Lucy Reynolds

Factors influencing antibiotic prescribing in China: An exploratory analysis

OBJECTIVES China has very high rates of antibiotic resistance and a health care system that provides strong incentives for over-prescribing. This paper describes the findings of a qualitative study in a province of southern China that seeks to assess knowledge, attitudes, and practices in relation to the use of antibiotics. METHODS Semi-structured interviews with patients and health workers at provincial, county, township, and village level. Interviews used four probes (common cold, cough, mild diarrhoea and tiredness) where antibiotics were not indicated, supplemented by questions on knowledge, attitudes, and practices. These data were supplemented by two focus groups, with medical students and pharmacists, and discussions with participants at a national conference on antibiotic use. RESULTS Coughs and diarrhoea are almost universally treated with antibiotics, while the cold is normally treated with antivirals instead or as well. Many physicians are aware that the cold is usually self-limiting but believe that they can speed recovery and that they are responding to patient expectations. Most physicians and many patients are aware of the phenomenon of antibiotic resistance, although it is often seen as a property acquired by the patient and not the micro-organism. Physicians face financial incentives to prescribe, with profit splitting with pharmaceutical suppliers. Sales profits form a major part of a hospitals income. National guidance on use of antibiotics is fragmentary and incomplete. CONCLUSION The misuse of antibiotics poses considerable risks. Effective action will require a multi-faceted strategy including education, based on an understanding of existing beliefs, the replacement of perverse incentives with those promoting best practice, and investment in improved surveillance. Much of this will require action at national level.

Serve the people or close the sale? Profit-driven overuse of injections and infusions in China's market-based healthcare system

Treatment by injection or infusion is widespread in China. Using the common cold as a tracer condition, we explored the reasons for over-prescription of injections and infusions in Guizhou, China. Interviews with prescribers, patients and key informants were supplemented by focus groups. These revealed how historical ideas encourage unnecessary use of percutaneous treatment: faith in the healing power of needles is locally attributed to association with acupuncture. Many patients and some staff believe that injections per se are therapeutic. However, the structure of health service financing and remuneration now reinforces this irrational faith. Market-based reforms have attempted to control costs and increase productivity with an incentive scheme which rewards prescribers financially for over-prescription in general and for use of injections and infusions in particular. Aggressive marketing has displaced oral treatment from health facilities into independent pharmacies, leaving doctors functioning mainly as injection providers. There is a need for a multi-faceted response encompassing education and reform of financial incentives to reduce the use of unnecessary treatment.

Factors mediating HIV risk among female sex workers in Europe: a systematic review and ecological analysis

Objectives We reviewed the epidemiology of HIV and selected sexually transmitted infections (STIs) among female sex workers (FSWs) in WHO-defined Europe. There were three objectives: (1) to assess the prevalence of HIV and STIs (chlamydia, syphilis and gonorrhoea); (2) to describe structural and individual-level risk factors associated with prevalence and (3) to examine the relationship between structural-level factors and national estimates of HIV prevalence among FSWs. Design A systematic search of published and unpublished literature measuring HIV/STIs and risk factors among FSWs, identified through electronic databases published since 2005. ‘Best’ estimates of HIV prevalence were calculated from the systematic review to provide national level estimates of HIV. Associations between HIV prevalence and selected structural-level indicators were assessed using linear regression models. Studies reviewed Of the 1993 papers identified in the search, 73 peer-reviewed and grey literature documents were identified as meeting our criteria of which 63 papers provided unique estimates of HIV and STI prevalence and nine reported multivariate risk factors for HIV/STI among FSWs. Results HIV in Europe remains low among FSWs who do not inject drugs (<1%), but STIs are high, particularly syphilis in the East and gonorrhoea. FSWs experience high levels of violence and structural risk factors associated with HIV, including lack of access to services and working on the street. Linear regression models showed HIV among FSWs to link with injecting drug use and imprisonment. Conclusions Findings show that HIV prevention interventions should be nested inside strategies that address the social welfare of sex workers, highlighting in turn the need to target the social determinants of health and inequality, including regarding access to services, experience of violence and migration. Future epidemiological and intervention studies of HIV among vulnerable populations need to better systematically delineate how microenvironmental and macroenvironmental factors combine to increase or reduce HIV/STI risk.

