having no insulation (e.g. for poorer house condition: odds ratio=1.97, 95% CI=1.25, 3.11). Univariate analyses also showed increased risk associated with high locality rainfall, and living in the most northern part of the country. The number of residents was significantly associated with reported mold in the multivariate analysis as were various behaviors in the univariate analysis (i.e. frequency of baths, showering and clothes washing). The high prevalence of unflued gas heating (32.9%) found in this sample is of potential concern given the potential respiratory hazards. Although this survey has a number of limitations, it does suggest that there are a number of potentially modifiable risk factors for mold that could be reduced by a range of policy responses.

PRACTICAL IMPLICATIONS

While further research is desirable, the available evidence associated with the health and other adverse impacts of both mold and dampness would favor additional policy responses by government. These could include changes to regulations around housing design including house position, access to sunlight, and level of insulation. The extension of low interest loans for insulation or subsidized installation can help to increase its level of use. Restrictions on the sales of unflued gas heaters could also be considered. A mass media campaign could also be used to inform the population of the readily modifiable risk factors for mold growth and dampness.

Retrofitting houses with insulation to reduce health inequalities: aims and methods of a clustered, randomised community-based trial

This paper describes the purpose and methods of a single-blinded, clustered and randomised trial of the health impacts of insulating existing houses. The key research question was whether this intervention increased the indoor temperature and lowered the relative humidity, energy consumption and mould growth in the houses, as well as improved the health and well-being of the occupants and thereby lowered their utilisation of health care. Households in which at least one person had symptoms of respiratory disease were recruited from seven predominantly low-income communities in New Zealand. These households were then randomised within communities to receive retrofitted insulation either during or after the study. Measures at baseline (2001) and follow-up (2002) included subjective measures of health, comfort and well-being and objective measures of house condition, temperature, relative humidity, mould (speciation and mass), endotoxin, beta glucans, house dust mite allergens, general practitioner and hospital visits, and energy or fuel usage. All measurements referred to the three coldest winter months, June, July and August. From the 1352 households that were initially recruited, baseline information was obtained from 1310 households and 4413 people. At follow-up, 3312 people and 1110 households remained, an 84% household retention rate and a 75% individual retention rate. Final outcome results will be reported in a subsequent paper. The study showed that large trials of complex environmental interventions can be conducted in a robust manner with high participation rates. Critical success factors are effective community involvement and an intervention that is valued by the participants.

Tokelau: a unique low allergen environment at sea level

BACKGROUND

Previous studies have shown that children in Tokelau have a lower prevalence of asthma and atopy compared to Tokelauan children resident in New Zealand. We hypothesized that the low asthma and atopy prevalence in Tokelau may be associated with low indoor allergen levels.

METHODS

Dust was collected from bedding and floors of 76 homes and four public buildings in Tokelau and from the homes of 30 Tokelauan families in Wellington, New Zealand. Dust samples were analysed for Der p 1, Der f 1, Can f 1, Fel d 1, Bla g 2 and Blo t 5 by ELISA, and for endotoxin by a kinetic amoebocyte lysate assay.

RESULTS

Der p 1 levels were over 1000-fold lower in Tokelau compared to New Zealand, geometric mean levels were 0.04 and 47.0 microg/g in beds and 0.04 and 44.7 microg/g on floors, respectively. Can f 1 and Fel d 1 levels were also significantly lower in Tokelau. Bed endotoxin levels were significantly higher in Tokelau, geometric mean: 26 736 EU (endotoxin units)/g, compared to 5181 EU/g in New Zealand. Floor endotoxin levels were similar between the two countries.

CONCLUSION

The very low indoor allergen levels in homes in Tokelau compared to much higher levels in New Zealand homes provides a logical explanation for the lower prevalence of asthma and atopy in Tokelau, compared to New Zealand.

Housing standards: a glossary of housing and health

This glossary has been designed to provide definitions that take account of different disciplinary and policy traditions and to consider the aspects of housing that provide scope for possible concerted research and action.

