Running Head: EAST SUSSEX 2010-2011 REPORT CRITIQUE

NHS East Sussex 2009-2010: Inquiry and Evaluation of Epidemiological Research Name Institution

EAST SUSSEX 2010-2011 REPORT CRITIQUE NHS East Sussex 2009-2010: Inquiry and Evaluation of Epidemiology

Introduction

Both the scientific value and the in formativeness of any medical design can be determined by a study design. The errors that are created during the designing of the study design cannot be corrected during or after the research. It is, therefore, vital for the care to be taken while choosing the research design to be used in any given research. How valid and reliable a study design matters a great deal, as far as the outcome of any research is concerned. The representativeness and comprehensiveness of data, as well has a great impact on the results of a study. The Validity of an assessment means the degree at which that assessment measures while reliability is the extent to which a certain measurement gives consistent results. Validity is dependent on the measurement that measures what it was designed for and not something else. Just becuase a measure can be reliable does not mean it is valid. However, validity and reliability can be similar when based on matters of degrees (Susanne, 2006). There are other concepts that should be put into consideration. This paper conducts an evaluation and inquiry into the annual report of the NHS East Sussex 2009-2010, in terms of health needs and health assessment.

Description of the Report

Epidemiological study designs fall into two categories; the observational study designs and the experimental study designs. The observation research designs include the cohort, the cross-section, the ecological and the case-controlled designs. Each study design represents the different way information is harnessed. The research question, concerns about the validity, ethical considerations and the efficiency of the method are key factors to put into consideration.

EAST SUSSEX 2010-2011 REPORT CRITIQUE In the annual report of the NHS East Sussex 2009-2010, the research method used was the retrospective cohort design. The design is a cohort because the population was categorized based on the rate of deprivation as most deprived and less deprived, followed by a study conducted to test various exposure levels as life expectancy, exposure to cancer cases, respiratory diseases, just to mention a few. The unit of analysis is the population and the individuals. The population under study includes the residents of the five districts of East Sussex, which include Hastings, Eastbourne, Walden, Rother, and Lewis.

The individuals in groups are used when dealing with those prone to smoking and other health related vulnerability. The design is a retrospective in the sense that the historical exposures are the unit under study. The selection of retrospective Cohort, as a study design for this study, was appropriate for this research because of the availability of study populations and records. It is also time saving and cheap to use the retrospective cohort study, especially when dealing with such a large population, compared to other methods such as experimental, crosssectional and prospective cohort study.

However, this design of study contributes to errors. First, there is little information available on the confounders, contacts for follow-up, exposures and outcomes since the design method used typically relies only on historical records that were not necessary designed for research purposes. Secondly, retrospective data make it difficult to identify the correct temporal relationship between the outcomes and the exposures. Thirdly, the study design used makes the research particularly prone to bias because the outcome occurs before the cohort is assembled, as well as before the exposures are assessed. The process of ascertaining the accuracy and reliability of the methods of measuring and the recording techniques is difficult.

EAST SUSSEX 2010-2011 REPORT CRITIQUE Basis of Evaluation: validity, comprehensiveness, representativeness and reliability of data

The aims of the study designs should be determining how the outcome relates with the exposure, given validity and precision with the use of minimum resources. Defining Validity as the lack of confounders and bias as an error that is committed by the investigator while conducting a study leading to a wrong association between exposure and disease, then in light of this data, its validity is lacking. The construct and statistical validities are the additional two types of validities. Statistical validity concerns the use of statistical methods and how those statistical methods are interpreted appropriately.

Construct validity, on the other hand, tests the extent at which the study tests that underlie the theoretical construct as intended. Construct validity is particular vital in development of measurement instruments, as well as the intervention. Internal validity concerns the extent to which the given results of the study are true, and if really it is the intervention that leads to behavioral change, or some other intervention factors. The external validity is concerned with the extent by which the results could be generalized to the population under study. Bias involves systematically distorting the real and true effect that comes due to the way a certain study is conducted. Often this leads to invalid conclusion about the working of the intervention.

While evaluating this study to ascertain the validity of the data, it is necessary to evaluate both internal and external validity of the sample selected. The following elements are important in confirming the validity.

First, was the target population identified?

