[Behaviour that exceeds the limits]. / Grensoverschrijdend gedrag.

When medical students first enter the clinic, they will experience situations in which they feel threatened or intimidated. In some cases, this may entail sexual harassment, as described by Van den Muijsenbergh and Lagro-Janssen in their study of students at Nijmegen Medical School. Such behaviour is often difficult to prevent if it concerns patients, especially psychiatric patients. However, it should be prevented if it concerns staff or supervisors. In all cases, students should be aware that such incidents may happen and be prepared to deal with them. They also deserve a safe environment in which to share and discuss such experiences. It is up to the University Medical Centres to provide such a safe haven.

Timeless epidemiology or history cannot be ignored.

Epidemiology has produced some useful effect measures, the etiologic fraction and the potential impact fraction, with which the effects of changes in risk factor prevalence on disease specific incidence can be estimated. However to be able to use them for decisions in health policy, adjustments need to be made, in order to incorporate elements that can be avoided in carefully designed epidemiologic studies but cannot be ignored if the results are applied to the "real world". Such necessary adjustments include an approach in which the multi factorial aspects of chronic disease epidemiology and time dimensions can be taken into account. In this article we show the effect of including a time dimension in epidemiologic effect measures. Such a time dimension is important, e.g. to be able to incorporate the effect of a gradual reduction in excess risk following cessation of exposure to a risk factor such as cigarette smoking.

Cardiovascular disease in the Netherlands, 1975 to 1995: decline in mortality, but increasing numbers of patients with chronic conditions.

OBJECTIVE: To examine the relation between trends over time in mortality and hospital morbidity caused by various cardiovascular diseases in the Netherlands. DESIGN: Trend analysis by Poisson regression of national data on mortality and hospital admissions from 1975 to 1995. SUBJECTS: The Dutch population. RESULTS: All cardiovascular diseases combined were responsible for 39% of all deaths and 16% of all hospital admissions in 1995. From 1975 to 1995, age adjusted cardiovascular mortality declined by an annual change of -2.0% (95% confidence intervals (CI) -2.1% to -1.9%), while in the same period age adjusted discharge rates increased annually by 1. 3% (95% CI 1.1% to 1.5%). Around 60% of the gain in life expectancy in this period was related to lower cardiovascular mortality. For mortality, major reductions were seen in coronary heart disease (annual change -2.9%) and in stroke (-2.1%), whereas the increase in hospital admissions was mainly caused by chronic manifestations of coronary heart disease (5.1%), heart failure (2.1%), and diseases of the arteries (1.8%). In recent years, the gap between men and women at risk of dying from coronary heart disease became smaller for those aged

Age, socioeconomic status, and mortality at the aggregate level.

STUDY OBJECTIVE: Indicators of socioeconomic status are associated with age. This study aimed to analyse the influence of the age distribution on the ranking of small areas by socioeconomic status and on the association between their socioeconomic status and standardised mortality. DESIGN: The ranking of small areas by socioeconomic status indicators (educational level, income, and unemployment) was compared with crude values and after correction for their age structure. The age and gender standardised mortality ratios (SMRs) of these areas for the age group 1-64 years was then rank correlated with both crude and age standardised measures of socioeconomic status. SETTING: This study used data for all (n = 22) boroughs of Amsterdam for the period 1986-91. MAIN RESULTS: Correction of indicators of socioeconomic status for the age structure of the population hardly affects the ranking of Amsterdam boroughs by socioeconomic status. All rank correlations between crude and age standardised socioeconomic status measures are above 0.95. Rank correlations between SMR and these socioeconomic status measures also hardly change after correction for the age structure of boroughs except for education. Mean income per earner is the socioeconomic status indicator most strongly associated with the SMR. CONCLUSIONS: This study shows that the age structure of Amsterdam boroughs has almost no influence on their ranking by socioeconomic status and a limited influence on the association between their socioeconomic status and SMR, except for educational level. The latter indicator has the strongest association with age. This result and theoretical considerations indicate that a correction for the age structure of the population will be more important if small areas differ little with regard to socioeconomic status, if they vary considerably in age structure, or if a given indicator of socioeconomic status shows a strong cohort effect or age association.

How should interventions to reduce inequalities in health be evaluated?

