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A tentative step towards healthy public policy

A tentative step towards healthy public policy
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  doi:10.1136/jech.2004.023697 2004;58;966-968 J. Epidemiol. Community Health   Michael Joffe and Jennifer Mindell A tentative step towards healthy public policy   http://jech.bmjjournals.com/cgi/content/full/58/12/966 Updated information and services can be found at: These include:    References   http://jech.bmjjournals.com/cgi/content/full/58/12/966#BIBL This article cites 10 articles, 8 of which can be accessed free at: Rapid responses   http://jech.bmjjournals.com/cgi/eletter-submit/58/12/966 You can respond to this article at: serviceEmail alerting top right corner of the article Receive free email alerts when new articles cite this article - sign up in the box at the Topic collections  (625 articles) Prevention and health promotion (2333 articles) Other Public Health Articles on similar topics can be found in the following collections Notes   http://www.bmjjournals.com/cgi/reprintform To order reprints of this article go to: http://www.bmjjournals.com/subscriptions/  go to: Journal of Epidemiology and Community Health  To subscribe to on 8 August 2005  jech.bmjjournals.comDownloaded from   Public health policy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  A tentative step towards healthy publicpolicy  Michael Joffe, Jennifer Mindell ................................................................................... More consistent attention to implementing healthy public policy,and amassing the evidence for it, are urgently required. H ealth has improved greatly inrecent decades, both in the devel-oped world and much of thedeveloping world. Nevertheless, manyhealth problems remain, and in parti-cular, social inequalities in health arenot diminishing. Recently there hasbeen considerable concern about therapid increase in obesity and relatedconditions such as adult onset diabetes, yet the debate remains largely phrasedin terms of health education and indi- vidual behaviour. In addition, somegrave health problems seldom evenenter public debate, as they are notincreasing—for example, we havebecome so accustomed to slaughterand maiming on the roads that roaddeaths are rarely even counted asnewsworthy. THE WANLESS REPORT In the United Kingdom, a recent reportfrom the Treasury (finance ministry),the ‘‘Wanless Report’’, 1 explores the ways that population health can beimproved and health inequalitiesreduced. This contribution to the healthdebate has a significance that goesbeyond the British context, as it deals with issues that are relevant throughoutthe economically developed world. Arguably they are even more importantin less well off regions, but the terms of the debate are considerably different inthat context and will not be furtherconsidered here.The report represents an importantstep forward—but also a step to theside. It builds on a previous report in2002, also by Derek Wanless, 2 on thefunding of the NHS, which consideredthat the recent substantial UK invest-ment in health care would lead to largehealth gains only if population healthalso improved significantly throughindividuals’ involvement in their ownhealth, ‘‘the fully engaged scenario’’.The focus of the more recent report is onhow to achieve this, the starting pointbeing that prevention is more costeffective than provision of health careto treat disease. It also accepts that pastand current public health approachesmay have contributed to wideninghealth inequalities.The report notes that the majordrivers of public health have beenknown since the 1970s, yet despite somesuccesses, implementation has at bestbeen partial and requires a step changein effort and achievement. In particularit notes that while the scientific justifi-cation for action is often strong, theevidence base on the cost effectivenessof preventive policies and their prac-tical implementation is weak, and thatthis is related to lack of fundingfor public health intervention research.Information is particularly scarce oninterventions that could reduce healthinequalities due to, say, smoking orobesity. The lack of a comprehensiveevidence base should not, however, bean excuse for inertia; rather, existinginitiatives should be evaluated as aseries of natural experiments.In summarising the roles and respon-sibilities of different agents, the reportrejects the view that all decisions shouldbe left completely up to each individual,as people may not have