Tobacco spending and children in low income households

OBJECTIVE

To examine the role of tobacco use in creating financial hardship for New Zealand (NZ) low income households with children.

DATA

The 1996 NZ census (smoking prevalence by household types), Statistics NZ (household spending surveys 1988-98), and NZ Customs (tobacco released from bond 1988-98).

MAIN OUTCOME MEASURES

Proportion of children in households with smokers and < or = 15,000 NZ dollars gross income per adult. Proportion of spending on tobacco of second lowest equivalised household disposable income decile and of solo parent households.

RESULTS

In < or = 15,000 NZ dollars gross income per adult households with both children and smokers, there were over 90,000 children, or 11% of the total population aged less than 15 years. Enabling second lowest income decile households with smokers to be smoker-free would on average allow an estimated 14% of the non-housing budgets of those households to be reallocated.

CONCLUSIONS

The children in low income households with smokers need to be protected from the financial hardship caused by tobacco use. This protection could take the form of more comprehensive government support for such households and stronger tobacco control programmes. A reliance on tobacco price policy alone to deter smokers is likely to have mixed outcomes-for example, increased hardship among some of these households. The challenge for tobacco control is to move from a sole focus on "doing good" towards incorporating the principle of "doing no harm".

Second-hand smoke at work: the exposure, perceptions and attitudes of bar and restaurant workers to environmental tobacco smoke

OBJECTIVES

To investigate the knowledge of, and perceptions, attitudes and exposure to second-hand smoke (SHS) of staff in the New Zealand hospitality industry.

METHOD

Face-to-face interviews with bar staff, waiters, and bar and eating-place managers and owners in Wellington during the 1999-2000 summer. An analysis was made of the 1999 New Zealand Electoral Roll to find the number of those most exposed to SHS.

RESULTS

435 interviews with full data recovery were completed at 364 locations; 59% of interviewees were exposed to SHS, including 77% of those at licensed premises. More than half of those exposed to workplace smoke reported irritation from SHS to their throat or lungs. Less than a third were aware of the risk of strokes from SHS. Three-quarters of interviewees wanted some sort of smoking restriction in bars.

CONCLUSIONS

The majority of interviewees were at risk of premature death and disease because of exposure to workplace smoke, and had an incomplete knowledge of the dangers to which they were exposed. More than 5,000 similar workers in New Zealand appear to share this risk.

IMPLICATIONS

This industry needs legislation to make it smoke free.

Promotion of smoking cessation by New Zealand general practitioners: a description of current practice

AIMS

To describe the advice and support New Zealand general practitioners (GPs) reported providing to patients about smoking cessation, to explore barriers encountered in providing this advice, and to compare reported practice with recommended best practice.

METHODS

450 GPs were surveyed from four different localities using a structured postal questionnaire.

RESULTS

Questionnaires were returned by 283 GPs, giving a response rate of 63%. Approximately one-third of GPs asked every adult patient about their smoking status. Fewer recorded this information in the patient's notes. GPs, based on their own experience, considered nicotine replacement therapy (NRT) and their own advice to quit to be the two most useful smoking cessation strategies. They perceived patient resistance and time pressures as the main barriers limiting their ability to give advice to patients about smoking cessation.

CONCLUSIONS

GPs provide smoking cessation advice to many patients, but this needs to be viewed in the context of the New Zealand fee-for-service primary care system and competing demands placed on the limited time available within a consultation. There is potential to increase the practice nurse's involvement in providing smoking cessation advice.

Public purchasing and private priorities for healthcare in New Zealand

The 1993 Health and Disability Services Act heralded a range of structural reforms in the New Zealand health care system. Despite these reforms considerable resources being spent on convincing consumers of their merits, have failed to gain widespread public approval. This paper examines two key issues that have arisen during the reform process. These are the difficulties associated with trying to set priorities in ways which are effective and politically acceptable, and the relationship between the public and private sectors. Unacknowledged conflicts of interest have helped to undermine the priority setting process. The discussion suggests that it may be increasingly difficult for any government in future to determine the allocation of resources without taking private sector interests and rising public concern into account. It remains to be seen which of these factors is more powerful.