OBJECTIVE: The effectiveness of interventions which have been proposed or are currently in progress to reduce socioeconomic inequalities in health is largely unknown. This paper aims to develop guidelines for evaluating these interventions. APPROACH: Starting from a set of general guidelines which was recently proposed by a group of experts reporting to the national Programme Committee on Socioeconomic Inequalities in Health in The Netherlands, an analysis was made of the appropriateness of different study designs which could be used to assess the effectiveness of interventions to reduce inequalities in health. RESULTS: A "full" study design requires the measurement, in one or more experimental populations and one or more control populations, of changes over time in the magnitude of socioeconomic inequalities in health. This will usually imply a community intervention trial. Five alternative study designs are distinguished which require less complex measurements but also require more assumptions to be made. Several examples are given. CONCLUSIONS: Building up a systematic knowledge base on the effectiveness of interventions to reduce socioeconomic inequalities in health will be a major enterprise. Elements of a strategy to increase learning speed are discussed. Although the guidelines and design recommendations developed in this paper apply to the evaluation of specific interventions where rigorous evaluation methods can often be used, they may also be useful for the interpretation of the results of less rigorous evaluation studies, for example of broader policies to reduce socioeconomic inequalities in health.

Variation in reported prevalences of hypertension in The Netherlands: the impact of methodological variables.

STUDY OBJECTIVE: To estimate the prevalence of hypertension in The Netherlands and to quantify the influence of methodological variables on the reported prevalences. DESIGN: A pooled analysis was performed based on reported age specific prevalences of hypertension. A logistic model was used to estimate the probability of hypertension. MAIN RESULTS: The age standardised prevalence of hypertension varies more than fivefold between studies carried out in The Netherlands. The probability of having hypertension was lower if blood pressure was measured at more than one point in time (Odds ratio 0.44 (OR) (95% confidence interval (95% CI) 0.38, 0.51) for men and 0.47 (0.41, 0.54) for women, and if the study was carried out more recently (OR 0.92 (0.91, 0.93) per year). The probability was higher if the study was carried out in a general practice (OR 1.14 (1.03, 1.27) for men and 1.52 (1.36, 1.69) for women). The inclusion of treated people as hypertensive yields contradictory results for men and women. CONCLUSIONS: The strong variation in prevalence is explained by methodology and by a period effect indicating a decrease of the prevalence of hypertension over time. Whether this decrease is true or caused by confounding due to unknown or unreported methodological variation over time is unknown. For future studies, a standardised method could reduce the influence of methodological variables and thereby the variation in reported prevalences.

Modelling the effects of increased physical activity on coronary heart disease in England and Wales.

OBJECTIVE: To investigate the use of computer models as tools for policy makers in evaluating physical activity interventions aimed at reducing deaths from coronary heart disease (CHD). DESIGN: The cell-based computer model Prevent, adapted to simulate risk factor interventions for an English and Welsh population, was used to simulate the effect of two strategies for increasing physical activity levels in respect of CHD mortality over 25 years. The first strategy involved a 25% increase in the proportion of 15-64 year olds who were moderately active, while the second strategy involved a similar increase in the proportion who were vigorously active. The effects of focusing on narrower age ranges and on people at different initial activity levels were also explored. MAIN RESULTS: The simulations showed a small reduction in the CHD death rates--less than 0.15% and 0.06% for men and women respectively. The strategies would postpone up to 12,100 deaths over 25 years, comparable to the effect of a 2% reduction in smoking prevalence. The strategies seemed as if they would be more effective if they concentrated on men rather than women, on those over 45 years of age as opposed to all or younger age groups, and on the least active members of the population rather than those already taking some exercise. CONCLUSION: The use of computer modelling for stimulating physical activity strategies has shown that concentrating these interventions on older sedentary men will produce the greatest health gain, but efforts to encourage smoking cessation may be more effective in terms of years of life saved.

Rationalising chances of success in intersectoral health policy making.

OBJECTIVE: It is generally accepted that a wide range of factors determine the health of a population, many of which are beyond the remit of the Ministry of Health. The aim of intersectoral health policy is to influence these factors. Success depends on a multi-stage process. This paper aims to provide support for the first stage of this process in the form of a quick scan for appraising the feasibility of intersectoral health policy. DESIGN: The content of the quick scan for intersectoral health policy was derived from a literature review. To determine the usefulness of this quick scan, the study looked at two examples in the policy sectors of education and safety. MAIN RESULTS: The quick scan distinguishes between three factors: (1) the availability of evidence, (2) the degree of support, and (3) the availability of tools for implementation. The quick scan made it possible to review the two policy sectors systematically in a relatively short time and to obtain sufficient information for priority setting in intersectoral health policy. The examples in this paper suggest that intersectoral health policy for community safety is more feasible than intersectoral policy for psychosocial problems in secondary education. However, specific information is required for a more precise assessment of feasibility. CONCLUSIONS: There are many ways of improving health through intersectoral health policy. The proposed quick scan may provide systematic support for setting priorities before developing policies of this kind.

