Helen Lambert

Cost effectiveness analysis of different approaches of screening for familial hypercholesterolaemia

Abstract Objectives: To assess the cost effectiveness of strategies to screen for and treat familial hypercholesterolaemia. Design: Cost effectiveness analysis. A care pathway for each patient was delineated and the associated probabilities, benefits, and costs were calculated. Participants: Simulated population aged 16-54 years in England and Wales. Interventions: Identification and treatment of patients with familial hypercholesterolaemia by universal screening, opportunistic screening in primary care, screening of people admitted to hospital with premature myocardial infarction, or tracing family members of affected patients. Main outcome measure: Cost effectiveness calculated as cost per life year gained (extension of life expectancy resulting from intervention) including estimated costs of screening and treatment. Results: Tracing of family members was the most cost effective strategy (£3097 (€5066,

Anthropology in health research: from qualitative methods to multidisciplinarity

4479) per life year gained) as 2.6 individuals need to be screened to identify one case at a cost of £133 per case detected. If the genetic mutation was known within the family then the cost per life year gained (£4914) was only slightly increased by genetic confirmation of the diagnosis. Universal population screening was least cost effective (£13 029 per life year gained) as 1365 individuals need to be screened at a cost of £9754 per case detected. For each strategy it was more cost effective to screen younger people and women. Targeted strategies were more expensive per person screened, but the cost per case detected was lower. Population screening of 16 year olds only was as cost effective as family tracing (£2777 with a clinical confirmation). Conclusions: Screening family members of people with familial hypercholesterolaemia is the most cost effective option for detecting cases across the whole population.

The Mortality Divide in India: The Differential Contributions of Gender, Caste, and Standard of Living Across the Life Course

As a response to concerns about the standard of qualitative research, attention has focused on the methods used. However, this may constrain the direction and content of qualitative studies andlegitimise substandard research. Helen Lambert and Christopher McKevitt explain why anthropology may be able to contribute useful insights to health research Qualitative methods are now common in research into the social and cultural dimensions of ill health and health care. These methods derive from several social sciences, but the concepts and knowledge from some disciplinary traditions are underused. Here we describe the potential contribution of anthropology, which is based on the empirical comparison of particular societies. Anthropology has biological, social, and cultural branches, but when applied to health issues it most commonly relates to the social and cultural dimensions of health, ill health, and medicine.1 ### Summary points Emphasis on methods in health related qualitative research obscures the value of substantiveknowledge and theoretical concepts based in some social sciences Anthropology views the familiar afresh through focusing on classification and on understanding rationality in social and cultural context It highlights the value of data gathered informally and the differences between what people say, think, and do Its emphasis on empirical particularity helps to avoid inaccurate generalisations and their potentially problematic applications Truly multidisciplinary research needs to incorporate the conceptual frameworks and knowledge bases of participating disciplines Explaining qualitative research to health professionals has been an essential step in gaining acceptance of these techniques.2 However, findings from such research have been deemed “thin,” “trite,” and “banal.”3 Concerns about standards and the need for particular types of evidence have led to quality control measures being recommended for qualitative health research (procedures such as multiple coding, purposive sampling, and software packages for text analysis). Imposing these measures, however, may constrain the direction and content of …

Tales of biographical disintegration: how parents make sense of their sons' suicides

OBJECTIVES We investigated the contributions of gender, caste, and standard of living to inequalities in mortality across the life course in India. METHODS We conducted a multilevel cross-sectional analysis of individual mortality, using the 1998-1999 Indian National Family Health Survey data for 529321 individuals from 26 states. RESULTS Substantial mortality differentials were observed between the lowest and highest standard-of-living quintiles across all age groups, ranging from an odds ratio (OR) of 4.61 (95% confidence interval [CI]=2.98, 7.13) in the age group 2 to 5 years to an OR of 1.97 (95% CI=1.68, 2.32) in the age group 45 to 64 years. Excess mortality for girls was evident only for the age group 2 to 5 years (OR=1.33, 95% CI=1.13, 1.58). Substantial caste differentials were observed at the beginning and end stages of life. Area variation in mortality is partially a result of the compositional effects of household standard of living and caste. CONCLUSIONS The mortality burden, across the life course in India, falls disproportionately on economically disadvantaged and lower-caste groups. Residual state-level variation in mortality suggests an underlying ecology to the mortality divide in India.

A comparative analysis of communication about sex, health and sexual health in India and South Africa: Implications for HIV prevention

Suicide research relies heavily on accounts provided by bereaved relatives, using a method known as the psychological autopsy. Psychological autopsy studies are invariably quantitative in design and their findings reinforce the medical model of suicide, emphasising the role of mental illness. They largely ignore the meanings that narrators attach to events, the nature of the sense-making task and the influences bearing upon it. This study drew on psychological autopsy data but used qualitative analytic methods. Fourteen semi-structured interviews with the parents of young men aged 18-30 who had taken their own lives form the basis for this paper. Some parents represent their sons as victims who were cruelly destroyed by external forces, while others portray them as agents of their own destruction. Either way, their narratives are dominated by moral rather than medical categories and by questions of personal accountability. We show how the parents use the interview to perform a complex reconstructive task, striving to piece together both their sons and their own shattered biographies and repair damage to their moral identities. We argue that their stories represent survival tools, enabling them not only to make sense of the past but also to face their own future.

