Nicholas B. King

Implicit value judgments in the measurement of health inequalities.

CONTEXT Quantitative estimates of the magnitude, direction, and rate of change of health inequalities play a crucial role in creating and assessing policies aimed at eliminating the disproportionate burden of disease in disadvantaged populations. It is generally assumed that the measurement of health inequalities is a value-neutral process, providing objective data that are then interpreted using normative judgments about whether a particular distribution of health is just, fair, or socially acceptable. METHODS We discuss five examples in which normative judgments play a role in the measurement process itself, through either the selection of one measurement strategy to the exclusion of others or the selection of the type, significance, or weight assigned to the variables being measured. FINDINGS Overall, we find that many commonly used measures of inequality are value laden and that the normative judgments implicit in these measures have important consequences for interpreting and responding to health inequalities. CONCLUSIONS Because values implicit in the generation of health inequality measures may lead to radically different interpretations of the same underlying data, we urge researchers to explicitly consider and transparently discuss the normative judgments underlying their measures. We also urge policymakers and other consumers of health inequalities data to pay close attention to the measures on which they base their assessments of current and future health policies.

Determinants of Increased Opioid-Related Mortality in the United States and Canada, 1990–2013: A Systematic Review

We review evidence of determinants contributing to increased opioid-related mortality in the United States and Canada between 1990 and 2013. We identified 17 determinants of opioid-related mortality and mortality increases that we classified into 3 categories: prescriber behavior, user behavior and characteristics, and environmental and systemic determinants. These determinants operate independently but interact in complex ways that vary according to geography and population, making generalization from single studies inadvisable. Researchers in this area face significant methodological difficulties; most of the studies in our review were ecological or observational and lacked control groups or adjustment for confounding factors; thus, causal inferences are difficult. Preventing additional opioid-related mortality will likely require interventions that address multiple determinants and are tailored to specific locations and populations.

Use of relative and absolute effect measures in reporting health inequalities: structured review

Objective To examine the frequency of reporting of absolute and relative effect measures in health inequalities research. Design Structured review of selected general medical and public health journals. Data sources 344 articles published during 2009 in American Journal of Epidemiology, American Journal of Public Health, BMJ, Epidemiology, International Journal of Epidemiology, JAMA, Journal of Epidemiology and Community Health, The Lancet, The New England Journal of Medicine, and Social Science and Medicine. Main outcome measures Frequency and proportion of studies reporting absolute effect measures, relative effect measures, or both in abstract and full text; availability of absolute risks in studies reporting only relative effect measures. Results 40% (138/344) of articles reported a measure of effect in the abstract; among these, 88% (122/138) reported only a relative measure, 9% (13/138) reported only an absolute measure, and 2% (3/138) reported both. 75% (258/344) of all articles reported only relative measures in the full text; among these, 46% (119/258) contained no information on absolute baseline risks that would facilitate calculation of absolute effect measures. 18% (61/344) of all articles reported only absolute measures in the full text, and 7% (25/344) reported both absolute and relative measures. These results were consistent across journals, exposures, and outcomes. Conclusions Health inequalities are most commonly reported using only relative measures of effect, which may influence readers’ judgments of the magnitude, direction, significance, and implications of reported health inequalities.

Ethical conflicts in public health research and practice: antimicrobial resistance and the ethics of drug development.

Since the 1960s, scientists and pharmaceutical representatives have called for the advancement and development of new antimicrobial drugs to combat infectious diseases. In January 2005, Senate Majority Leader Bill Frist (R-TN), MD, introduced a biopreparedness bill that included provisions for patent extensions and tax incentives to stimulate industry research on new antimicrobials. Although government stimulus for private development of new antimicrobials is important, it does not resolve long-standing conflicts of interest between private entities and society. Rising rates of antimicrobial resistance have only exacerbated these conflicts. We used methicillin-resistant Staphylococcus aureus as a case study for reviewing these problems, and we have suggested alternative approaches that may halt the vicious cycle of resistance and obsolescence generated by the current model of antimicrobial production.

Untreated Pain, Narcotics Regulation, and Global Health Ideologies

Pain management is marginalized or ignored, with millions of people worldwide unnecessarily living with untreated pain. Reducing global inequalities in untreated pain requires a concerted global effort, say Veronique Fraser and colleagues, which must attend to the complexity of pain and promote multimodal, multidisciplinary pain management.

Impact of selective evidence presentation on judgments of health inequality trends: an experimental study.

Reducing health inequalities is a key objective for many governments and public health organizations. Whether inequalities are measured on the absolute (difference) or relative (ratio) scale can have a significant impact on judgments about whether health inequalities are increasing or decreasing, but both of these measures are not often presented in empirical studies. In this study we investigated the impact of selective presentation of health inequality measures on judgments of health inequality trends among 40 university undergraduates. We randomized participants to see either a difference or ratio measure of health inequality alongside raw mortality rates in 5 different scenarios. At baseline there were no differences between treatment groups in assessments of inequality trends, but selective exposure to the same raw data augmented with ratio versus difference inequality graphs altered participants’ assessments of inequality change. When absolute inequality decreased and relative inequality increased, exposure to ratio measures increased the probability of concluding that inequality had increased from 32.5% to 70%, but exposure to difference measures did not (35% vs. 25%). Selective exposure to ratio versus difference inequality graphs thus increased the difference between groups in concluding that inequality had increased from 2.5% (95% CI −9.5% to 14.5%) to 45% (95% CI 29.4 to 60.6). A similar pattern was evident for other scenarios where absolute and relative inequality trends gave conflicting results. In cases where measures of absolute and relative inequality both increased or both decreased, we did not find any evidence that assignment to ratio vs. difference graphs had an impact on assessments of inequality change. Selective reporting of measures of health inequality has the potential to create biased judgments of progress in ameliorating health inequalities.