Socioeconomic differentials in mortality among men within Great Britain: time trends and contributory causes.

STUDY OBJECTIVE: To assess the size of mortality differentials in men by social class in Scotland as compared with England and Wales, and to analyse the time trends in these differentials. SUBJECTS: Men from England and Wales and Scotland around each census from 1951 to 1981. METHODS: Poisson regression analysis was used to calculate relative indices of inequality for disease specific and all cause mortality as a measure of mortality differentials between social classes. This measure is not dependent on the size of the social class groups, so it can be used to compare the magnitude of differentials over time periods during which the relative sizes of social class groups change. MAIN RESULTS: While overall death rates were higher in Scotland than in England and Wales around the 1951, 1961, and 1971 censuses the relative indices of inequality indicated smaller mortality differences between social classes in Scotland. Inequality, as indexed by the relative index of inequality, increased over time in both Scotland and England and Wales, but to a greater degree in Scotland, resulting in greater social class mortality differentials for Scotland in 1981 (the relative index of inequality increased from 1.40 to 2.43 for England and Wales, and from 1.22 to 2.57 for Scotland between 1951 and 1981). This greater increase in the magnitude of inequalities in all cause mortality in Scotland seemed to result from increasing social class differentials in cardiovascular disease, accidents and external causes, and "all other causes of death". Examining the trends in overall death rates, it seems that the greater increase in social class differences in Scotland occurred because of the greater decrease in death rates among the privileged social groups, in combination with a smaller decrease (or a greater increase) in the death rates in the lower social class groups. CONCLUSIONS: This study has shown that trends in mortality and in inequalities in mortality differ within Great Britain. Although death rates were higher in Scotland than in England and Wales, smaller mortality differentials by social class were found in Scotland over the period 1951 to 1971. By 1981, however, social class mortality differentials were greater in Scotland than in England and Wales. The greater increase in the social class differentials over time in Scotland, may have contributed to the worsening overall mortality profile in Scotland as compared with England and Wales that occurred between 1971 and 1981.

Decline of the relative risk of death associated with low employment grade at older age: the impact of age related differences in smoking, blood pressure and plasma cholesterol.

STUDY OBJECTIVE: To explore whether the observed age related decline in the relative risk of death associated with low employment grade can be explained by the profiles of smoking, blood pressure and plasma cholesterol changing differently with age between the employment grades. DESIGN: Prospective cohort study with 25 years of mortality follow up. SETTING: Whitehall study. PARTICIPANTS: There were 16,984 men aged 40 to 69 years at baseline with complete information on smoking, blood pressure and plasma cholesterol. MAIN RESULTS: The relative risk of death associated with low employment grade decreased from 2.1 at 55-59 years of age to 1.3 at 85-89 years of age. Adjustment for smoking status and blood pressure, attenuated the age related decline of the relative risk by 18% and 3% respectively; adjustment for plasma cholesterol increased the decline by 3%. Taken together, these risk factors explain 20% of the observed age related decline. CONCLUSIONS: A small part of the observed age related decline in the relative risk of death associated with low employment grade can be explained by differential changes in the profiles of smoking, blood pressure and plasma cholesterol with age between the employment grades.

Avoidable burden of illness: how much can prevention contribute to health?

The WHO campaign for health for all by the year 2000 brought health back into the centre of attention in health policy making. Different authors have analysed the determinants of health in different models. One of these is the well-known model of Lalonde, in which health is seen as the result of four determinants: human biology, life style, environment and health care. Dever, in the U.S., has tried to quantify this model in order to compare the percentages of mortality attributable to each of the four determinants with the percentage of resources from the health care budget, allocated to them. The authors have, individually, tried to replicate these estimates, through a survey of Dutch experts. The results of these surveys are presented and discussed. The authors conclude that, although a quantification of the relative importance of the determinants of health would be extremely useful in health policy making, the methodology proposed by Dever does not yield suitable results. An alternative approach suggested, would be to subdivide the broad determinants into known risk factors and to arrive at a quantification through the utilization of known epidemiologic relationships between risk factors and disease.

