High and low incomes in general practice.

The Review Body on Doctors'' and Dentists'' Remuneration deals with average incomes and costs, and little evidence is available on local variability. In a study on general practice the distribution of high and low incomes was assessed. High income practices (defined as those with net incomes per partner of more than 35,000 pounds a year) were more likely to be larger, to have younger partners, and to be located in affluent areas. Low income practices (with a net income of less than 20,000 pounds per partner) were smaller, located in more urban areas, and more likely to have Asian partners. High income practices had higher costs per patient and more staff resources. Low income practices had fewer practice resources and faced great disincentives to investment. These practices were concentrated in less affluent areas, where the need for improved organisation of practices is greatest. General practice is becoming increasingly divided between high income, high cost practices and those with low incomes and few resources.     

Disabling violence: intellectual disability and the limits of ethical engagement

Those giving care to people with intellectual disabilities in the United Kingdom are obliged to drive bad forms of intimacy, such as abuse, out of the caring relationship. They must also enable these individuals to find positive forms of intimacy through reciprocal relationships such as friendships. These two aims are normally separated, but in an organization called L'Arche UK, they are combined in the same relationship when caregivers pursue reciprocal friendships with those they support. What happens to this ethical project when those with intellectual disabilities are violent to their caregivers? Trying to pursue intimate engagement in this context has the unexpected result of creating distrustful and tense relationships, which raises questions not only about why this ethical project goes so wrong, but also about what it would mean for it to go right: that is, what a richer and fully positive reciprocity between limited and complex human beings would actually look like in practice.     

What Should Dental Services for People with Disabilities Be Like? Results of an Irish Delphi Panel Survey

Background

This study aimed to generate prioritised goals for oral health services for people with disabilities as a first step in meeting the need for evidence based oral health services for people with disabilities in Ireland.

Methods

The study used a three round modified e-Delphi method, involving dental service professionals and people with disabilities or their representatives, in Ireland. Three rounds were completed online using SurveyMonkey. Round 1 asked: “List what you think dental services for people with disabilities in Ireland should be like.” Items for subsequent rounds were generated from responses to Round 1. Round 2 and Round 3 used 5 point Likert scales to rank these items by priority: from No Priority (1) to Top Priority (5). Consensus was achieved on each item where at least 80% of respondents considered an item either High or Top Priority. A consensus meeting concluded the process.

Results

Sixty-one panelists started and 48 completed the survey. The Delphi panel agreed on level of priority for 69 items and generated 16 consensus statements. These statements covered a range of topics such as access to care, availability of information and training, quality of care, dental treatment and cost. A recurrent theme relating to the appropriateness of care to individual need arose across topics suggesting a need to match service delivery according to the individual''s needs, wants and expectations rather than the disability type/diagnosis based service which predominates today.

Conclusions

This process produced a list of prioritised goals for dental services for people with disabilities. This creates a foundation for building evidence-based service models for people with disabilities in Ireland.     

Estimating treatment coverage for people with substance use disorders: an analysis of data from the World Mental Health Surveys

Substance use is a major cause of disability globally. This has been recognized in the recent United Nations Sustainable Development Goals (SDGs), in which treatment coverage for substance use disorders is identified as one of the indicators. There have been no estimates of this treatment coverage cross‐nationally, making it difficult to know what is the baseline for that SDG target. Here we report data from the World Health Organization (WHO)'s World Mental Health Surveys (WMHS), based on representative community household surveys in 26 countries. We assessed the 12‐month prevalence of substance use disorders (alcohol or drug abuse/dependence); the proportion of people with these disorders who were aware that they needed treatment and who wished to receive care; the proportion of those seeking care who received it; and the proportion of such treatment that met minimal standards for treatment quality (“minimally adequate treatment”). Among the 70,880 participants, 2.6% met 12‐month criteria for substance use disorders; the prevalence was higher in upper‐middle income (3.3%) than in high‐income (2.6%) and low/lower‐middle income (2.0%) countries. Overall, 39.1% of those with 12‐month substance use disorders recognized a treatment need; this recognition was more common in high‐income (43.1%) than in upper‐middle (35.6%) and low/lower‐middle income (31.5%) countries. Among those who recognized treatment need, 61.3% made at least one visit to a service provider, and 29.5% of the latter received minimally adequate treatment exposure (35.3% in high, 20.3% in upper‐middle, and 8.6% in low/lower‐middle income countries). Overall, only 7.1% of those with past‐year substance use disorders received minimally adequate treatment: 10.3% in high income, 4.3% in upper‐middle income and 1.0% in low/lower‐middle income countries. These data suggest that only a small minority of people with substance use disorders receive even minimally adequate treatment. At least three barriers are involved: awareness/perceived treatment need, accessing treatment once a need is recognized, and compliance (on the part of both provider and client) to obtain adequate treatment. Various factors are likely to be involved in each of these three barriers, all of which need to be addressed to improve treatment coverage of substance use disorders. These data provide a baseline for the global monitoring of progress of treatment coverage for these disorders as an indicator within the SDGs.     

