Health Justice Partnerships: An International Comparison of Approaches to Employing Law to Promote Prevention and Health Equity.

This article traces the development and growth of health justice partnerships (HJPs) in three countries: the United States, Australia and the United Kingdom.

A qualitative interview study of Australian physicians on defensive practice and low value care: "it's easier to talk about our fear of lawyers than to talk about our fear of looking bad in front of each other".

BACKGROUND: Defensive practice occurs when physicians provide services, such as tests, treatments and referrals, mainly to reduce their perceived legal or reputational risks, rather than to advance patient care. This behaviour is counter to physicians' ethical responsibilities, yet is widely reported in surveys of doctors in various countries. There is a lack of qualitative research on the drivers of defensive practice, which is needed to inform strategies to prevent this ethically problematic behaviour. METHODS: A qualitative interview study investigated the views and experiences of physicians in Australia on defensive practice and its contribution to low value care. Interviewees were recruited based on interest in medico-legal issues or experience in a health service involved in 'Choosing Wisely' initiatives. Semi-structured interviews averaged 60 min in length. Data were coded using the Theoretical Domains Framework, which encapsulates theories of behaviour and behaviour change. RESULTS: All participants (n = 17) perceived defensive practice as a problem and a contributor to low value care. Behavioural drivers of defensive practice spanned seven domains in the TDF: knowledge, focused on inadequate knowledge of the law and the risks of low value care; skills, emphasising patient communication and clinical decision-making skills; professional role and identity, particularly clinicians' perception of patient expectations and concern for their professional reputation; beliefs about consequences, especially perceptions of the beneficial and harmful consequences of defensive practice; environmental context and resources, including processes for handling patient complaints; social influences, focused on group norms that encourage or discourage defensive behaviour; and emotions, especially fear of missing a diagnosis. Overall, defensive practice is motivated by physicians' desire to avoid criticism or scrutiny from a range of sources, and censure from their professional peers can be a more potent driver than perceived legal consequences. CONCLUSIONS: The findings call for strengthening knowledge and skills, for example, to improve clinicians' understanding of the law and their awareness of the risks of low value care and using effective communication strategies with patients. Importantly, supportive cultures of practice and organisational environments are needed to create conditions in which clinicians feel confident in avoiding defensive practice and other forms of low value care.

Enduring Powers of Attorney and Financial Exploitation of Older People: A Conceptual Analysis and Strategies for Prevention.

Enduring powers of attorney (POAs) are commonly used legal instruments that enable older people to plan for asset management in the event of future incapacity. The policy objective of POAs - empowering control over money and property - are frustrated when POAs are misused to financially exploit older people. This commentary integrates theory and evidence to propose a conceptual framework for POA-facilitated financial exploitation (POA-FE). Identified risk factors include inadequate knowledge about the POA role; family conflicts; attitudes of entitlement; and lack of planning and preparation for financial decision-making. POA-FE occurs on a continuum of behavior and strategies for preventing POA-FE are suggested using strengths-based approaches for older people and their attorneys.

Nudge or not: can incentives change health behaviours?

The approach of "nudging" people toward healthier behaviours is currently in vogue, and user financial incentives (UFIs) are one possible nudge tool. Interesting debates arise as to the criteria UFIs must meet to qualify as a nudge. The more pressing issue, however, is to determine how UFIs can be structured and implemented to motivate and sustain health behaviour change. To date, Canadian public health strategies to promote physical activity and balanced nutrition focus mainly on information provision, with some product regulation measures and indirect financial incentives. Governments cannot afford direct UFI programs to incent all 60% of overweight and obese Canadians to reduce their body mass, but governments could consider UFIs targeted to specific risk groups where a shorter-term intervention could have long-term payoffs.

Financial incentives for weight loss and healthy behaviours.

Rising rates of overweight and obesity are of serious concern in Canada. Until recently, discussion of policy options to promote healthier lifestyles has ignored the topic of direct financial incentives. The idea of paying people to lose weight or adopt healthier behaviours is now attracting study and debate. Some governments and companies are already experimenting with reward programs.Available evidence indicates that financial incentives help promote short-term change, but there is a dearth of evidence on longer-term programs and outcomes. Targeted incentives for specific risk groups have shown more success. With creative design, targeted use and evaluation, financial incentives for weight loss and healthy behaviour may be a useful addition to the health policy toolkit.