sufficientscientific information, may be unableto accurately balance risks and benefits,and may lack a supportive social con-text. This is particularly important inrelation to social inequalities in health.Shifting social norms is a legitimateactivity for government where it has setnational objectives for behaviourchange. The report concludes by review-ing the levers available to government—taxes, subsidies, service provision, reg-ulation, and information—with a parti-cularly lucid section on fiscal policies. THE MAJOR IMPACT OF HEALTHY PUBLIC POLICY  Nevertheless, the report places insuffi-cient emphasis on the extent to whichlarge health gains have historicallyresulted from healthy public policy, inthe sense of regulation, fiscal policy, andthe provision of reliable informationother than health education campaigns,as well as other types of initiative suchas infrastructure construction projects.Sometimes this is without even havinghealth improvement as a major objec-tive, as was originally the case withtobacco taxation.One of the most dramatic of allhistorical processes has been the declinein the major infectious diseases thatused to dominate society, especiallyaffecting the poor, which has occurredin all economically advanced societies.This was mainly attributable toimproved food supply and the provisionof sewerage and clean water, 3 together with socio-political action. 4 Similarmeasures remain a priority in poorregions of the world.Subsequent government actions havealso played an important part in improv-ing health. For example, in the UK thesehave included the Clean Air Act of 1956that put an end to the lethal smogs thathad occurred in London and elsewhereduring the earlier 1950s. While thehealth impact is only now beingassessed, 5 a ban on coal sales in Dublinin 1990 is estimated to have saved over350 lives a year in a population of lessthan a million. 6  A more recent UK example is a taxadvantage that was given to unleadedpetrol in 1989, which resulted in rapidlydeclining environmental lead levels, 7  with probable important benefits onthe neurological development of chil-dren, especially those from deprivedbackgrounds. 8 Other important trans-port related measures have been theintroduction of the breathalyser andspeed control, which have greatlyreduced road deaths and serious inju-ries. 9  And although health was not amajor motivating factor in their intro-duction, policy initiatives by the currentgovernment aiming at economic redis-tribution, such as the goal of fullemployment and the use of tax creditsto reduce poverty, are likely to have hadmajor beneficial health impacts. 10 There is a reason for the effectivenessof healthy public policy: Rose famouslypointed out that whereas identifyingpeople at high risk, for example, of raised blood pressure, and treating themindividually was a never ending task, aseach year more people would enter thishigh risk category, a ‘‘whole popula-tion’’ approach would produce a oncefor all change in the population, as longas it remained in effect. 11 This appliesparticularly strongly to healthy publicpolicy, because strategies that rely onhealth education can be interfered withby new fads such as the Atkins diet, orfears about immunisation with MMR (measles, mumps, and rubella) vaccine.In contrast, in the UK cholera has notreturned and tuberculosis (althoughincreasing) is rare compared with itsravages in the 19th century; smogs fromcoal burning have disappeared; lead 966  EDITORIALS  www.jech.com  on 8 August 2005  jech.bmjjournals.comDownloaded from   exposure remains low; alcohol andspeed related road casualties are lowerthan they were—although furtheraction here is warranted. 9 Inequalities People with more education and socio-economic resources tend to respondmore to health education, thereby tend-ing to increase inequalities. 12 Oneadvantage of healthy public policy isthat the impact is typically felt acrossthe whole population. Thus, withtobacco taxation, people on lowerincomes are more responsive to priceincreases. 