Why do Australians live longer than New Zealanders?

The aim of this study was to compare patterns of mortality in Australia and New Zealand, using routinely collected data. Life expectancy at birth is greater in Australia than in New Zealand (in 1996 the gap was 1.5 years for women and 1.1 years for men). Prior to 1970, mortality was lower in New Zealand than Australia. Possible reasons for the divergence in life expectancies include slower economic growth in New Zealand, more marked increases in economic inequalities which have affected Maöri in particular and, to a modest extent, differentials in health care.

Open houses and closed rooms: Tokelau housing in New Zealand

The migrant Tokelau community in New Zealand, through the Wellington Tokelau Association, is playing an active role in partnership with the Wellington School of Medicine to develop a research program to help improve the health of its people. The relationship between crowded homes and health was investigated in six focus groups. While cultural patterns were an essential part of Tokelau hospitality, the decision to "double up" households was often the result of "rational" economic decision making in relation to household expenditures such as rent and food. The implication for public health practitioners is that while overcrowding may be a health hazard for residents, the most effective solutions by the community are higher household income and more flexible housing designs that accommodate multifamily households.

Lesbians in New Zealand: their mental health and satisfaction with mental health services

OBJECTIVES

To describe the mental health of lesbians in New Zealand, and to document their accounts of their experience of mental health services.

METHOD

This is a descriptive cross-sectional study. A postal questionnaire, the Lesbian Mental Health Survey, was distributed via lesbian newsletters to 1222 women throughout New Zealand. Mental health measures included the General Health Questionnaire (GHQ-28), Interview Schedule for Social Interaction (ISSI), and respondents' histories of sexual abuse and psychiatric histories. Experiences of mental health services were sought.

RESULTS

The estimated response rate was 50.8%. The respondent group were predominantly New Zealand European, highly educated, urban women between 25 and 50 years of age. Three-quarters had identified as lesbian for more than 5 years. Recent self-identification as lesbian was associated with higher GHQ score, as was being younger than 35, having a history of sexual abuse, and not living with a partner. Eighty percent of respondents had used mental health services sometime in their lives and nearly 30 percent of users had received 'lesbian-unfriendly' treatment at some point. One-sixth of respondents had experienced discrimination from service providers in the previous 5 years.

CONCLUSION

While the mental health of lesbians is influenced by factors similar to those influencing women's mental health in general, because of social factors, such as stigma and isolation, lesbians may be more vulnerable to common mental illnesses. Health professionals, mental health professionals in particular, need to raise their awareness of the issues lesbians face in dealing with their sexuality, therapeutic relationships and mental health services. Increased training about sexuality for health professionals, as well as further research into areas such as stress and stigma, sexual abuse and attempted suicide among lesbian women, is recommended.

Socioeconomic inequalities in health: how big is the problem and what can be done?

Socioeconomic factors shape the working day for many doctors in New Zealand. The occurrence and severity of most common conditions confronting doctors in day-to-day practice are linked to the socioeconomic conditions in which patients live and work. Poorer people are likely to have worse health than wealthier people; but it is also becoming clearer that it is not just the absolute level of poverty that affects people's health, but also the distribution of material resources in society. This article highlights important aspects of our current knowledge concerning the effects of socioeconomic factors on health, and makes practical suggestions for day-to-day practice. An essential first step is to identify and characterise the socioeconomic characteristics of patients. Information routinely collected by many general practitioners can be used to characterise the socioeconomic circumstances of individual patients and the practice population as a whole. Doctors can then take action at three levels to mitigate the risks associated with these socioeconomic factors: at a broad social level; at a community and practice level; and at an individual level.

National infant mortality rates in relation to gross national product and distribution of income

We examined the relation between infant mortality rates, gross national product, and income distribution. Our findings support the hypothesis that average measures of population health are influenced by the distribution of income within societies.

Smoking hygiene: a study of attitudes to passive smoking

AIM

To study the attitudes and knowledge of adults in the Wellington area about the effects of passive smoking and measures to reduce exposure to smoke.