Evidence based road safety? The Driving Standards Agency's schools programme

In March 2000, the British Government launched its road safety strategy, setting out how it plans to achieve a 40% reduction in road deaths and serious injuries by 2010. Prominent within the strategy is a plan to reduce deaths and serious injuries in teenage drivers. Drivers aged 17-21 years make up 7% of licence holders but 13% of drivers involved in road traffic crashes resulting in injury. The government proposed to tackle the problem of teenage road deaths with driver education programmes in schools and colleges. Students aged 16 to 18 years were offered an education package developed by the Driving Standards Agency (DSA), the executive agency of the Department of Environment, Transport and the Regions (DETR) responsible for driving tests in Britain and funded from driving test fees. The DSA Schools Programme involves presentations by driving examiners about selecting a driving instructor, the theory and practical tests, and a range of road safety issues. In the year the policy was announced, driving examiners made 800 presentations to schools and colleges in Britain reaching 125,000 students. In December 2000, Mr Keith Hill, Parliamentary Under Secretary of State for the DETR, announced an expansion of the programme to reach some 750,000 students.

How the Health and Social Care Bill 2011 would end entitlement to comprehensive health care in England

The National Health Service (NHS) in England has been a leading international model of tax-financed, universal health care. Legal analysis shows that the Health and Social Care Bill currently making its way through the UK Parliament would abolish that model and pave the way for the introduction of a US-style health system by eroding entitlement to equality of healthcare provision. The Bill severs the duty of the Secretary of State for Health to secure comprehensive health care throughout England and introduces competitive markets and structures consistent with greater inequality of provision, mixed funding, and widespread provision by private health corporations. The Bill has had a turbulent passage. Unusually, the legislative process was suspended for more than 2 months in 2011 because of the weight of public concern. It was recommitted to Parliament largely unaltered after a “listening exercise”. These and more recent amendments to the Bill do not sufficiently address major concerns that continue to be raised by Peers and a Constitution Committee of the House of Lords, where the Bill now faces one of its last parliamentary hurdles before becoming law. Fundamental to the Bill are provisions that transform a mandatory system into a discretionary one with structures that permit the introduction of charging for services that are currently free under the NHS, as well as a system in which much delivery would be privatised. Under the current statutory framework the Government has a legal duty to secure comprehensive health care, whereas, under the new system, substantial discretionary powers will instead be extended to commissioners and providers of care. These measures will increase inequalities of provision. Clauses 1 and 12 of the Bill will dismantle key sections of the 1946 founding legislation of the NHS by repealing the unifying duty from which all other legislative powers and functions flow. This unifying duty is currently laid down in Sections 1 and 3 of the National Health Service Act 2006. It requires the Government to promote a comprehensive health service by providing or securing the provision throughout England of a list of specified NHS services and hospital accommodation in ways that meet all reasonable requirements. Accordingly, since 1948, most NHS hospital and community-based provision has its own facilities and NHS staff. The whole system has been publicly administered and funded on the basis of contiguous geographical areas by bodies, now called primary care trusts (PCTs), that act on behalf of the Secretary of State and have responsibility for the health-care needs of everyone in their area. Experiments with internal and external markets since 1990 have taken place within this overarching geographical framework. The Bill creates two new bodies with responsibility for managing care: an NHS Commissioning Board and Clinical Commissioning Groups (CCGs), the number of which remain unclear. PCTs will be abolished and not replaced. Powers currently exercised by the Secretary of State for Health will be transferred to each CCG, which, in contrast to PCTs, will act in place of, and not on behalf of, the minister. The NHS Commissioning Board will exercise its functions at a distance from the Secretary of State and have oversight of CCGs. These changes will repeal the minister’s core duty to provide or secure provision of specified health services. Clause 12 of the Health and Social Care Bill repeals the Secretary of State’s “duty to provide” specific services.

All in this together: the corporate capture of public health

The UK government is increasingly handing over its role of health policy maker to private corporations

Organised crime and the efforts to combat it: a concern for public health

This paper considers the public health impacts of the income-generating activities of organised crime. These range from the traditional vice activities of running prostitution and supplying narcotics, to the newer growth areas of human trafficking in its various forms, from international supply of young people and children as sex workers through deceit, coercion or purchase from family, through to smuggling of migrants, forced labour and the theft of human tissues for transplant, and the sale of fake medications, foodstuffs and beverages, cigarettes and other counterfeit manufactures. It looks at the effect of globalisation on integrating supply chains from poorly-regulated and impoverished source regions through to their distant markets, often via disparate groups of organised criminals who have linked across their traditional territories for mutual benefit and enhanced profit, with both traditional and newly-created linkages between production, distribution and retail functions of cooperating criminal networks from different cultures. It discusses the interactions between criminals and the structures of the state which enable illegal and socially undesirable activities to proceed on a massive scale through corruption and subversion of regulatory mechanisms. It argues that conventional approaches to tackling organised crime often have deleterious consequences for public health, and calls for an evidence-based approach with a focus on outcomes rather than ideology.