12 However, healthy publicpolicy strategies do not inevitably reduceinequalities, and case by case analysis isneeded. For tobacco taxation, it dependson alternative cheaper sources of tobacco not being available, 13 Customsand Excise staff having sufficientresources to tackle smuggling and illicitsales of contraband, 14 and there beingsupport for smokers who remainaddicted (for example, through targetedcessation support and increased childbenefit). Otherwise, low income peopleincrease their expenditure on tobacco,leaving even less disposable incomeavailable for food, housing, and otheressentials. In this way social inequalitiesmay increase, and this has health andother implications. Such inequality isnot solely socioeconomic in srcin, as italso applies to those with psychologicalor psychiatric problems who use tobaccoas a crutch. The costs of healthy public policy interventions The financial costs of healthy publicpolicy interventions are typically com-paratively small. They can even generaterevenue, as with tobacco taxation. Whilethis can lead to public relations difficul-ties—with speed cameras beingattacked in the press as merely moneymaking devices, and the success of theLondon Congestion Charge Scheme por-trayed as a financial failure becausetraffic levels fell ‘‘too much’’—it canundoubtedly be an advantage.In other circumstances, the case foran intervention is that it redresseshidden costs. Thus, while the road lobbycompares what drivers pay in taxes withthe cost to government of providinginfrastructure, the true cost includesalso road deaths and injuries, air pollu-tion, etc. 9 Economists, includingWanless, call these wider costs to societythat fall outside the transaction betweendriver and government ‘‘externalities’’,and recommend taxation at a level that‘‘internalises’’ them. 1 15 To make thispossible, the analysis of health impactshas to be augmented by economic valuation of the various health (andother) outcomes. A small expenditure can be veryeffective. In early 1989, most UK cardrivers were reluctant to convert theirengines to lead free petrol; industry sawno demand for lead free pumps at petrolstations. A slight tax advantage for leadfree petrol in the Budget was followedby a rapid change in behaviour of bothgroups, with beneficial effects as notedabove. This raises another point:although likely to have been ‘‘profit-able’’ on the basis of internalising theexternality, this action was probably justifiable even if it were not: asWanless says, sometimes the healthgain outweighs the economic argu-ment—it is worth paying for. 1 THE NEGLECT OF HEALTHY PUBLICPOLICY  We have seen that healthy public policycan be highly effective and has animpressive track record, that it doesnot increase inequalities in the way thathealth education typically does, and thatit tends to have low costs. Nevertheless,implementation of healthy public policyinterventions is piecemeal. In addition,there is an apparent tendency in recentdecades for their scope to become moretentative, although still important.Even the Wanless Report, whileaccepting the role of healthy publicpolicy in tobacco control, does notproduce clear recommendations in areasof more recent concern such as obesity,nutrition, and physical activity. It con-siders a ‘‘fat tax’’, and subsidised gymmembership, which it rejects for goodreasons, but does not analyse diet andphysical activity in relation to existing orpotential policies in the food/agricultureindustry and transport.Why then is healthy public policy notroutinely considered as a major meansof tackling health problems? It could bethat governments are uneasy about the wider economic and social effects, and/ or the ideological reaction to suchinterventions. If so, these concerns needto be analysed, just as they are whenenvironmental criteria are consideredacross the broad range of governmentpolicy. Indirect ‘‘costs’’ and trade offs  Apart from the costs of implementationthat tend to be low, there are other typesof ‘‘cost’’ that have to be considered. As with the impact on social inequalities, acase by case analysis is required.The most important is employment.Even with a product as harmful astobacco, it needs to be recognised thatthe tobacco industry is an importantemployer in a few areas of the country.We need to consider whether reducingtobacco consumption would mean redu-cing employment. In fact, job loss hasbeen mainly attributable to automation,not lower production. 