Measuring the impact of England’s public smoking ban on infant mortality

A PHS 795 student draws our attention to a quasi-experimental study examining the impact of England’s comprehensive public smoking ban on infant birth weight and mortality. Although it is true that an interrupted time series design is relatively weak, the magnitude of this intervention as a nationwide policy and the strength of the biological mechanisms connecting maternal smoking to these outcomes gives a whole lot of weight to its conclusion (why it was published in a high impact journal like Nature). Our student writes:

In July 2007, England passed a nationwide, comprehensive smoking ban. Since then, virtually all work and public places have been smoke-free. A few studies have looked at the positive impacts of this on adult health, in terms of direct smoking as well as second-hand smoke.

This research article from 2015 uses a quasi-experimental design to look at the effect of England’s smoke-free legislation on perinatal survival. As we’ve learned in this class, exposures during early stages of the life course can have the biggest impacts on lifetime health. This study looked at death certificates for all births between 1995 and 2011: over 52,000 stillbirths and over 10 million live-births were examined. They found the smoking ban caused a near-immediate reduction in stillbirths, low birth weight, and neonatal mortality for the study group.

Despite being one of the largest studies to investigate this topic, there are some inherent limitations to this type of analysis. How does the experimental design used here relate to the quasi experimental methods discussed with Dr. Remington? Are there other experimental designs that might be reasonable to examine the relationship between smoking bans and health benefits?

Balancing nurse practitioners and physicians to improve primary care access

In a recent PHS 795 lecture, UW Health ACO chief Dr. Jonathan Jaffery discussed the importance of ensuring that health care providers are spending their time “practicing at the top of their license.” A PHS student notes that availability of supervisory physicians is serving as a barrier to nurse practitioners in “filling the primary care gap.” They write:

This article discusses the ongoing demand for primary care physicians. Despite efforts in the past few years to increase the number of primary care physicians, and the demand is increasing as more Americans get health coverage through the ACA. They used match data to track the number of new primary care physicians and nurse practitioner graduation rates. The number of nurse practitioners (NPs) has greatly increased but the number of primary care physicians isn’t keeping up with the number of new NPs, and since there are many regulations around the type of work and amount of supervision needed for NPs, it inhibits NPs from filling the primary care gap. There are still 10 states that limit the number of NPs physicians can supervise, which means that some states cannot make use of all of the available NPs because there aren’t enough primary care physicians to oversee the NPs. The article mentions that in order to meet the goals of the “Triple Aim” health care system approach, we need to make it possible for all providers to provide the maximum care that their licenses permit.

The changes implemented by the ACA (both insurance and delivery reform) cannot be fully realized unless we can change the policies and regulations limiting the roles of health care providers and improve incentives to work as primary care providers. In Jaffery’s class lecture, he spoke about how the aspect of health care that needs the most improvement is routine and preventative care. We need more primary care physicians and NPs to not only catch up to the increasing demand for primary care services, but also to improve primary care and make primary care more accessible.

 a Primary Care Workforce: The Need To Remove Barriers For Nurse Practitioners And Physicians

healthaffairs.org

Primary Care Workforce: The Need To Remove Barriers For Nurse Practitioners And Physicians | At the intersection of health, health care, and policy.

“Poor kids who do everything right don’t do better than rich kids who do everything wrong…”

Reinforcing cycles and feedback loops are part of the “systems approach” to describing phenomena — an approach that underlies many of the most interesting conceptual frameworks in population health. In class, we’ve seen clues about how poor maternal health can influence child health and development, which can lead to generation-spanning cycles of poor health. Social mobility is key to breaking free from these health disparity “traps.” A PHS 795 student draws our attention to an article from the Washington Post (with a rather attention-grabbing headline) about a self reinforcing cycle of social economic status and educational attainment. They write:

Often times, there is a large focus on the reinforcing cycle of inequity that low socioeconomic status (SES) families and individuals are caught in. An example of this cycle involves a low SES infant being born with the higher likelihood of health problems/ vulnerabilities, being raised in high stress environment, going to a school with lower quality education, engaging at risky health behaviors at a younger age, having less access to social capital and opportunities for employment or education, not having the resources in engage in healthy behaviors, and then experiencing worse health outcomes while receiving lower quality care when illnesses occur.

What often gets neglected in discussions of inequity is the reinforcing cycle of privilege experienced by high SES individuals. The existence of this cycle can reinforce inequities experienced by low SES communities by creating a silo of privilege that the low SES communities struggle to break into.