METHODS

A sample of 200 people, randomly selected in the Wellington area, answered a telephone survey on passive smoking.

RESULTS

Of the 200 respondents, 160 (80%) were males, 40 (20%) were females and approximately one-third (30%) were smokers. Most people (85.5%) thought public and private areas should be smoke-free when there were children around, but only half (53.5%) thought that smoking should be banned in cars when there are passengers. Most people (92.5%) correctly defined passive smoking. Half were aware that passive smoking negatively contributed to all the following diseases (asthma, cancer, heart disease, respiratory problems) and cot death but a higher percentage identified cancer (75.5%) and cot deaths (68.5%) specifically. Most smokers reported that they smoke at home or in their cars rather than in public places. Half the smokers (50.9%) did not smoke in front of children; a further 17.3% reported that they smoked less.

CONCLUSIONS

In this sample there was a relatively low level of awareness of the effects of passive smoking on health and a high prevalence of smoking in the presence of children. Smokers and non-smokers were almost equally divided on whether there should be a law restricting smoking in private cars, although the majority agreed that cars carrying children should be smoke-free. Public health efforts to reduce the harm from passive smoking should be focused on discouraging smoking, in settings in which children are exposed, including private cars when children are passengers.

The New Zealand Socioeconomic Index: developing and validating an occupationally-derived indicator of socio-economic status

OBJECTIVE

Following revision of the international standard classification (ISCO88), to update and validate on health data an occupationally derived indicator of socio-economic status (SES) adapted to changing occupational and demographic conditions.

METHOD

The development of the New Zealand Socioeconomic Index (NZSEI) is based on a 'returns to human capital' model of the stratification process and uses data from the 1991 New Zealand Census (n = 1,051, 926) to generate scores for 97 occupational groups. The construct validation of the scale is carried out on data from the 1992-93 nationwide Household Health Survey (n = 3,000) using three health indicators (self-assessed health, cigarette smoking, general practitioner visits).

RESULTS

In general, the results are consistent with expected socio-economic patterns drawn from the literature for the three indicators.

CONCLUSIONS

While further work is required on a number of methodological and conceptual issues, the NZSEI provides a robust, standardised and internationally comparable occupational scale of SES for both males and females in either full- or part-time employment.

IMPLICATIONS

The NZSEI can be used on routinely collected occupational data. It has a clear conceptual rationale, updates existing SES scales, and provides a link to international standards in SES and occupational classification.

Does the frame affect the picture? A study into how attitudes to screening for cancer are affected by the way benefits are expressed

OBJECTIVE

To find out how presenting information about the benefits of screening for cancer in different ways affects an individual's decision to accept or reject screening.

METHODS

A telephone survey of the Wellington region, New Zealand was carried out.

RESULTS

A response rate of 75.6% was obtained. Respondents were most likely to accept screening when the benefits of screening were presented as a relative risk reduction. They were most likely to reject screening when the benefits were presented as numbers needed to screen to save on life.

CONCLUSIONS

An individual's decision about screening for cancer is affected by the way the benefits are framed. Health professionals must choose between framing the benefits of screening in the most positive light, to enhance participation rates, and presenting information in such a way as to reduce framing effects--for example, by expressing the benefits in a variety of forms. Clearly there may be a tension between these approaches; the former is arguably manipulation, and the latter may enhance informed choice, but may also reduce participation rates in screening programmes.

Survey of drug and alcohol use by lesbian women in New Zealand

The objective of this study is to describe the prevalence of alcohol and drug use and attitudes towards alcohol use in a group of New Zealand lesbian women. The method used is 1,222 copies of a postal questionnaire (the Lesbian Mental Health Survey [LMHS]) were distributed via lesbian newsletters over a 4-month period. Responses were received from 561 women, an estimated response rate of 50.8%. The respondents were predominantly New Zealand European, highly educated, urban women in the 25- to 50-year age bracket; 30.1% smoked cigarettes, and 90.2% had drunk alcohol at some time in the past year, over half once per week or less. The median number of drinks per week was 1.5 drinks, equivalent to 22.5 ml alcohol per week. Despite a comparatively low reported use of alcohol, 48.1% of respondents expressed the view that alcohol is used excessively in the lesbian community; 75.8% had used cannabis at least once, 32.6% in the past year; 30.8% had used recreational drugs other than cannabis and alcohol at some time, 4.5% in the past year.