16 Furthermore, ascigarette production is not labour inten-sive, money spent by former smokers onother things generates more employ-ment: a 40% reduction in tobaccoconsumption would create about150 000 jobs in the UK. 16 There is alsothe ethical argument: most people would not oppose a road safety cam-paign to protect employment in the carbodywork repair industry. Principle and ideology  More recently, arguing for healthy pub-lic policy in the UK has had to deal witha libertarian reaction, summed up in thephrase ‘‘the nanny state’’, implying thatthe state is telling people what to do,thereby interfering with personal free-dom. This has introduced an unneces-sary defensiveness into attempts totackle current health priorities, such asrising obesity and associated conditions.When the health problem concerned isimportant, as with lung cancer, increas-ing obesity and related problems, orroad deaths and injuries, government‘‘interference’’ is more justified than forless serious and/or widespread condi-tions. Given sufficient explanation,action is likely to be acceptable if thecosts (of all kinds) are proportionate tothe benefits.While libertarian opposition is noth-ing new, it now tends to have adismissive tone, ignoring argumentsabout competing rights; for example,smoking bans in public places (endorsedby Wanless, subject to further evidence)can readily be defended in terms of freedom to breathe smoke free air. Thesame argument applies to other types of pollution, and to the right to consumefood free of excess hidden fats, sugar,and salt. It is analogous to the govern-ment’s accepted role of ensuring thatfood additives must be safe: the wholepopulation benefits, not just those withthe toxicological knowledge, time, andmotivation to scrutinise labels.Perhaps less reliance on telling people what to do, and more emphasis onmaking healthy choices easier, wouldfind readier acceptance. This wouldrequire a state that is clever, prudent,capable, and shrewd, in other words a‘‘canny state’’. It is more promising thansimply re-iterating the healthy livingmessages. IMPLEMENTATION Healthy public policy has an ample trackrecord despite never having been sys-tematically adopted by any government worldwide. Yet this marginalisationcontinues except in a few areas such as EDITORIALS  967  www.jech.com  on 8 August 2005  jech.bmjjournals.comDownloaded from   tobacco control and food safety. Admittedly the evidence base needs tobe improved, which requires morefinancial and institutional support forthe necessary research (a topic beyondthe scope of this paper), but we alreadyknow a great deal. For example, provid-ing good facilities increases cycling, andcycling benefits health. 9 Consumption of healthy food depends on its price andavailability 1 and these could be influ-enced by policies, for example, on taxesand subsidies. Food promotion canadversely influence children’s foodchoices, 17 and this could also beaddressed by government policy. Andthere are many more such examples.In this respect Wanless fails to graspthe nettle: the implementation model isseen as a health service function, pri-marily at the local level. This is not apurely UK problem; while the existenceof the British NHS encourages the viewthat improving health should be ahealth service function—that ‘the NHSshould become a ‘‘health’’ service not just a ‘‘sickness’’ service’—the confla-tion of health with health care is by nomeans confined to the UK. For example,the draft EU constitution states, ‘‘A highlevel of human health protection shallbe ensured in the definition and imple-mentation of all Union policies andactivities’’, but this is subsumed underthe heading ‘‘Health care’’. 18 (A similarprovision in earlier treaties has not beentranslated into practice.)For a report with a primary focus oneffectiveness and cost effectiveness it isodd that this view is accepted uncriti-cally (especially as the now highlydecentralised NHS structure is not wellsuited to this role). What is the evidencefor this being the best approach? Someevidence against the effectiveness of locally provided services is quoted inthe report (page137), but ignored whendrawing conclusions: in a prospective,controlled trial, TV antismoking adver-tising proved effective, whereas locallyorganised antismoking campaigning was not. 19 More consistent attention to imple-menting healthy public policy, andamassing the evidence for it, areurgently required. The Wanless Reporthas opened the door, but refuses to gothrough it.  J Epidemiol Community Health 2004; 58 :966–968.doi: 10.1136/jech.2004.023697   Authors’ affiliations...................... M Joffe, J Mindell,  Department of Epidemiology and Public Health, ImperialCollege London, London, UK Correspondence to: Dr M Joffe, Department of Epidemiology and Public Health, ImperialCollege London, St Mary’s Campus, Norfolk Place, London W2 1PF, UK; m.joffe@imperial.ac.uk Funding: none.Conflicts of interest: none declared. REFERENCES 1  Wanless D .  Securing good health for the whole population . London: HM Treasury, 2004.2  Wanless D .  Securing our future health . London:HM Treasury, 2002.3  McKeown T .  The role of medicine  . Oxford: BasilBlackwell, 1979.4  Szreter S . Rethinking McKeown: the relationshipbetween public health and social change.  