EAST SUSSEX 2010-2011 REPORT CRITIQUE A good quality study needs to specify clearly the target population and be able to pull the intervention and the control participants from the very population. In light of the annual report for East Sussex, the researcher specified the target population as residents of East Sussex. In theory, in this study, the researcher might have targeted the same population for the control conditions and the intervention. However, in reality, he/she must have used the control participants from the five different districts i.e. from Hastings, Eastbourne, Wealden, Rother, and Lewis. This causes an increase in the risk that differences in the outcomes of the study would reflect the differences in people that are assigned to study conditions hence leading to a selection bias.

Secondly, were the inclusion and exclusion criterion explained clearly?

A good and quality study need to inform the reader the characteristics that people are required to be eligible for that study. Specifying the enrollment criteria could show that the researcher had clearly identified the target population and was thoughtful and systematic in the selection of the sample. It shows how well the sample can be reflecting the population. The researcher of the health inequalities in East Sussex failed to list the inclusion criteria but only relied on historical evidences that indicate the criteria used in grouping alcohol cases, tobacco cases, heart related cases, cancer cases in various districts. This increases generalization of the research.

In selecting of the sample, some of the salient questions that need to be answered as a way of testing the validity of the data used include: in inviting the participants to join the study, how did the researcher do the selection of the sample from the given population? Who did he or she invite the participants? Did the researcher follow same procedures that were followed in

EAST SUSSEX 2010-2011 REPORT CRITIQUE recruiting people to the control conditions and to the intervention? Were all the recruitment staff blind in the group assignment? Was the eligibility assessment done and if it was conducted then was is it done? Finally, how many participants were selected to take part in this study? An appropriate quality study should specify exactly how the researcher selected the participants to take part in the research. In this case, did he or she invite everyone within the population that met his or her criteria or just a sample of the eligible?

Evaluation of the Report

The researcher for East Sussex report relied on various reports which included graphs and maps to quantify health inequalities in East Sussex. However, these reports were limited with the data provided since they failed to provide any information of the participants who were selected to take part in the reported research. For instance, there is no information provided to show how participants were selected when finding out the index of deprivation in 2007, and this problem is reflected across in finding life expectancy, infant mortality, all age causal mortality, slope index inequality, cancer mortality and in circulatory diseases mortality for the East Sussex districts. Clearly, confidence within the internal validity of the given study lessens whenever the selection process is not fully described. Such omissions increase the likelihood that the study selection was not at all systematic hence it was biased (McDowell, 1987). For instance, did all hospitals have nurse indicators on duty seven days in a week for them to recruit all those affected by the range of diseases? If not then some individuals with the cancer, heart related diseases among others from some districts must have gone unnoticed.

There is little information available on confounders. Additionally, accuracy of the techniques used cannot be justified. There are various other factors other than health inequalities

EAST SUSSEX 2010-2011 REPORT CRITIQUE that can lead to differences in life expectancy, deprivation levels, and disability free-expectancy. Such factors that might alter the results are not taken into consideration. Differences might be due to problems such as disease, war, genetics and famine. In this research, it is also found an association between lifestyle and heart diseases and cancer cases. Among the factors identified to be contributing to lifestyle included, smoking, alcohol consumption, inadequate physical activities, and poor sexual and mental health. But there are other factors that contribute to lifestyle hence can, as well be the causes of increased heart diseases and cancer cases. For instance, research shows that loneliness and lack of support lead to increase in risks of cancer, heart diseases and viral diseases and hence high mortality rates. This is true especially when dealing with the ageing groups in the population. The researcher fails to take into consideration such factors. This implies that the conclusion reached in this annual report is not accurate hence the data used is not valid.

Representativeness of the data

There are various questions to answer in selecting a representative sample. First, does the target population a true representative of the population it is to be generalized? For a study to be considered good and quality, it should state the inclusion, as well as the exclusion rules in helping people to decide how well the study population seems to mirror their own. In light of the annual report for East Sussex, the researcher did not take into account such issues as stating the inclusion and the exclusion rules. However, his or her keenness in stating the conclusion and the recommendations allows people a chance to evaluate how well the study might have reflected the topic of interest i.e. health inequalities in East Sussex.