Social adversity,low birth weight,and preterm delivery.

A prospective study of 483 pregnant women was undertaken to examine possible associations of social and psychiatric factors with both low birth weight (less than 2500 g) and preterm delivery (less than 37 weeks'' gestation). As few babies were born before term (n = 14) or with a low birth weight (n = 14) further analyses were conducted to investigate predictors of absolute birth weight and gestational age. Low income was found to be an independent predictor of birth weight when birth weight was treated both as a dichotomous and as a continuous variable. Unemployment was found to be associated with absolute birth weight. Although this effect was statistically accounted for by low income, a low income was frequently caused by unemployment. Smoking independently predicted absolute birth weight and tended to be associated with preterm delivery. None of the factors investigated was associated with gestational age. In contrast with previous findings, factors such as social class, adverse life events, and psychiatric state were not associated with birth outcome. The mechanism underlying the association between low income and low birth weight requires further investigation.     

Safety belts and public health. The role of medical practitioners.

Medical practitioners have helped the public become aware of the importance of health-promoting life-style changes such as getting more exercise and abstaining from smoking. They can likewise help their patients protect themselves from the threat of automobile crash injury. Safety belt use remains too low, and increased use offers unusual potential for averting death and disability. Various characteristics associated with a failure to use safety belts can be used to help identify patients at high risk of traffic injury. These include male sex, persons who are ethnic minorities, young people, poor people, those with low educational levels, and persons with negative attitudes to seat belt use. Various methods and resources are available to help practitioners provide appropriate safety belt advice to patients, although the specific resources available vary from place to place. At a minimum, patients need to be told that a proper use of occupant protection can at least double the chances of avoiding death or severe injury in an automobile crash.     

Cardiorespiratory fitness and muscular strength of wheelchair users.

The classification of lower-limb disabilities is commonly based on the site of the spinal cord lesion or the amount of functional muscle. Another important variable in assessing wheelchair users is their ability to carry out the activities of daily living. The cardiorespiratory fitness of those with lower-limb disabilities is usually assessed with arm-ergometry and wheelchair tests, each of which has some advantages. Muscle strength and endurance are also important aspects of the disabled person''s ability to function. Fitness is often poor in the disabled, and normal wheelchair use does not seem to prove an adequate training stimulus. Exercise with an arm ergometer and with pulleys and participation in vigorous wheelchair sports can improve physical condition. Participation in exercise programs should be based on the results of a fitness assessment and on the level of the spinal cord lesion in those with paraplegia. Progression in such programs should be gradual to ensure that the exerciser does not become discouraged and drop out of classes before fitness is increased. Data on wheelchair athletes suggest that, with persistence, many individuals in wheelchairs can adjust relatively well to their disabilities.     

Assessment of objectively measured physical activity levels in individuals with intellectual disabilities with and without Down's syndrome

Objective

To investigate, using accelerometers, the levels of physical activity being undertaken by individuals with intellectual disabilities with and without Down''s syndrome.

Methods

One hundred and fifty two individuals with intellectual disabilities aged 12–70 years from East and South-East England. Physical activity levels in counts per minute (counts/min), steps per day (steps/day), and minutes of sedentary, light, moderate, vigorous, and moderate to vigorous physical activity (MVPA) measured with a uni-axial accelerometer (Actigraph GT1M) for seven days.

Results

No individuals with intellectual disabilities met current physical activity recommendations. Males were more active than females. There was a trend for physical activity to decline and sedentary behaviour to increase with age, and for those with more severe levels of intellectual disability to be more sedentary and less physically active, however any relationship was not significant when adjusted for confounding variables. Participants with Down''s syndrome engaged in significantly less physical activity than those with intellectual disabilities without Down''s syndrome and levels of activity declined significantly with age.