Am J Public Health  2002; 92 :722–5.5  Hansell A  , Knorr-Held L, Best N,  et al. COPD mortality trends , 1950–1999 in England and Wales—did the 1956 Clean Air Act make adetectable difference ?  [Abstract].  Epidemiology  2003; 14 :S55.6  Clancy L , Goodman P, Sinclair H,  et al.  Effect of air-pollution control on death rates in Dublin,Ireland: an intervention study.  Lancet  2002; 360 :1210–14.7   Delves HT , Diaper SJ, Oppert S,  et al.  Bloodlead concentrations in United Kingdom havefallen substantially since 1984.  BMJ  1996; 313 :883–4.8  Pocock SJ , Smith M, Baghurst P. Environmentallead and children’s intelligence: a systematicreview of the epidemiological evidence.  BMJ  1994; 309 :1189–97.9  British Medical Association .  Road transport and health . London: British Medical Association,1997.10  Marmot MG . Tackling health inequalities sincethe Acheson Inquiry.  J Epidemiol Community Health  2004; 58 :262–3.11  Rose G .  The strategy of preventive medicine  .Oxford: Oxford University Press, 1992.12  Townsend J , Roderick P, Cooper J. Cigarettesmoking by socioeconomic group, sex, and age:effects of price, income, and health publicity.  BMJ  1994; 309 :923–7.13  Mindell J , Whynes DK. Cigarette consumption inthe Netherlands 1970–1995: does tax policy encourage the use of hand-rolling tobacco ? Eur J Public Health  2000; 10 :214–19.14  Joossens L , Raw M. How can cigarette smugglingbe reduced ?  BMJ   2000; 321 :947–50.15  Bannock J , Baxter RE, Davis E.  Penguin dictionary of economics.  6th ed. London: Penguin Books,1998.16  Buck D , Godfrey C, Raw M,  et al. Tobacco and jobs . York: Centre for Health Economics,University of York, 1995.17   Hastings G , Stead M, McDermott L,  et al.  Review of research on the effects of food promotion tochildren.  Final report, prepared for the Food Standards Agency  . Glasgow: Centre for SocialMarketing, University of Strathclyde, 2003.http://www.food.gov.uk/multimedia/pdfs/foodpromotiontochildren1.pdf (accessed 5 Jul2004).18  The European Convention .  Draft treaty establishing a constitution for Europe  . Brussels:The European Convention, 2003. http://european-convention.eu.int/docs/Treaty/cv00850.en03.pdf (accessed 5 Jul 2004).19  McVey D , Stapleton J. Can anti-smokingtelevision advertising affect smoking behaviour  ? Controlled trial of the Health Education Authority for England’s anti-smoking TV campaign. Tobacco Control   2000; 9 :273–82. Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Assessing psychosocial/quality of lifeoutcomes in screening: how do we do it better  ? Kirsten J McCaffery, Alexandra L Barratt  ................................................................................... High quality research on the psychosocial outcomes of screeningprogrammes is urgently needed.  A  ssessing non-medical outcomes of screening presents constant chal-lenges. Marteau and colleagues 1 offer some insight into the complexitiesof assessing non-medical outcomes intheir study of abdominal aortic aneur- ysm (AAA) screening. The paper reportsthat self assessed health (SAH) waslower among men who were found tohave an aortic aneurysm than men whodid not, yet baseline measurementindicated that much of this differencepre-dated screening. Poorer SAHseemed to predict having an aorticaneurysm. The authors suggest thatthe findings have implications for themethods used to assess psychologicalimpact of screening tests and warn usnot to erroneously conclude that pooreroutcomes are necessarily a product of screening, if baseline differences are notassessed.Marteau  et al ’s 1 findings are extremelyinteresting and raise important issuesfor the assessment of psychosocial orquality of life (QOL) outcomes in thescreening context. Adequate assessmentof psychosocial as well as medical out-comes, is crucially important, especiallygiven the potential of screening to detectinconsequential disease 2–4 but presents  Abbreviations:  SAH, self assessed health;QOL, quality of life968  EDITORIALS  www.jech.com  on 8 August 2005  jech.bmjjournals.comDownloaded from   many challenges. These have receivedcomparatively little attention. We haveidentified three main methodologicalconcerns: (1) the need for a controlgroup (preferably created by randomisa-tion); (2) the need for baseline andfollow up measurements; (3) the needfor reliable measurement tools withhigh criterion and content validity.The first concern, obtaining an ade-quate control group, perhaps presentsthe most difficulty. If our goal is toassess the impact of screening we needto measure the combined impact of thescreening procedure, follow up tests,and treatments. The best way to achievethis is to randomise people to bescreened or not screened and to measurethe psychosocial impact on everyone atmultiple times (see fig 1), in a way thatis analogous to the assessment of themedical outcomes of screening. 