EAST SUSSEX 2010-2011 REPORT CRITIQUE Secondly, is the given sample unbiased or random representation of the population of interest? However much the sample matches the population of interest in terms of demographics i.e. age and ethnicity, at times a recruitment procedure makes the study sample to be a nonrepresentative population subgroup. In light of the East Sussex study, the researcher ensured full representation of the entire population. This is evident in the report because before the study, the population must have been divided into district subunits named as Hastings, Eastbourne, Wealden, Rother, and Lewis, and even in terms of the country like in the case of East Sussex, South Sussex and England. In using the techniques employed in the analysis of the data, it can be inferred that the presented data was divided into regions. For an instant, looking at life expectancy for the duration of years 2006-2008 in East Sussex, one can be able to tell that the given population was segmented into districts since data presented represents each district. The same in reflected when estimating the index of multiple deprivations in 2007 at levels of ALSOA in the classification of rural/ urban. It is the case with the technique of average MID scores for the rural and urban areas in East Sussex. More so, when dealing with possible life expectancy among the East Sussex districts, the researcher classified gains in life expectancy according to regions.

Thirdly, what is the proportion of the eligible invitees consented to enroll and were then randomized? Good quality study should enroll a high proportion of participants invited and known to being eligible for the study (Ezekiel, 2003). For cases where a large number of eligible participants refuse to come or otherwise failed to be randomized for other reasons, then the study sample can be a non-representative in selecting subgroup of the entire population. The degree to which this study in East Sussex was analyzed, it is purely subjective. Because of basing on the historical documents and methods of analysis employed by other groups, the researcher was not

EAST SUSSEX 2010-2011 REPORT CRITIQUE keen at outlining how the participants in every method used were selected and how eligible to the study they were. We are only told of the final association. For instant, nothing is told about the participant selection in the technique used to calculate the deprivation rates in East Sussex, neither is it for other techniques employed. This is a problem created in the choice of study design used that made everything rely of the historical documents.

Assumptions made in the study and report.

The methods of data collection assume a normal population distribution. This is indicated by the selection of random samples child care and respiratory infections data. The researcher conducts census in 5 representative districts to represent the entire East Sussex. Data collected is an appropriate population representative.

In the collection of respiratory infections data, the research focuses on men and ignores women and children (Miker 2010). They focus on active smokers and leave out the passive smokers. Those reported to be adversely affected by smoking are the low income group. This discriminates against the middle income group which also has smokers that need attention. The data collected on respiratory diseases is biased, thus, further research should be done. This shows the researcher had a keen interest in the low income group and men in particular. Their interest was to provide solutions to these low income groups that form the largest population (Draper 1991). They are also seen to have an interest in mal behavior when confronted with unemployment and a lot of idle time. It this light; an indirect signal is sent to economic planners in the government to address the problem of unemployment (East Sussex Annual report).

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EAST SUSSEX 2010-2011 REPORT CRITIQUE While collecting data on sexuality, again, sexual bias is noted. The reported cases of unplanned pregnancies are of teenage girls, where and who are the fathers? It shows that unplanned pregnancies are as a result of premature sex but fails to show the cases of unwanted pregnancies in marriage and sexual abuse cases (Miker 2010). These shows that the researcher was more interested in the plight of the girl child in the wake of poverty, low literacy levels, and imbalanced gender rights that favor the boy child at the expense of the girl. The lack of concentration on cases of sexual abuse and unwanted pregnancies in marriage show that the researcher is not concerned in the moral standards of the society. They are more concerned on the basic humanitarian issues that would affect an average low income moral society. The vices noted by the researcher are more individual destructive than social harming. The researchers, therefore, assumes that only teenage girls are affected by unplanned pregnancies and hence focuses on teenage pregnancies.

While collecting cancer data, the researcher zeros in on only two forms of cancer, bowel and lung cancer. Bowel cancer is reported to affect the affluent society to a greater extent, whereas lung cancer is prevalent among the poor (Draper 1991). This indicates types of lifestyles in the region. It shows that a large population is poor, and they lack the means to cater for medical expenses. As a result, deaths among the poor are high, and the researcher wishes to find a solution to help reduce death cases from cancer among the poor. Cervical cancer is quickly brushed over, and breast cancer in both men and women is not targeted. Cancer in children, which is on the rise, is not well addressed. The researchers, therefore, seem to be interested in cancers that arise from behavioral trends. They assume cancer affects only the elderly and more specifically men in the East Sussex region and ignore cancer in children, women and young people which reduces the mortality rate.

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EAST SUSSEX 2010-2011 REPORT CRITIQUE The researcher exhaustively handles mental health from age 5 to old age. The study shows the different ways that poor communication skills affect these age bracket and how low income affects the older people (Draper 1991). The data collected assume only two causes of mental ailments, poor communication skills and poverty locking out other factors such as self esteem in children and teenagers. It also wades off hostile parenting, poor feeding habits and disease that could cause depression in children below 5 years.