La hausse des taux de surpoids et d'obésité constitue une grande préoccupation au Canada. Jusqu'à récemment, les discussions politiques entourant la promotion de styles de vie plus sains ont évité d'aborder la question des incitatifs financiers directs. L'idée de payer les gens pour qu'ils perdent du poids et adoptent des comportements plus sains fait de plus en plus l'objet d'études et de débats. Certains gouvernements et compagnies en font l'expérience à l'aide de programmes de récompense.Les données disponibles indiquent que les incitatifs financiers aident à favoriser des changements à court terme, mais pour les programmes et les résultats à plus long terme, il y a un manque flagrant de données. Les mesures incitatives ciblées sur des groupes à risque précis connaissent un plus grand succès. S'ils sont conçus de façon créative, s'ils sont utilisés de façon ciblée et s'ils font l'objet d'évaluation, les incitatifs financiers qui visent la perte de poids et des comportements sains pourraient servir d'outils supplémentaires aux politiques de santé.

Exposure assessment in cohort studies of childhood asthma.

BACKGROUND: The environment is suspected to play an important role in the development of childhood asthma. Cohort studies are a powerful observational design for studying exposure-response relationships, but their power depends in part upon the accuracy of the exposure assessment. OBJECTIVE: The purpose of this paper is to summarize and discuss issues that make accurate exposure assessment a challenge and to suggest strategies for improving exposure assessment in longitudinal cohort studies of childhood asthma and allergies. DATA SYNTHESIS: Exposures of interest need to be prioritized, because a single study cannot measure all potentially relevant exposures. Hypotheses need to be based on proposed mechanisms, critical time windows for effects, prior knowledge of physical, physiologic, and immunologic development, as well as genetic pathways potentially influenced by the exposures. Modifiable exposures are most important from the public health perspective. Given the interest in evaluating gene-environment interactions, large cohort sizes are required, and planning for data pooling across independent studies is critical. Collection of additional samples, possibly through subject participation, will permit secondary analyses. Models combining air quality, environmental, and dose data provide exposure estimates across large cohorts but can still be improved. CONCLUSIONS: Exposure is best characterized through a combination of information sources. Improving exposure assessment is critical for reducing measurement error and increasing power, which increase confidence in characterization of children at risk, leading to improved health outcomes.

Newspaper reporting on legislative and policy interventions to address obesity: United States, Canada, and the United Kingdom.

This article analyzes the content of articles in major newspapers in the United States, Canada, and the United Kingdom that discuss legislative and policy measures to control obesity. The aim was to identify and compare measures that attract media attention in the three jurisdictions: the tone of print media coverage, the characterization of obesity, and attitudes toward government interventions to address obesity. We collected 360 articles published between January 1989 and April 2009 in 12 major newspapers: 83 were published in the United States, 85 in Canada, and 192 in the United Kingdom. Articles in the three jurisdictions discussed the nature and causes of obesity in similar terms, but revealed differences in attitudes toward obesity and toward legal and policy interventions to control rising obesity rates. Obesity is reported principally as a lifestyle problem, but articles state (in varying proportions) that individuals, governments, and industry all share a role in addressing modern environments to promote healthier choices.

Handling ethical, legal and social issues in birth cohort studies involving genetic research: responses from studies in six countries.