Differences between studies in reported relative risks associated with smoking: an overview.

Reported Relative Risks associated with smoking differ between studies; these differences may reflect true biological differences between populations or may be research artifacts introduced by differences in factors such as amount smoked or smoking duration. The authors reviewed the literature published before June 1992 on relative risks associated with smoking for heart disease, stroke, lung cancer, and chronic obstructive lung disease. They quantified the effect of variables such as age, amount smoked, and smoking duration on reported relative risks. The main reasons for the variation in reported relative risks were: misclassification of former smokers as never smokers, the use of mortality rate ratios rather than incidence rate ratios, a possible period effect suggesting increasing relative risks over time, and differences in the amounts smoked. It is far more likely that these factors are responsible for the observed variation between studies than that the variations reflect true biological differences between populations. Using relative risks from other studies is therefore justified in calculating a population attributable risk if the studies are carefully selected and address factors such as amount smoked and period effects.

"Health for all by the year 2000": a mere slogan or a workable formula?

In the last decade WHO launched its world-wide Health for All by the Year 2000 (HFA 2000) campaign. This has also been picked up by the WHO European Region and by individual countries within that region. In this context The Netherlands has started up work on a Health 2000 Report. In this article, the work on this report and its underlying model are carefully reviewed in the light of the HFA 2000 strategy, and the HFA 2000 goal is evaluated in the light of the health problems Western European countries are controlled with. The conclusion is that all three main elements of the HFA 2000 strategy are useful for long term health planning efforts in the European Region. Health for All by the Year 2000 is not a mere slogan but has proved to be a workable formula.

Computer-assisted health impact assessment for intersectoral health policy.

Intersectoral health policy implies negotiations with politicians outside the health sector. Health politicians have a stronger position if they can quantify health impact. In this Dutch case-study we used a computer simulation approach to answer the following questions: Which anti-tobacco intervention has the largest health gain? Will a commuter cycling policy result in any substantial health gain? What is the relative health gain of promoting higher consumption of vegetables and fruit? We concluded that substantial health gain can be achieved if cigarette packet price were to increase by 2 Dutch guilders. A commitment of all general practitioners to implement a smoking cessation intervention will result in a similar health gain. Stimulating commuter cycling could be a promising example of intersectoral health policy. Interventions to promote higher vegetable and fruit consumption will result in a relatively small health gain. Pros and cons of simulation models to support intersectoral health policy are discussed.

Targets as a tool in health policy. Part I: Lessons learned.

This article reviews the start of the use of targets as a tool in health policy, summarises the fruitful uses and frequently-heard objections, and proposes some conditions for successful health target setting. Targets as tool in health policy are based on the 'management by objectives' approach (1954). The use in health policy was possible due to advances in the use of epidemiology for public health purposes. It provisionally ends with the new health targets adopted by WHO in 1998. The setting and monitoring of health targets is one way in which a government can provide leadership, guidance and strategic direction for the health sector. These benefits, and others, will also be reviewed. Drawbacks - such as political accountability and the limited malleability of society - will also be discussed. To overcome most of the objections, the article ends with some SMART conditions for successful health target setting: specific, measurable, achievable, realistic and time-bound. When SMART conditions are met, political will and daring are the recipe for a successful health target approach.

The use of the waiting list in a fair selection of patients for nursing home care.

When health care resources are scarce, waiting lists may be used as a distribution measure in order to enhance the fair allocation of resources through selection of patients. In this study, the structure and use of a waiting list for a fair selection of patients for nursing home admission was studied. Qualitative research took place in two regions in the Netherlands, where scarcity exists in nursing home care. Selection meetings were attended and 39 health care workers were interviewed. Not only did waiting list criteria like urgency and chronology determine the final selection decision, but also efficiency and quality of care considerations (patients' preferences for particular nursing homes and nursing homes' considerations of matching the unit and work load). These considerations, their relative importance, and the resulting need for enforcement of the decision-making procedures, should be part of the discussion of patient selection. This acknowledges the complexity of the selection of patients.

Urgency coding as a dynamic tool in management of waiting lists for psychogeriatric nursing home care in The Netherlands.