A cut above: the rising Caesarean section rate in New Zealand

AIM

To examine the trends in frequency of Caesarean section in New Zealand.

METHODS

Caesarean section rates (CSR) were calculated from the National Minimum Data Set between 1988/89 and 1994/95. Demographic data relating to women having Caesarean sections were examined for 1994/95. The results were checked with regional health authorities and Crown health enterprises containing teaching hospitals.

RESULTS

The national CSR, which was 9.6% in 1983/84, increased from 11.6% in 1988/89 to 15.3% in 1994/95. Previous Caesarean and dystocia are reported to be the indicators for nearly half of all Caesareans.

CONCLUSIONS

The national CSR is high and continues to increase. The international literature shows that national recommendations to reduce the CSR are less effective than hospital-based initiatives.

Translating research findings into health policy

Evidence of the influence of research on health policy is paradoxical. While there is scant evidence that research has had any impact on the direction or implementation of widespread health reforms, research on evidence-based medicine has dramatically increased, despite limited evidence that it has affected clinical practice. These developments have occurred in the context of a general decline in state intervention and provision and a post-modern questioning of researchers' authority. Models of the relationship between research and policy range from one where empirical research rationally informs decision-making, through research incrementally affecting policy, to an "enlightenment" or "infiltration" model, which may operate on a conceptual level. Health research that contributes to large-scale socio-political change may require more methodological pluralism and greater focus on key institutional structures. Case studies reviewed suggest that dissemination is enhanced if researchers involve managers and policy-makers in the development of the framework for and focus of research and if investigators assume a responsibility for seeing their research translated into policy. Public health research is more influential if topical, timely, well-funded and carried out by a collaborative team that includes academics. Evaluations are more influential if, in addition, they are commissioned by health authorities but based on local collection of data, and instruments and incentives to implement policy are available. In some areas, such as the recent policy focus on careers in the community, researchers were largely responsible for raising this policy issue, whereas in other areas, such as the relationship between unemployment and health, researchers are just one of the groups of experts making competing claims about causality. In conclusion, clear research findings are not always a passport to policy, but researchers can reframe the way health policy issues are seen, and collaboration with policy-makers initially can enhance implementation later.

Community-based asthma care: trial of a "credit card" asthma self-management plan

Although asthma self-management plans are widely recommended as essential in the long-term treatment of adult asthma, there have been few studies examining their use. Our objective was to assess the effect of a "credit card" adult asthma self-management plan in a community experiencing major health problems from asthma, by means of a before and after intervention trial of the efficacy of the "credit card" plan, when introduced through community-based asthma clinics. The participants were 69 Maori people with asthma. The "credit card" plan consisted of written guidelines for the self-management of asthma, based on self-assessment of asthma severity, printed on a plastic card. On one side, management guidelines were based on the interpretation of peak expiratory flow rate (PEFR) recordings, whilst the reverse side was based on symptoms. The outcome measures used were before and after comparison of markers of asthma morbidity and requirement for acute medical treatment; and a structured questionnaire assessing the acceptability and use of the credit card plan. Following the introduction of the plan, the mean PEFR increased from 347 to 389 l.min-1, the percentage of nights woken fell from 30.4 to 16.9%, and the number of days "out of action" fell from 3.8 to 1.7%. The requirements for acute medical treatment also fell during the intervention period. Most participants commented favourably on the content and usefulness of the plan. In the situation of worsening asthma, 28% of subjects found the peak flow side of the card most helpful, 7% the symptoms side, and 48% found both sides equally helpful.(ABSTRACT TRUNCATED AT 250 WORDS)