The influence of popular media on perceptions of personal and population risk in possible disease outbreaks

Infectious disease outbreaks are uncertain and potentially risky events that often attract significant media attention. Previous research has shown that, regardless of their objective severity, diseases receiving greater coverage in the media are considered to be more serious and more representative of a disease than those receiving less coverage. This study assesses the role of media coverage in estimations of population risk (measured as perceived incidence among a specific population within a 1-year time period) and personal risk (measured as perceived personal likelihood of infection). Diseases with higher media coverage were considered more serious and more representative of a disease, and estimated to have lower incidence, than diseases less frequently found in the media. No difference in estimates of personal risk was found. A significant correlation between estimates of population and personal risk was found for diseases infrequently reported in the media. A weaker correlation between estimates of population and personal risk was found for diseases frequently reported in the media. The correlation remained unchanged when participants were exposed to additional information, including symptoms, mortality and estimates of prevalence.

A Difference-in-Differences Approach to Assess the Effect of a Heat Action Plan on Heat-Related Mortality, and Differences in Effectiveness According to Sex, Age, and Socioeconomic Status (Montreal, Quebec)

Background: The impact of heat waves on mortality and health inequalities is well documented. Very few studies have assessed the effectiveness of heat action plans (HAPs) on health, and none has used quasi-experimental methods to estimate causal effects of such programs. Objectives: We developed a quasi-experimental method to estimate the causal effects associated with HAPs that allows the identification of heterogeneity across subpopulations, and to apply this method specifically to the case of the Montreal (Quebec, Canada) HAP. Methods: A difference-in-differences approach was undertaken using Montreal death registry data for the summers of 2000–2007 to assess the effectiveness of the Montreal HAP, implemented in 2004, on mortality. To study equity in the effect of HAP implementation, we assessed whether the program effects were heterogeneous across sex (male vs. female), age (≥ 65 years vs. < 65 years), and neighborhood education levels (first vs. third tertile). We conducted sensitivity analyses to assess the validity of the estimated causal effect of the HAP program. Results: We found evidence that the HAP contributed to reducing mortality on hot days, and that the mortality reduction attributable to the program was greater for elderly people and people living in low-education neighborhoods. Conclusion: These findings show promise for programs aimed at reducing the impact of extreme temperatures and health inequities. We propose a new quasi-experimental approach that can be easily applied to evaluate the impact of any program or intervention triggered when daily thresholds are reached. Citation: Benmarhnia T, Bailey Z, Kaiser D, Auger N, King N, Kaufman J. 2016. A difference-in-differences approach to assess the effect of a heat action plan on heat-related mortality, and differences in effectiveness according to sex, age, and socioeconomic status (Montreal, Quebec). Environ Health Perspect 124:1694–1699; http://dx.doi.org/10.1289/EHP203

Ethical Conflicts in Public Health Research and Practice

Since the 1960s, scientists and pharmaceutical representatives have called for the advancement and development of new antimicrobial drugs to combat infectious diseases. In January 2005, Senate Majority Leader Bill Frist (R-TN), MD, introduced a biopreparedness bill that included provisions for patent extensions and tax incentives to stimulate industry research on new antimicrobials. Although government stimulus for private development of new antimicrobials is important, it does not resolve long-standing conflicts of interest between private entities and society. Rising rates of antimicrobial resistance have only exacerbated these conflicts. We used methicillin-resistant Staphylococcus aureus as a case study for reviewing these problems, and we have suggested alternative approaches that may halt the vicious cycle of resistance and obsolescence generated by the current model of antimicrobial production.

Population Medicine in a Curricular Revision at Case Western Reserve

Inclusion of population medicine in a medical school curriculum has received growing attention. Recently, the Association of American Medical Colleges has highlighted this issue through support of the Regional Medicine and Public Health Education Centers initiative. The Case Western Reserve University School of Medicine joined this consortium while implementing a new curriculum in which population medicine would be an underlying theme woven with the classic science elements of disease. The organization for the first two years of the new curriculum, which was implemented in 2006, is a six-block structure during which the basic sciences are learned with key concepts of population medicine woven throughout. The focus for this article is Block One, in which population medicine is the major emphasis of the introduction to medicine. The first week, students learn social determinants, impact on communities, and social aspects of diabetes mellitus, even before addressing a patients clinical presentation. Emphasis on student-centered learning is undertaken as part of the new curriculum, using a series of weekly, case-based, small-group sessions. This type of group learning is used throughout Block One as students encounter key components of population medicine. A thesis requirement was also introduced as a mechanism to emphasize research with opportunities for research in population medicine as well as other medical sciences. A variety of mechanisms are described to measure the outcomes of Block One.