Evaluation of interpretations, conclusions and recommendations made.

The research shows that health inequalities go beyond genetics, lifestyle choices and access to services. Social and economic disparities also contribute. The cost of health can be measured in human terms as lives lost and years of disability free life. Economically, it can be measured in terms of the additional cost to the economy due to illness. This amounts to productivity losses of approximately 30-33 billion per annum, lost taxes lower welfare payments to the tune of 20-32 billion per annum and additional NHS cost of treating the inequality amounting to excess of 5.5 billion per year. To address the health needs is, therefore, a matter of justice since this is a preventable evil. The recommendation is to put in place both simple and sophisticated mechanisms to address these social economic challenges. Clear understanding of the gravity of each situation should be considered while solving the problem.

Respiratory diseases and cancer are ranked high amongst the contributors of the wide gap in life expectancy in the most and least deprived areas with the exceptions in the district and borough levels. The possible gain in life expectancy in the districts and boroughs are clearly indicated per disease in respect to specific issues affecting the region. For instance, a reduction in deaths caused by heart disease would buy a man 1-3 more years of life. To improve on the life

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EAST SUSSEX 2010-2011 REPORT CRITIQUE expectancy per ward in the twenty wards, the Joint Strategic Needs Assessment Program should be maintained and developed to support commissioning and improvement of health care and the reduction in inequalities in heath levels.

The key focus areas of the research are in alcohol, respiratory and circulatory diseases, cancer, obesity, mental health and welfare (Tannahill 2000). The main focus groups are children, the young and old people. To reduce deaths from these diseases, there should be a reduction in the variation, identification, treatment and support of patients regionally. Interventions should also be evidence-based, cost-effective and should focus on high priority areas and improve health access areas in marginalized societies (Carole & Brian, 2008). This will help reduce the health inequality and address the high demand for health care using the Children and Young Peoples Plan.

Recommendations

In achieving a sustainable health provision system, the government expenditure needs to expand greatly. This will require both internal borrowing via high taxation and selective credit controls to cater for recurring investment costs, and external borrowing to cater for infrastructural developments. These finances should go into funding the NHS and other strategic organizations that cater for the above mentioned needs (Bowling, 1997). The public sector should heavily invest in the establishment of health centers that will offer preventive, primary and specialized health.

The low income situation in the East Sussex requires an increase in the investment level. I would recommend the encouragement of foreign direct investment (FDI) via government and

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EAST SUSSEX 2010-2011 REPORT CRITIQUE economic incentives in the onset (Grice 2010/11). The short run costs of this will be loss of government control on policies geared towards investment and growth and the crowding out of some indigenous investors due to the huge economies of scale enjoyed by these FDIs.

East Sussex has a large population. These forms a pool of labor, which if trained will move the economy forward and improve the health sector (Grice 2010/11). The available experts in the region should be trained in the new strategy requirements, and focus on community groups should be used to educate the community on health issues. It is reported that few people with chronic illnesses are fully diagnosed, and those that are diagnosed do not go through with their full treatment programs (Katz, Peberdy & Douglas, 2000). The young people should be put through school. This will work backward and forward in educating the entire community. They will educate their old and motivate the young to get an education. Primary health care should be taught in school too.

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EAST SUSSEX 2010-2011 REPORT CRITIQUE References Bowling, A (1997), Research Methods in Health investigating health and Health Services, Open University Press. Buckingham Carole, M. & Brian, C. (2008), Validating Clinical Data Reporting With SAS Draper, P. (1991), Health through Public Policy: The Greening of Public Health. Green Print Ezekiel, J. ( 2003). Ethical and Regulatory Aspects of Clinical Research: readings and commentary Grice, D.( 2010), Reducing Health Inequalities in East Sussex. Sussex: East Sussex County Council. Katz, J., Douglas, J. & Peberdy, A. (2000), Promoting Health: Knowledge & Practice, London, Belgrave/ Milton Keynes. OUP McDowell, I. (1987), Measuring Health: A Guide to rating scales and questionnaires. Oxford, Oxford University Press Miker, G. (2010), Sex Differences in Children and Adolescent Mortality by Parental Education in Nordic Countries Susanne, P. (2006). Practical Guide to Clinical Data Management Tannahill, A (2000), Epidemiology & Health Promotion, in Bunton, R & MacDonald, G, eds. Heath Promotion: Discipline & Diversity. London, Routledge