In this article, an example silo of privilege is presented in the context of the academic world. Despite better academic performance compared to poor performing, high SES students, low SES students encounter multiple hurdles that interfere with improving their SES.

 a Poor kids who do everything right don’t do better than …

www.washingtonpost.com

America is the land of opportunity, just for some more than others. That’s because, in large part, inequality starts in the crib. Rich parents can afford …

 

Male contraception and the pleasure deficit

One of the most thought-provoking lectures of this semester so far has been from Prof. Jenny Higgins, who introduced us to the concept of the “pleasure deficit” – that research on the use of contraception for birth control and disease prevention cannot ignore the important role of sexual satisfaction. In class, we noted that the pleasure deficit may extend to better understanding other interventions to improve healthy behaviors, such as exercise or healthy eating – which involve individual perceptions of pleasure or displeasure from such activities. A PHS 795 student draws our attention to an article and YouTube video about factors underlying the lack of parity in male birth control options. They write:

Dr. Higgins’ lecture has renewed my interest in male birth control options. I’m including an article from 2011 WIRED about Vasagel. It does reinforce the pleasure deficit, discussing that it is difficult to develop hormonal birth control that doesn’t impact male libido, without discussing the sexual side effects of female birth control that has been on the market for years. Truth be told, I feel like I’ve been hearing about Vasagel-like products for over 10 years, but we haven’t gotten any closer to parity in male contraceptive options. MTV’s feminist vlogger Laci Green rightly asks why this is the case, and offers some intriguing ideas. I feel that the pleasure deficit is part of a larger issue in which women are asked to assume both the responsibility and health and sexual side effects of contraception.

https://www.wired.com/2011/04/ff_vasectomy/

https://www.youtube.com/watch?v=qUlQiELaR7M

Pop Health dissemination via music video…

A PHS Student notes the powerful message of hip hop artist Macklemore’s single “Drug Dealer.” They write:

Macklemore, an influential hip hop artist, has unveiled his addictive personality using music as an outlet. In his latest single, Drug Dealer, he etches a powerful landscape – one filled with prescription and over-the-counter drugs that percolate through the walls of our healthcare system. The aim of Drug Dealer is bringing to surface the abuse of prescription (and over-the-counter) drugs. Earlier in the semester we discussed socioecological models on health and how Scott, once a respected nurse/caretaker, was driven to a lifestyle dependent on drugs. Under the guidance of John Mullahy, we also considered health as a consumer product. Given that prescription drugs are a product of healthcare and are intended to improve health, they are a health good – a unit of health that you can just pluck off of the shelf and buy. Macklemore (and many other victims of addiction), however, brings forward an idea that we haven’t covered about health resources in 795: there’s such a thing as too much of a health good. The salience of this idea raises so many questions: how do we address the consumption of these drugs? How should their access by addressed? Should their tax rates be increased? Should drug management be more intensive and more engaged? Where’s that crystal ball when you need it?

Here’s a link to Macklemore’s single:
https://www.youtube.com/watch?v=Gps0LQq3uEo

Medical-Legal Partnerships — a new paradigm for health care?

A PHS 795 student introduced me to the concept of Medical Legal Partnerships (MLPs), which integrate health services with the delivery of legal services (including help with, for example, housing code violations, domestic violence interventions, application for public health insurance,  etc) in addition to health care services. Our student writes:

The community health center I worked at the past 2 years, was working on putting together the infrastructure to have their own medical legal partnership. As a future physician, I think this type of collaboration is essential to addressing health disparities.

This article [medical-legal-partnerships] looks at how health care is changing. “For too long, society has ignored the extent to which social determinants of health (SDH)—the conditions in which people live, learn, work, and play—are inextricably woven into and affect individual and population health.” The social determinants make improving the health of an individual and the health of the population too great of a challenge for a physician in a short clinic visit. There are too many factors influencing the health and wellness of populations. Health professionals can only address and treat what a patient presents in the clinical setting. But when the ailment would be treated more effectively with a change in the patient’s home environment or social situation, how does the physician or health professional make that recommendation or change that environment?

One-way health professionals are working to address social determinants of health are through Medical Legal Partnerships (MLP). MLPs bring together the ability to treat health conditions of physicians with the ability to address legal needs of lawyers. In a medical legal partnership, the physician would “write a prescription” to the partnering lawyer stating the need for legal intervention. From here the lawyer, can proceed with legal action until the situation is resolved.

MLPs can work to address legal issues such as housing, healthcare access, citizenship, domestic issues, and any other situation that is causing a negative impact on the patient’s health.

The situation of every person is different, and for some, simply changing apartments or pursuing legal action on their own is not feasible. Patients may feel intimated, threatened, or unable to stand up for themselves due to a host of barriers, and MLPs provide people the opportunity and support to improve their health free from these barriers.

MSF rejects free vaccines – why?