Matching supply and demand for blood in Guizhou province, China: an unresolved challenge

BACKGROUND Problems with blood supply in China in the 1990s stimulated measures to achieve 100% voluntary donation but supply remains inadequate to meet demand. STUDY DESIGN AND METHODS Review of official policies, supplemented with observation of practice and interviews with key informants (potential and actual donors and health workers) in Guizhou province in Southern China. RESULTS Interviewees perceived the transfusion system as a mutual social contract. However, some individuals were unwilling to donate because of concerns about health risks, the idea of transferring blood between people, wastage or profits being made from blood. Inappropriate incentives, including cash, were used to encourage donation. Recent reforms have increased confidence in donation and transfusion safety although concerns persist about misuse. There is a need to reduce unnecessary use of blood and its products. CONCLUSION China still relies heavily on blood supplies obtained through quota, purchase or use of incentives. There is scope to expand voluntary donation further. However, as a priority it will be necessary to reduce overuse.

Home is where the patient is: a qualitative analysis of a patient-centred model of care for multi-drug resistant tuberculosis.

BackgroundAmbulatory, community-based care for multi-drug resistant tuberculosis (MDR-TB) has been found to be effective in multiple settings with high cure rates. However, little is known about patient preferences around models of MDR-TB care. Médecins Sans Frontières (MSF) has delivered home-based MDR-TB treatment in the rural Kitgum and Lamwo districts of northern Uganda since 2009 in collaboration with the Ministry of Health and the National TB and Leprosy Programme. We conducted a qualitative study examining the experience of patients and key stakeholders of home-based MDR-TB treatment.MethodsWe used semi-structured interviews and focus-group discussions to examine patients’ perceptions, views and experiences of home-based treatment and care for MDR-TB versus their perceptions of care in hospital. We identified how these perceptions interacted with those of their families and other stakeholders involved with TB. Participants were selected purposively following a stakeholder analysis. Sample size was determined by data saturation being reached within each identified homogenous category of respondents: health-care receiving, health-care providing and key informant. Iterative data collection and analysis enabled adaptation of topic guides and testing of emerging themes. The grounded theory method of analysis was applied, with data, codes and categories being continually compared and refined.ResultsSeveral key themes emerged: the perceived preference and acceptability of home-based treatment and care as a model of MDR-TB treatment by patients, family, community members and health-care workers; the fear of transmission of other infections within hospital settings; and the identification of MDR-TB developing through poor adherence to and inadequate treatment regimens for DS-TB.ConclusionsHome-based treatment and care was acceptable to patients, families, communities and health-care workers and was seen as preferable to hospital-based care by most respondents. Home-based care was perceived as safe, conducive to recovery, facilitating psychosocial support and allowing more free time and earning potential for patients and caretakers. These findings could contribute to development of an adaptation of treatment approach strategy at national level.

HIV Epidemics in the European Region : Vulnerability and Response

This report aims to describe the dynamics of HIV epidemics among vulnerable and key populations at high risk in the European region, focusing specifically on people who inject drugs (PWID), sex workers (SWs) and men who have sex with men (MSM). This report covers 54 countries of the WHO European Region and Lichtenstein. It does so in order to inform future HIV prevention, treatment and care responses as well as to guide future HIV prevention surveillance and research. In addition to a description of methods (below), the report comprises three main sections. Chapter 2 synthesizes evidence drawn from European HIV surveillance data (chapter 2.1) and targeted HIV prevalence studies (chapter 2.2). Chapter 3 synthesizes evidence drawn from systematic reviews of epidemiological studies among PWID, SWs, and MSM. Chapter 4 draws on the evidence reviewed in chapter 3 as well as the international literature more broadly to consider implications for strengthening responses, including in relation to HIV surveillance and HIV prevention for PWID, SWs, and MSM. In chapter 5, we draw conclusions. This report confirms that these populations are disproportionately affected by the growing HIV epidemic in Europe.