Why invest in a national public health program for stroke? An example using Australian data to estimate the potential benefits and cost implications

Objectives: Stroke is the world’s second leading cause of death in people aged over 60 years. Approximately 50,000 strokes occur annually in Australia with numbers predicted to increase by about one third over 10-years. Our objectives were to assess the economic implications of a public health program for stroke by: (1) predicting what potential health-gains and cost-offsets could be achieved; and (2) determining the net level of annual investment that would offer value-for-money.

Methods: Lifetime costs and outcomes were calculated for additional cases that would benefit if ‘current practice’ was feasibly improved, estimated for one indicative year using: (i) local epidemiological data, coverage rates and costs; and (ii) pooled effect sizes from systematic reviews.

Interventions: blood pressure lowering; warfarin for atrial fibrillation; increased access to stroke units; intravenous thrombolysis and aspirin for ischemic events; and carotid endarterectomy. Value-for-money threshold: AUD$30,000/DALY recovered.

Results: Improved, prevention and management could prevent about 27,000 (38%) strokes in 2015. In present terms (2004), about 85,000 DALYs and AUD$1.06 billion in lifetime cost-offsets could be recovered. The net level of annual warranted investment was AUD$3.63 billion.

Conclusions: Primary prevention, in particular blood pressure lowering, was most effective. A public health program for stroke
is warranted

Providing health services to migrants and refugees settling in Victoria, Australia: an analysis of the complexity, cost and policy implications for public health

The aim of the research was to identify factors related to the increased costs of providing health services to clients from a non-English speaking background (NESB), using a cross-sectional analysis of the administrative records of clients using community health services in the Northern Metropolitan region of Melbourne for the 2001/2002 financial year. The higher cost of providing services to NESB clients was influenced by four factors: increased consultation time, group attendance to an appointment, increased interpreting costs and the type of service provider. Family members and multilingual staff play a significant role in providing informal interpreting services or low-cost support for NESB consultants, and these activities should receive appropriate support. Additional funding is needed to support interpreting requirements when dealing with the health needs of NESB clients.

Research methods, evidence and public health

In theory, our research questions should drive our choice of method. In practice, we know this is not always the case. At various stages of the research process different factors may apply to restrict the choice of research method. These filters might include a series of inter-related factors such as the political context of the research, the disciplinary affiliation of the researchers, the research setting and peer-review. We suggest that as researchers conduct research and encounter the various filters they come to know the methods that are more likely to survive the filtering process. In future projects they may favour these methods. Public health problems and research questions may increasingly be framed in the terms that can be addressed by a restricted array of methods. Innovative proposals - where new methods are applied to old problems, old methods to new areas of inquiry and high-quality interdisciplinary research - may be unlikely to survive the processes of filtering. This may skew the public health knowledge base, limiting public health action. We argue that we must begin to investigate the process of research. We need to document how and why particular methods are chosen to investigate particular sets of public health problems. This will help us understand how we know what we know in public health and help us plan how we may more appropriately draw upon a range of research methods.

Evidence-based public health: what does it offer developing countries?

The global burden of disease and illness is primarily situated in developing countries. As developing countries have limited resources, it is particularly important to invest in public health and health promotion strategies that are effective. Systematic reviews are central to evidence-based public health and health promotion practice and policy. This paper discusses issues surrounding the relevance of evidence-based public health and systematic reviews to the health of developing countries. It argues that there is a lack of systematic reviews relevant to the health priorities of developing countries; many interventions reviewed can not be implemented in resource-poor situations; and, a limited amount of primary research is conducted in developing countries. The paper further argues that improvements in public health are determined not only by effective health services and interventions, but through an approach that includes other sectors and influences broader structural and systematic barriers to health. Given the social complexity of human development, and the inter-sections amongst different development goals, there is no question that gains in developing country public health are unlikely to emerge from systematic reviews alone, but will require decisions about inter-sectoral collaboration and social policy initiatives. Nonetheless, evidence around intervention effectiveness has an important role to play in addressing health priorities in developing countries and resource-poor areas. The public health evidence base urgently needs strengthening, with dedicated effort towards increasing the relevance of primary evidence and systematic reviews.

Criteria for the systematic review of health promotion and public health interventions

Systematic reviews of public health interventions are fraught with challenges. Complexity is inherent; this may be due to multi-component interventions, diverse study populations, multiple outcomes measured, mixed study designs utilized and the effect of context on intervention design, implementation and effectiveness. For policy makers and practitioners to use systematic reviews to implement effective public health programmes, systematic reviews must include this information, which seeks to answer the questions posed by decision makers, including recipients of programmes. This necessitates expanding the traditional evaluation of evidence to incorporate the assessment of theory, integrity of interventions, context and sustainability of the interventions and outcomes. Unfortunately however, the critical information required for judging both the quality of a public health intervention and whether or not an intervention is worthwhile or replicable is missing from most public health intervention studies. When the raw material is not available in primary studies the systematic review process becomes even more challenging. Systematic reviews, which highlight these critical gaps, may act to encourage better reporting in primary studies. This paper provides recommendations to reviewers on the issues to address within a public health systematic review and, indirectly, provides advice to researchers on the reporting requirements of primary studies for the production of high quality systematic reviews.

Environmental risk factors of young onset Parkinson`s disease: a case-control study

While the cause of Parkinson's disease (PD) remains unknown, recent evidence suggests certain environmental factors, such as well water drinking, herbicides and pesticides exposure, and neurotoxins, may trigger the chain of oxidative reactions culminating in the death of dopaminergic neurons in substantia nigra to cause parkinsonism. Most studies to date focused on PD with old age onset. However, there is a peculiar group of parkinsonian patients, the young onset Parkinson's disease (YOPD), in whom the age of onset is before 40. It is intriguing to know whether earlier exposure to the putative neurotoxin(s) may contribute to the earlier onset. We therefore conducted this case-control study in which 60 PD patients, 30 YOPD patients and the same number of age- and sex-matched young controls were included. Using logistic regression, we found well water drinking and head injury were risk factors for the development of YOPD. When YOPD patients were compared with PD, we found head injury and exercise were the significant predictors. Keeping all other variables constant, head injury was a risk factor and exercise appeared to be a protective factor. We conclude early exposure to well water drinking and head trauma may trigger and expedite the appearance of parkinsonian features, but such acceleration may be prevented through regular exercise.

A glossary for evidence based public health

This glossary seeks to define and explain some of the main concepts underpinning evidence based public health. It draws on the published literature, experience gained over several years analysis of the topic, and discussions with public health colleagues, including researchers, practitioners, policy makers, and students.

Public health nutrition : from principles to practice

A systematic, research-based overview of the central principles and practice issues in the growing field of public health nutrition. With chapters by leading international experts, this is essential reading for practitioners and students in public health, nutrition, health policy and related fields.