A PHS 795 student came across an interesting blog post at Médecins Sans Frontières (Doctors Without Borders):

Why Médecins Sans Frontières rejected Pfizer’s 1 Million Free Pneumonia Vaccine

It is quite stunning how Pfizer offered 1 million free vaccine to MSF but it rejected every one of it. But, why?????? Apparently, these doctors are well-awared of the fact that there is no free lunch in reality and that the price will be on the rest of the world–who make purchase of the vaccines. As most of you would agree, it is never an easy decision to prioritize one over another in public health. Of course there is no right or wrong but it sure leads to the ultimate question of who should live (instead of whom). MSF does have a fair point in that free vaccine will lead to higher price which is looking ahead to the future; while there are countless people dying at this very moment.

In the meantime, I would like to point out what Gavi, an international organization – a global Vaccine Alliance created in 2000, does in this context. There has been a set of global efforts involving various stakeholders, in the name of Gavi, that brings together public and private sectors with the shared goal of creating equal access to new and underused vaccines for children living in the world’s poorest countries. (Yeah, it’s from the website…..) Besides providing vaccines to the needed, it works closely with pharmaceutical industry to provide vaccines more quickly and at prices far lower than in developed countries. (Check out their website if interested: http://www.gavi.org)

Instead of a report from the media, I am suggesting the blog posting by Jason Cone, the Executive Director of MSF in the U.S. where he gave a thorough reason to the rejection.

Tracing the history of housing discrimination and its impacts…

A fascinating online tool shows the historical use of “redlining” to determine home mortgage eligibility. Given the critical link between housing and health, this could be a very valuable tool for exploring the roots of health disparities. A PHS 795 student writes:

 a Interactive Redlining Map Zooms In On America’s History Of Discrimination

www.npr.org

In the early 20th century, the federal government categorized neighborhoods, based largely on race, to determine mortgage eligibility. A new site combines the maps — and their revealing backstories.

This article discusses the history or red lining, which led to many of the inequalities we have talked about in class, and a new interactive map that has been created to show the original maps overlaid on modern streets.  These maps were made as part of the New Deal in the second half of the 1930’s by the Home Owners Loan Corporation and were used to determine who should be granted home loans.  The rankings were largely based on the race of the people living in the area being evaluated.  These policies led to people from minority groups not being able to accumulate wealth through homeowner ship, which in turn leads to not being able to accumulate wealth down through subsequent generations.

Is there a “culture of poverty”

A PHS 795 student links to a thoughtful piece by Paul Gorski challenging the concept that there is a “culture of poverty.” As we know from class, poverty is a powerful predictor of health outcomes — one that goes beyond simple correlation, with plausible physiological mechanisms drawing causal links. We also know that culture is a powerful influence on behavior and can serve as a positive or negative catalyst for change. But does poverty create its own culture? Our student writes:

This was an interesting write by Paul Gorski who basically debunks myths associates with the idea of “culture of poverty”; a term coined by Oscar Lewis. This gives the perception that children who grow up in poor families, become accustomed to the values and norms that perpetuate poverty. Also the idea that all poor people some how share the same mentality and circumstances. He addresses what he thinks to be behind the achievement gap that is between high and low income students. The term he used to describe this is culture of classism.

 

Use of registries for chronic disease management

A PHS 795 student alerts us to a Robert Wood Johnson Foundation “culture of health” report on how Sweden is using a disease registry to improve quality and reduce costs for management of rheumatoid arthritis. Many registries are for long term outcomes research only; this one appears to involve tools to allow for patient engagement and clinical decision support. Very interesting.  Our student writes:

The idea that disease registries can also help to move us closer to patient-centered care (which we know from lecture is one of the 6 important domains of quality) comes from a model used in Sweden. They created a disease registry for rheumatology patients to serve as an interactive tool that both patients and their doctors can use to optimize care. Over 10 years Sweden saw good results in improved use of medications, reduced inflammation, & decrease in hip replacements among those with rheumatoid arthritis. RWJF and other partners are working to adapt the SRQ model in the U.S. for patients with cystic fibrosis.

While specific disease registries like the SRQ model seem like an excellent tool, I’m not sure how this specific type of patient-centered quality of care improvement might have an effect on reducing health disparities. The article mentions that increased patient engagement can improve health outcomes. “A patient can log on to the registry on her laptop, tablet or mobile device. While sitting at her kitchen table, she can review her doctor’s notes, check her test results and enter information of her own on her symptoms, progress and challenges. These data are synthesized and graphically displayed to provide a real-time snapshot of her health and a longitudinal image that shows her health and treatment trends over time.” However, it seems that realistically many low-income patients or patients from racial/ethnic minority groups may not have the means (i.e. technology) required to update this information in real time on their end. Would this change the effectiveness of the tool?