Criteria are used to prioritise patients on waiting lists for health care services. This is also true for waiting lists for admission to psychogeriatric nursing homes. A patient's position on these latter waiting lists is determined by (changes in) urgency and waiting time. The present article focuses on the process and outcome of an urgency coding system in a fair selection of patients. It discusses the use of urgency codes in the daily practice of waiting list management and the related waiting times. Patients and their informal caregivers were followed from entry on the waiting list to admission to a nursing home. Caregivers were interviewed during the waiting period and after their relative's admission to a nursing home, and the formal urgency codes on the waiting list were monitored. Seventy-eight of the initial 93 patients were admitted to a nursing home. High urgency codes were commonly assigned and the waiting times were shorter for patients with higher urgency codes. Negative consequences of an urgency coding system, e.g. patients with less urgency not being admitted at all and patients not being admitted to the nursing home of their choice, could not be demonstrated. Patients without higher urgency codes were admitted after a mean waiting time of 28 weeks. It may be questioned whether this long waiting time is problematic, because satisfaction of the caregivers with regard to waiting times was not influenced by the actual waiting times. An urgency coding system enables health care professionals to react to changes in the situation of both patients and caregivers by adjusting urgency codes to influence the length of time until nursing home admission.

Burden of delayed admission to psychogeriatric nursing homes on patients and their informal caregivers.

OBJECTIVE: To assess the deleterious effects of waiting for admission to a nursing home on the state of health of patients and their informal caregivers, and on the burden of caring. DESIGN AND PARTICIPANTS: Prospective longitudinal study consisting of interviews with informal caregivers during the period on the waiting list and after admission of the patient to a nursing home. Analysis of patients' files on diagnosis, date of registration on the waiting list, and date of admission to nursing home. SETTING: Ninety three patients registered on waiting lists for admission to a psychogeriatric nursing home in two regions of Amsterdam. RESULTS: Seventy eight of the 93 patients were admitted to a nursing home. The burden on the caregivers declined after admission of the patient but depressive symptoms did not. After 6 months a subgroup of 19 caregivers whose relatives were still waiting to be admitted were interviewed. The health of these patients remained stable during this waiting period and only problems in activities of daily living increased. The burden on these 19 informal caregivers and their state of health remained stable during the waiting period. CONCLUSIONS: A decline in the state of health and a rise in the burden on caregivers during the waiting period did not occur. However, a decrease in the burden and an improvement in mental health could have started earlier if patients had been admitted earlier.

[Waiting lists for psychogeriatric nursing home admissions: insight into the problematic waiting times]. / Wachtlijsten voor psychogeriatrische verpleeghuisopname: inzicht in problematische wachttijden?

In this article the waiting list for psychogeriatric nursing home care has been described for a large town in the Randstad (Netherlands). A literature study on psychogeriatric waiting lists was conducted; in a qualitative research project the procedure for admission on the waiting list was studied; and in a files study the characteristics of patients on the waiting lists, the waiting times and factors influencing waiting time have been studied. During the research period (1991) 111 patients were admitted to a waiting list, including 8 patients for whom admission was considered to be very urgent. These highly urgent patients were all mildly demented and had a mean waiting time of nine days. Almost half of the patients who were considered 'normally urgent' were moderately demented. The normally urgent patients had a mean waiting time of fourteen weeks. Hospitalized patients waiting for admission to a nursing home, had a lower waiting time than patients with the same urgency who were waiting at home. In comparison to the norms (8 weeks), the mean waiting time was unacceptably long.

Who should decide? Qualitative analysis of panel data from public, patients, healthcare professionals, and insurers on priorities in health care.

OBJECTIVE: To explore the arguments underlying the choices of patients, the public, general practitioners, specialists, and health insurers regarding priorities in health care. DESIGN: A qualitative analysis of data gathered in a series of panels. Members were asked to economise on the publicly funded healthcare budget, exemplified by 10 services. RESULTS: From a medical point of view, both panels of healthcare professionals thought most services were necessary. The general practitioners tried to achieve the budget cuts by limiting access to services to those most in need of them or those who cannot afford to pay for them. The specialists emphasised the possibilities of reducing costs by increasing the efficiency within services and preventing inappropriate utilisation. The patients mainly economised by limiting universal access to preventive and acute services. The "public" panels excluded services that are relatively inexpensive for individual patients. Moreover, they emphasised the individual's own responsibility for health behaviour and the costs of health care, resulting in the choice for copayments. The health insurers emphasised the importance of including services that relate to a risk only, as well as feasibility aspects. CONCLUSIONS: There were substantial differences in the way the different groups approached the issue of what should be included in the basic package. Healthcare professionals seem to be most aware of the importance of maintaining equal access for everyone in need of health care.