Conclusions

Individuals with intellectual disabilities, especially those with Down''s syndrome may be at risk of developing diseases associated with physical inactivity. There is a need for well-designed, accessible, preventive health promotion strategies and interventions designed to raise the levels of physical activity for individuals with intellectual disabilities. We propose that there are physiological reasons why individuals with Down''s syndrome have particularly low levels of physical activity that also decline markedly with age.     

Childlessness drives the sex difference in the association between income and reproductive success of modern Europeans

The association between reproductive success and income in economically developed societies remains a controversial and understudied topic. The commonly made statement that individuals with a higher income have fewer children defies evolutionary explanation. Here we present results from an analyses of the association between lifetime reproductive success (LRS) and income for modern Europeans from 13 countries. We examine the relationships among income, partner income, sex and LRS, and the role of childlessness in driving the relationships. For women, we find a negative association between LRS and income, while for men, we find a flat or slightly positive one. The sex difference in the association appears to be driven by income's sex-specific association with childlessness; men with a low income have a relatively high risk of childlessness, while women with a low income have a low risk of childlessness. Consequently, once childless people are excluded from the analysis, LRS is negatively associated with income for both sexes. We argue that the observed LRS–income associations may be an outcome of evolved behavioural predispositions operating in modern environments and conclude that, even though humans fail to maximise LRS at all income levels in modern settings, evolutionary theory can still help to explain sex differences in LRS.     

"They're doing people a service"-qualitative study of smoking, smuggling, and social deprivation

ObjectivesTo examine the behaviour and attitudes related to smoking and contraband tobacco products among smokers in two socially deprived areas.DesignCross sectional study with qualitative semistructured interviews, augmented by smokers'' day grid.SettingTwo areas of socioeconomic deprivation in Edinburgh.Participants50 male and 50 female smokers aged 25-40 years randomly selected from general practitioners'' lists from two health centres, each located in an area of deprivation.ResultsMost smokers wanted to quit but felt unable to because of the importance of smoking in their daily routine and their addiction to nicotine. Strategies for maintaining consumption levels in the face of increasing cigarette prices and low income included purchasing contraband cigarettes and tobacco. Vendors were contacted through social networks, family, and friends as well as common knowledge of people and places, particularly pubs where contraband was available. Most users of contraband considered that smugglers were providing a valuable service. Purchasing contraband tobacco was viewed as rational in the face of material hardship. Many smokers criticised the government for its high tobacco taxation and the lack of local services to help them to stop smoking.ConclusionsSmokers in deprived areas perceive a lack of support to help them to stop smoking. Cigarette and tobacco smuggling is therefore viewed positively by low income smokers as a way of dealing with the increasing cost of cigarettes. Smokers in areas of deprivation may thus show little support for tackling smuggling until more action is taken to deal with the material and personal factors that make it difficult for them to quit.

What is already known on this topic

Areas of deprivation have the highest rates of smoking and lowest levels of cessationAround 25-30% of cigarettes consumed in the United Kingdom are contrabandWe know little about the attitudes of smokers in these areas to smuggled cigarettes or whether and how they access them

What this study adds

In such areas the easy availability of cheap tobacco products through contraband networks works against many smokers'' desire to quitGiven the perceived lack of support to help them to stop smoking, this smuggling network is viewed positively by low income smokers as a way of dealing with the increasing cost of cigarettesSmokers in areas of deprivation may thus show little support for tackling smuggling until more action is taken to address the material and personal factors that make it difficult for them to quit     

The Association of Income with Health Behavior Change and Disease Monitoring among Patients with Chronic Disease

Background

Management of chronic diseases requires patients to adhere to recommended health behavior change and complete tests for monitoring. While studies have shown an association between low income and lack of adherence, the reasons why people with low income may be less likely to adhere are unclear. We sought to determine the association between household income and receipt of health behavior change advice, adherence to advice, receipt of recommended monitoring tests, and self-reported reasons for non-adherence/non-receipt.

Methods

We conducted a population-weighted survey, with 1849 respondents with cardiovascular-related chronic diseases (heart disease, hypertension, diabetes, stroke) from Western Canada (n = 1849). We used log-binomial regression to examine the association between household income and the outcome variables of interest: receipt of advice for and adherence to health behavior change (sodium reduction, dietary improvement, increased physical activity, smoking cessation, weight loss), reasons for non-adherence, receipt of recommended monitoring tests (cholesterol, blood glucose, blood pressure), and reasons for non-receipt of tests.