Recognising and responding to suicidal crisis within family and social networks: qualitative study

This paper provides a comparative analysis of modes of dialogue, non‐verbal communication and embodied action relating to sex and health in two contrasting countries—India and South Africa—which have the worlds two most heavily HIV‐affected populations (in terms of numbers of people living with HIV). Drawing on material derived from multiple studies, including ethnographic and other forms of qualitative and multi‐disciplinary research, the paper identifies commonalities as well as differences in communication relating to sex and sexual health in these diverse settings. The paper considers: first, how and by whom sex is and is not talked about, in public discourse and private conversation; second, how sexual intention and desire are communicated through indirect, non‐verbal means in everyday life; and third, how references to sexuality and the sexual body re‐enter within a more explicit set of indigenous discourses about health (rather than ‘sexual health’ per se), such as semen loss in India and womb ‘dirtiness’ in South Africa. The concluding section reflects on the implications of a comparative analysis such as this for current policy emphases on the importance of promoting verbal communication skills as part of ‘life skills’ for HIV prevention.

Discrimination and health in an English study

Objective To shed light on the difficulties faced by relatives, friends, and colleagues in interpreting signs of suicidality and deciding whether and how to intervene. Design Qualitative study of completed suicides, based on in-depth interviews with multiple informants. Setting London, southwest England, and south Wales. Participants 31 lay informants (one to five for each case), including parents, partners, siblings, friends, and colleagues of 14 cases of suicide in which the deceased was aged 18-34 and was not in contact with secondary mental health services. Results Informants described both intellectual and emotional barriers to awareness and intervention within the family and social network. They reported that signs and communications of distress were often oblique and difficult to interpret, that they may have disregarded warning signals and focused instead on positive signs, and that, even when they were aware that something was seriously wrong, taking any action at all involved considerable personal risks. Conclusions As the suicidal process unfolds, significant others are faced with a highly complex task. Their proximity to the suicidal person and their emotional investment in the relationship make it difficult for them to see what is happening, to say anything to the person or to other members of the network, or to seek help outside the network. Efforts to strengthen the capacity of lay people to play a role in preventing suicide are urgently needed and should be informed by a thorough understanding of these difficulties. They should highlight the ambiguous nature of warning signs and should focus on helping people to acknowledge and overcome their fears about intervening.

Suicide communication events: Lay interpretation of the communication of suicidal ideation and intent

In this study we examine the relationship between education, racial discrimination and health among white (n=227), African Caribbean (n=213) and Indian and Pakistani (n=233) adults aged between 18 and 59 years living in Leeds, England, as measured in a stratified population survey. Measures of discrimination included any physical attack, verbal abuse and a combined variable, any discrimination due to race, colour, ethnicity or sex. Analyses were conducted examining the relationship between education and discrimination, discrimination and health, and discrimination and health controlling for education. People educated above secondary level were more likely than people educated to secondary level or below to report being physically attacked, verbally abused and exposed to discrimination. People from minority ethnic groups (African Caribbean and Indian Pakistani) were more likely to be verbally abused and exposed to discrimination than the white group. Ethnicity and education interacted for African Caribbeans, such that respondents with post-school qualifications were more likely to report verbal abuse or any discrimination. There was no association between having been exposed to any kind of discrimination and having fair or poor health. Physical attack and any discrimination were associated with anxiety, worry and depression. The results remained unchanged when ethnicity and education were included in the models. Education and ethnicity were associated with differences in exposure to discrimination. In turn, exposure to discrimination was associated with higher levels of anxiety, worry or depression although there was no association between discrimination and health. The results support the contention that racial discrimination may play an important role in modifying the relationship between ethnicity, socioeconomic position and health. The counter-intuitive relationship between education and levels of reported discrimination in non-minority ethnic groups highlights the value of explicitly modeling discrimination to gain a better understanding of the social determinants of health.

Social and behavioural science education in UK medical schools: current practice and future directions

Previous research has shown that a majority of people communicate their suicidal ideas and intent prior to the act of suicide, but very little is known about the way in which these suicide communication events are interpreted by relatives, friends and significant others. A suicide communication event (SCE) is defined as a set of circumstances in which a person expresses suicidal feelings, thoughts, intentions or plans, either directly or indirectly, in interaction with other people in their social environment. In a qualitative study conducted in 2008-9 we collected narratives from people bereaved by suicide. Here we examine these narratives using an analytic framework derived from communication pragmatics and face-work theory. We analysed 14 cases of completed suicide drawn from coroners case files in London, Southwest England and South Wales. We found that the SCEs described were potentially face-threatening situations requiring face-saving strategies, which often resulted in off-record, indirect, ambiguous, humorous and euphemistic communications. Listeners frequently found it difficult to judge the meaning and intention of utterances referring to suicide. The outcome was often misunderstanding and closure of the communication, limiting the possibility of further support and referral for professional help. SCEs are important elements of the suicide process and we conclude that better understanding of how they occur and the challenges they pose for significant others may provide a basis for strengthening public involvement in suicide prevention. We draw our findings together in a model that could inform public awareness campaigns designed to improve the way people communicate with each other about suicide and distress.

The Impact of Different Measures of Socioeconomic Position on the Relationship Between Ethnicity and Health

Introduction  The increasing importance accorded the social and behavioural sciences in medical education presents opportunities for developing new and innovative forms of teaching and learning in this field. Yet social and behavioural scientists often feel isolated and marginalized. This research was designed to build a network of such practitioners to share and compare current practice, and to develop better models and resources.