Screening induced by health services: impact and consequences. Ethical issues.

Segura-Benedicto A.

Departamento de Salud Publica de la Universidad de Barcelona. Barcelona. Espana.Area de Salud Publica e Investigacion en Servicios de Salud. Institut dEstudisde la Salut. Generalitat de Catalunya. Barcelona. Espana.

The main aim of screening is to identify people with an increased probability to benefit from preventive interventions, generally from secondary prevention but also from primary prevention activities. The goal is to facilitate early diagnosis and treatment in order to modify positively the prognosis (the former case), or to recognize people exposed to risk factors which increase the incidence rate of disease, and then to prevent the disease (the latter case).Good intentions are not enough to achieve good results in terms of effectiveness, safety, efficiency or equity. It is necessary to have a systematic assessment of the consequences of screening, particularly on the impact on peoples health and on the health services. Due to the diversity of types of screenings that are done, it is very difficult to estimate the net impact caused by their implementation. Moreover, the changes in the health of a population depend on many factors other than health service interventions. Thus,it is very important to determine the effectiveness and safety of the screening methods that are most frequently applied. Unfortunately, assessment of the benefits and the harm potentially caused by preventive interventions has not been done often. In Spain only a few partial assessments have been published,and they focus on the activities and the processes them selves rather than the final outcomes. Given that screening activities are carried out in health care services, and that the populations screened are mostly healthy people, the ethical issues have great importance when health policies are designed and implemented. Thus, it is recommended that screenings activities be analyzed applying the ethical principles of autonomy, benefit, safety and justice. If any screening program cannot reasonably satisfy these principles then they should beremoved from the list of public health activities that are financed by public resources. In the same sense, all screening procedures offered to the population must be subjected to a systematic evaluation of their effectiveness, safety,efficiency and equity in terms of how the procedure would be applied. Lastly, to achieve an effective implementation of the principle of autonomy as well thedesired goal of empowering the population to exercise some control over their determinants of health, it is recommended to explore new ways of achieving active citizen participation to establish preventive priorities and to assess the impact of screening interventions.

Does amblyopia affect educational, health, and social outcomes? Findings from 1958 British birth cohort.

J S Rahi, P M Cumberland, C S Peckham
BMJ 2006;332:820-825, doi:10.1136/bmj.38751.597963.AE

Centre for Paediatric Epidemiology and Biostatistics, Institute of Child Health,London WC1N 1EH. j.rahi@ich.ucl.ac.uk

OBJECTIVE: To determine any association of amblyopia with diverse educational,health, and social outcomes in order to inform current debate about populationscreening for this condition.

DESIGN, SETTING, AND PARTICIPANTS: Comparison of8432 people with normal vision in each eye with 429 (4.8%) people with amblyopia(childhood unilateral reduced acuity when tested with correction and unaccountedfor by eye disease) from the 1958 British birth cohort, with respect tosubsequent health and social functioning.

RESULTS: No functionally or clinicallysignificant differences existed between people with and without amblyopia ineducational outcomes, behavioural difficulties or social maladjustment,participation in social activities, unintended injuries (school, workplace, orroad traffic accidents as driver), general or mental health and mortality, paidemployment, or occupation based social class trajectories.

CONCLUSIONS: It maybe difficult to distinguish, at population level, between the lives of peoplewith amblyopia and those without, in terms of several important outcomes. Apressing need exists for further concerted research on what it means to haveamblyopia and, specifically, how this varies with severity and how it changeswith treatment, so that screening programmes can best serve those who have themost to gain from early identification.

Interventions for promoting booster seat use in four to eight year olds.

Cochrane Database Syst Rev. 2006 Jan 25;(1):CD004334.
Ehiri JE, Ejere HO, Magnussen L, Emusu D, King W, Osberg JS.

BACKGROUND: Public health and traffic safety agencies recommend use of booster seats in motor vehicles for children aged four to eight years, and various interventions have been implemented to increase their use by individuals who transport children in motor vehicles. There is little evidence regarding the effectiveness of these interventions, hence the need to examine what works and what does not.

OBJECTIVES: To assess the effectiveness of interventions intended to increase acquisition and use of booster seats in motor vehicles among four to eight year olds.

SEARCH STRATEGY: We searched the Cochrane Injuries Group's Specialized Register, the Cochrane Central Register of Controlled Trials, MEDLINE (January 1966 to April 2005), EMBASE (1980 to April 2005), LILACS,Transport Research Databases (1988 to April 2005), Australian Transport Index(1976 to April 2005), additional databases and reference lists of relevant articles. We also contacted experts in the field.

SELECTION CRITERIA: We included randomized and controlled before-and-after trials that investigated the effects of interventions to promote booster seat use.

DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data.Study authors were contacted for additional information.

MAIN RESULTS: Five studies involving 3,070 individuals met the criteria for inclusion in the meta-analysis. All interventions for promoting use of booster seats among 4 to 8 year olds demonstrated a positive effect (relative risk (RR) 1.43; 95% confidence intervals (CI) 1.05 to 1.96). Incentives combined with education demonstrated a beneficial effect (RR 1.32, 95% CI 1.12 to 1.55; n = 1,898).Distribution of free booster seats combined with education also had a beneficial effect (RR 2.34; 95% CI 1.50 to 3.63; n = 380) as did education-only interventions (RR 1.32; 95% CI 1.16 to 1.49; n = 563). One study which evaluated enforcement of booster seat law met the criteria for inclusion in the meta-analysis, but demonstrated no marked beneficial effect.

AUTHORS' CONCLUSIONS: Available evidence suggests that interventions to increase use of booster seats among children age four to eight years are effective. Combining incentives (booster seat discount coupons or gift certificates) or distributionof free booster seats with education demonstrated marked beneficial outcomes for acquisition and use of booster seats for four to eight year olds. There is some evidence of beneficial effect of legislation on acquisition and use of booster seats but this was mainly from uncontrolled before-and-after studies, which did not meet the criteria for inclusion in the meta-analysis.