Results

Behavior change advice was received equally by both low and high income respondents. Low income respondents were more likely than those with high income to not adhere to recommendations regarding smoking cessation (adjusted prevalence rate ratio (PRR): 1.55, 95%CI: 1.09–2.20), and more likely to not receive measurements of blood cholesterol (PRR: 1.72, 95%CI 1.24–2.40) or glucose (PRR: 1.80, 95%CI: 1.26–2.58). Those with low income were less likely to state that non-adherence/non-receipt was due to personal choice, and more likely to state that it was due to an extrinsic factor, such as cost or lack of accessibility.

Conclusions

There are important income-related differences in the patterns of health behavior change and disease monitoring, as well as reasons for non-adherence or non-receipt. Among those with low income, adherence to health behavior change and monitoring may be improved by addressing modifiable barriers such as cost and access.     

A rehabilitation ward in a district general hospital: first three years' experience.

The experience of the first three years'' work on a ward for the rehabilitation of patients was reviewed. Adults with physical disabilities or mixed physical and psychological disabilities, including unstable or deteriorating conditions, were accepted for intensive rehabilitation. Most patients had neurological disorders. The ward policy was that each patient had considerable time with the therapist, maximum personal independence was encouraged, and multidisciplinary staff meetings were held to agree the goals of treatment. Much effort was spent helping patients and relatives to adapt to conditions of progressive disability, but the response to questionnaires suggested that these patients as well as those who did improve received some benefit from being on the ward. Overall the benefits of the intensive rehabilitation that was offered on this ward outweighed those from short stays on medical wards.     

Know Thy Neighbor: Costly Information Can Hurt Cooperation in Dynamic Networks

People need to rely on cooperation with other individuals in many aspects of everyday life, such as teamwork and economic exchange in anonymous markets. We study whether and how the ability to make or break links in social networks fosters cooperate, paying particular attention to whether information on an individual''s actions is freely available to potential partners. Studying the role of information is relevant as information on other people''s actions is often not available for free: a recruiting firm may need to call a job candidate''s references, a bank may need to find out about the credit history of a new client, etc. We find that people cooperate almost fully when information on their actions is freely available to their potential partners. Cooperation is less likely, however, if people have to pay about half of what they gain from cooperating with a cooperator. Cooperation declines even further if people have to pay a cost that is almost equivalent to the gain from cooperating with a cooperator. Thus, costly information on potential neighbors'' actions can undermine the incentive to cooperate in fluid networks.     

Quantifying the Impoverishing Effects of Purchasing Medicines: A Cross-Country Comparison of the Affordability of Medicines in the Developing World

Background

Increasing attention is being paid to the affordability of medicines in low- and middle-income countries (LICs and MICs) where medicines are often highly priced in relation to income levels. The impoverishing effect of medicine purchases can be estimated by determining pre- and postpayment incomes, which are then compared to a poverty line. Here we estimate the impoverishing effects of four medicines in 16 LICs and MICs using the impoverishment method as a metric of affordability.

Methods and Findings

Affordability was assessed in terms of the proportion of the population being pushed below US$1.25 or US$2 per day poverty levels because of the purchase of medicines. The prices of salbutamol 100 mcg/dose inhaler, glibenclamide 5 mg cap/tab, atenolol 50 mg cap/tab, and amoxicillin 250 mg cap/tab were obtained from facility-based surveys undertaken using a standard measurement methodology. The World Bank''s World Development Indicators provided household expenditure data and information on income distributions. In the countries studied, purchasing these medicines would impoverish large portions of the population (up to 86%). Originator brand products were less affordable than the lowest-priced generic equivalents. In the Philippines, for example, originator brand atenolol would push an additional 22% of the population below US$1.25 per day, whereas for the lowest priced generic equivalent this demographic shift is 7%. Given related prevalence figures, substantial numbers of people are affected by the unaffordability of medicines.

Conclusions

Comparing medicine prices to available income in LICs and MICs shows that medicine purchases by individuals in those countries could lead to the impoverishment of large numbers of people. Action is needed to improve medicine affordability, such as promoting the use of quality assured, low-priced generics, and establishing health insurance systems. Please see later in the article for the Editors'' Summary     

Attitudes and access: advancing the rights of people with disabilities

Barriers to movement and communication in the physical environment prevent people with disabilities from enjoying the same rights, privileges and opportunities as other members of society. The guidelines presented by Drs. Karen E. Jones and Itamar E. Tamari in this issue (page 647) remind us that access to physicians'' offices is one area in which improvement is greatly needed. But, as Jones and Tamari acknowledge, accessibility involves more than the removal of physical barriers. The greatest obstacles faced by disabled people are often attitudinal ones. Programs that place responsibility for rehabilitation and integration within the community can foster a better understanding of the issues. Family physicians and other professionals must work with communities to change the attitudes, beliefs and behaviours of policy-makers and the public. Until significant progress is made on this front, problems of access that serve to marginalize people with disabilities will persist.     