Shopping for health: purchasing health services through contracts

The 1993 New Zealand health service reforms were based on the purported efficiencies of the purchaser/provider split. Purchasers are required to contract for services that will maintain, improve and restore the health of the populations they serve. The purchasing role, which requires the development of contracting skills as well as the setting of strategic directions and priorities, is new and as yet poorly developed. This paper describes the role of purchasing agents in setting priorities, the different approaches that are being taken to contracting for services and some of the problems that have arisen in the first year of contracting. It explores the trade-off that is evident between the potential for improving efficiency through contestable contracting and the need to minimise transaction costs associated with the contracting process. The purchasers' accountability to the public and the Minister is analysed in the broader political context of the purchasers' role in shaping a public health service and improving the health of the population.

Blood ties: accountability for blood quality in New Zealand

Blood donations are 'gifts' that do not fit easily into a more market-oriented health care system. The new commercial organisational arrangements in New Zealand for the collection, manufacture and distribution of blood and blood products are compared in this paper with the old organisational arrangements. The particular case of screening blood for hepatitis C is examined. A socio-legal framework, which looks at the regulation of social institutions, is used to explore the different ways in which people have tried to maintain the quality of blood and blood products, both in New Zealand and internationally. One conclusion drawn is that blood production and distribution cannot be commercialised without affecting supply and quality.

Trial of an asthma action plan in the Maori community of the Wairarapa

AIMS

An asthma action plan has been tested in a study conducted by Wairarapa Maori community health workers and the Wellington asthma research group. There were several distinctive features of the project, including the programme of marae-based asthma clinics, and the partnership between the researchers and the Maori community groups. This paper describes the process by which the study was conducted since this experience may be relevant to future Maori health research projects.

METHODS

The programme was launched with a series of hui at marae in the Wairarapa, and marae-based clinics were set up. These were followed up by further support from the Maori community health workers who helped people to keep diaries to monitor their asthma, and generally maintained contact. The severity of asthma in the participants was compared for a two-month period before the action plan was introduced, and for a four-month period after the plan was introduced.

RESULTS

There was a high participation rate, with 91% (63/69) of participants finishing the programme, 75% of whom adequately completed their daily asthma diaries. Asthma control improved significantly in the participants. They commented positively on the programme, and particularly on the marae-based clinics.

CONCLUSIONS

The study was successful in terms of participation in the marae-based clinics, acceptance and use of the plan, and improvement in asthma control of the participants. The findings indicate what can be achieved when researchers and Maori community groups work in partnership.

Doing the splits: contracting issues in the New Zealand health service

The purchaser-provider split is an integral part of the New Zealand and UK health care reforms. The split is seen as an opportunity to introduce competition by increasing the number of players. The assumption is that competition among providers, purchasers or indeed funders, increases efficiency and provides more consumer choice. This paper looks at the issue of contracting in the New Zealand health services within the framework of transaction cost analysis. It examines evidence about the effects of formal contracting rather than the more traditional, informal negotiations that take place within a hierarchy. A number of potential problems with an indiscriminate provider split are highlighted and the conclusion drawn, that the outcome of such a split is likely to be more unpredictable than official expectations. In the absence of pilots, monitoring the implementation will be critically important to be able to compare the outcomes of different ways of organising the health care system.

Evaluation of effectiveness of aftercare in alcoholism treatment

Providing aftercare to alcoholic patients upon discharge is seen as an important factor in recovery. The purpose of this study was to investigate whether providing contractual aftercare would increase the aftercare attendance and influence their drinking. The subjects were 55 patients who underwent inpatient treatment over a one year period. They either signed a contract to attend a specified number of meetings and upon failure to do so were actively followed up (contract group, n = 28) or did not sign a contract but were only verbally encouraged to attend the meetings (control group, n = 27). Six months after discharge, patients in both groups were followed up and data obtained on drinking and social stability measured. A multiple regression analysis showed that although the use of a contract was effective in increasing patients' return rate to the unit, attendance of aftercare meetings was not a significant predictor of drinking. The significant predictor was the employment situation. Patients' perceptions of aftercare provided was evaluated and the necessity for providing aftercare based on patients' needs was seen as important.