BACKGROUND: Research involving minors has been the subject of much ethical debate. The growing number of longitudinal, pediatric studies that involve genetic research present even more complex challenges to ensure appropriate protection of children and families as research participants. Long-term studies with a genetic component involve collection, retention and use of biological samples and personal information over many years. Cohort studies may be established to study specific conditions (e.g. autism, asthma) or may have a broad aim to research a range of factors that influence the health and development of children. Studies are increasingly intended to serve as research platforms by providing access to data and biological samples to researchers over many years.This study examines how six birth cohort studies in North America and Europe that involve genetic research handle key ethical, legal and social (ELS) issues: recruitment, especially parental authority to include a child in research; initial parental consent and subsequent assent and/or consent from the maturing child; withdrawal; confidentiality and sample/data protection; handling sensitive information; and disclosure of results. METHODS: Semi-structured telephone interviews were carried out in 2008/09 with investigators involved in six birth cohort studies in Canada, Denmark, England, France, the Netherlands and the United States. Interviewees self-identified as being knowledgeable about ELS aspects of the study. Interviews were conducted in English. RESULTS: The studies vary in breadth of initial consent, but none adopt a blanket consent for future use of samples/data. Ethics review of new studies is a common requirement. Studies that follow children past early childhood recognise a need to seek assent/consent as the child matures. All studies limit access to identifiable data and advise participants of the right to withdraw. The clearest differences among studies concern handling of sensitive information and return of results. In all studies, signs of child abuse require reports to authorities, but this disclosure duty is not always stated in consent materials. Studies vary in whether they will return to participants results of routine tests/measures, but none inform participants about findings with unknown clinical significance. CONCLUSIONS: Analysis of how cohort studies in various jurisdictions handle key ELS issues provides informative data for comparison and contrast. Consideration of these and other examples and further scholarly exploration of ELS issues provides insight on how best to address these aspects in ways that respect the well-being of participants, especially children who become research subjects at the start of their lives.

Reuse of single use medical devices in Canada: clinical and economic outcomes, legal and ethical issues, and current hospital practice.

OBJECTIVES: The aim of this study was to assess the evidence that reuse of medical devices marketed for single use only (SUDs) is safe, effective and cost-effective, and to consider the use and health services impact of this practice in Canada. METHODS: A systematic review was performed of studies that reported clinical or economic outcomes following reuse of SUDs in humans. Direct costs of adverse health events associated with SUD reuse and indications of budget impact were obtained using data for devices for laparoscopic cholecystectomy and coronary angioplasty. Legal and ethical issues were reviewed, drawing on material relevant to Canada. Data on current reuse of SUDs were obtained through a survey of Canadian acute care hospitals. RESULTS: Studies of variable quality suggested that SUD reuse could be safe and effective, and would give cost savings, if there were no adverse events. Eliminating reuse of SUDs for laparoscopic cholecystectomy and coronary angioplasty would add less than 0.1 percent to costs of the procedures over 1 year. Adverse health events associated with device reuse create liability risks; patients should be informed of any known or foreseeable risks of reuse. Most of the 28 percent (111/398) of acute hospitals that reprocess SUDs do so in-house. Some do not have a written policy or an incident reporting mechanism. CONCLUSIONS: There is insufficient evidence to establish the safety, efficacy and cost-effectiveness of reusing SUDs. Legal and ethical issues require attention to minimize liability and maintain patient safety and trust. Some hospitals that reprocess SUDs do not have adequate documentation. These findings do not support the reuse of SUDs in Canadian hospitals.

Ethical, legal and social issues in nutrigenomics: the challenges of regulating service delivery and building health professional capacity.

Nutrigenomics, the conjunction of molecular nutrition with human genomics, is among the first publicly available applications of the human genome project. Nutrigenomics raises ethical, legal and social issues particularly with respect to how the public may access nutrigenetic tests and associated nutritional and lifestyle advice. Current regulatory controversy focuses on potential harms associated with direct-to-consumer (DTC) marketing of nutrigenetic tests and especially the need to protect consumers from unreliable tests, false claims and unproven dietary supplements. Nutrigenomics does, however, offer the potential of important health benefits for some individuals. The regulation of nutrigenomic services is slowly evolving, but there is little indication of increased professional capacity to support service delivery. Primary care physicians have minimal training in nutrition and genetics, and medical geneticists are in high demand and short supply. Dietetic practitioners are experts in nutrition science and interest in nutrigenomics is growing among members of this professional group. However, as with physicians, dietetics practitioners would require considerable training to bring nutrigenomics into their practice capacity. A downside of regulatory restrictions on direct consumer access to nutrigenomics companies is that responsible businesses may be hindered in meeting emergent public demand while health care professional groups have not yet developed capacity to provide nutrigenomics services.