Inequalities in income and long-term disability in Spain: analysis of recent hypotheses using cross sectional study based on individual data.

OBJECTIVE: To compare the relation between inequalities in long-term disability and income in the 17 regions of Spain. DESIGN: Data were taken from the survey on impairments, disabilities, and handicaps that was carried out in Spain in 1986. For each region the inequality in long-term disability associated with income was calculated as the odds ratio associated with reducing monthly household income by 10,000 pesetas (about Ponds 50) (estimate of effect of inequality of income) and the odds ratio for the inequality in long-term disability between those at the bottom and those at the top of the income hierarchy (relative index of inequality). MAIN OUTCOME MEASURE: Prevalence of long-term disability. RESULTS: Five of the eight regions where lowering income had a greater effect on long-term disability were among those with the lowest income per head, while six of the remaining nine regions where the effect was smaller were among those with the highest income per head. Three regions with the highest estimate of relative index of inequality had the highest estimate of effect, and another three regions with the lowest estimate of relative index of inequality had the lowest estimate of effect. In contrast, the relative position of the remaining 11 regions varied from one measure to another. CONCLUSIONS: These results support the theory that additional increments in material wellbeing have a negligible effect on health in countries with high socioeconomic development. However, inequality in income distribution did not determine inequality in health between those at the bottom and those at the top of the income hierarchy in many Spanish regions.     

Concerns with oral health care services for adults with cognitive and intellectual disabilities

It is of interest to document data on oral health care services for adults with cognitive and intellectual disabilities. Hence, a study protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO) with registration number: CRD42020150759. We used PubMed, Science Direct, LILACS and SCIELO to collect data from known literature using keywords containing MESH (Medical Subject Headings) terms. The risk of bias rating for the collected data was calculated using the Newcastle-Ottawa assessment Scale. The AHRQ (Agency for Healthcare, Research and Quality) was used for classifying the level of evidence in the collected data. Analysis of available data shows that there is a lack of dentists with adequate skills to treat people with disabilities resulting in high cost for dental treatment. Thus, we conclude that inconvenient location of dental clinic, lack of dentists willing to treat people with disabilities and attitude of dental staff towards people with learning disabilities were considered as barriers and challenges faced for dental health service utilization in this context.     

Public Opinion About Laws to Prohibit Weight Discrimination in the United States

Weight discrimination is pervasive in American society and impairs quality of life for obese persons. With approximately two‐thirds of Americans now overweight or obese, vast numbers of people are vulnerable to weight prejudice and its consequences. Currently, no laws exist to prohibit weight discrimination. This study conducted an online survey with a national sample of 1,001 adults (representing demographics of the United States) to examine public support for six potential legislative measures to prohibit weight discrimination in the United States. Results indicated substantial support (65% of men, 81% of women) for laws to prohibit weight discrimination in the workplace, especially for legal measures that would prohibit employers from refusing to hire, terminate, or deny promotion based on a person's body weight. Laws that proposed extending the same protections to obese persons as people with physical disabilities received the least support, suggesting that Americans may not be in favor of considering obesity as a disability. Findings also highlight specific predictors of support (related to sex, age, education, income, body weight, and political ideology). These findings can be used to inform policy makers in efforts to develop antidiscrimination laws. Such measures will rectify health disparities for overweight Americans and facilitate public health efforts to address obesity.     

Old people's homes: the relatives' view.

On 1 April new arrangements came into force for arranging and funding residential care for elderly people in Britain. From now on those who seem to need full time care will be assessed first by care managers employed by local authority social services departments. This may lead to admission to an old people''s home or a nursing home. Local authorities have been told to consult both users and carers about such decisions. But what about relatives who have not actually been giving care directly? The Relatives Association was set up last year as a voluntary organisation for the relatives and friends of older people living in residential homes. Below, its vice president, Mavis Nicholson, a journalist and broadcaster whose mother died of Alzheimer''s disease in a residential home last year, gives her personal view of being such a relative. And Dorothy White, the association''s founder, explains what the future may hold for elderly residents and their relatives.