2 This would mean that, as well as establish-ing, for example, the mortality rate frombreast cancer (in a trial of mammogra-phy screening) in all those randomisedto screening and all those randomised tousual care, the investigators would needto measure average QOL effects in thesegroups as well. Investigators will thushave to ensure appropriate measures aretaken from those randomised to screen-ing who (1) do not respond to thescreening invitation; (2) test negative(including those who are truly negativeand those who later are discovered to befalse negatives); (3) test positive (againboth true and false positives), or fromrandom samples of people in each of these groups. Comparable measures willalso be needed in the usual care group,including in those who do and do notseek screening through alternative sys-tems. Some of the test positive group will in fact have inconsequential dis-ease, but as this is not identifiable on anindividual level, the only way to esti-mate the psychosocial impact of this isby comparison of the screened group asa whole with the usual care controlgroup. Clearly this will add to thecomplexity and challenges of data col-lection for randomised trials of screen-ing, but comparatively small samplesizes will be needed for psychosocialoutcomes (compared with medical out-comes). Furthermore, efficiencies maybe achievable by carefully designedsampling strategies. In summary, itshould be feasible to validly answerquestions about the real psychosocialimpact of screening in this way. Alternatively in some circumstancesother designs may be feasible. Forexample, people could be randomisedto receive or not receive their results andsubsequent tests and treatments, withfollow up of psychosocial outcomes.Such designs have commonly been usedin the past to evaluate screening for riskfactors such as high cholesterol andhigh blood pressure in terms of medicaloutcomes. 2 The second concern is the importanceof taking baseline and follow up mea-sures in both screened and unscreenedgroups. All psychosocial/QOL studiesobviously take measures after screening(point 3, see fig 1), and many, as inMarteau’s study, 1 take them before andafter testing (points 1 and 3). However, we have been unable to find studies thathave taken and reported measures atpoints 1, 2, 3, and 4 (see fig 1) or more.In particular, measures are rarely takenand/or reported among appropriate con-trols, at points 2 and 4. For example, astudy by Wardle  et al 5 assessed anxietyamong adults randomised to receiveinformation about sigmoidoscopyscreening and asked if they would beinterested to attend, or not, but followup measures were not reported in eitherarm.Thirdly, it is imperative to selectinstruments that adequately capturepsychosocial outcomes/QOL. Whatexactly constitutes psychosocial out-comes or QOL is often loosely defined.QOL itself has been described by manyresearchers as an atheoretical con-struct 6–10 and there is little clear con-sensus about what should or should notbe used to adequately assess it, particu-larly in the context of screening. Mostpsychological and QOL measures aredesigned for use in patient populationsand as such they are designed to capturerelatively large decrements in QOL/well-being. Screening may lead to compara-tively small decreases in psychological wellbeing/QOL but the decrement mayoccur across very large numbers of people so may still be important. Useof general psychological/QOL measuresmay not be sensitive enough to captureall outcomes. Some screening specificmeasures have been developed to com-bat this problem, for example, perceivedconsequences questionnaire, 11 cervicalscreening questionnaire, 12 and thePEAPS Q. 13 It has been argued recentlythat such measures should be used toassess screening outcomes rather thanother widely used generic measures. 14 However, the need for quantitativemeasures that can be equated to andcalibrated against other adverse healthoutcomes and events is crucial if we areto truly gain a measure of how screeningaffects the wellbeing of individual’s andpopulations. Once the psychosocial/QOLimpact of a screening test is adequatelycaptured it may then be weighed againstthe test’s medical outcomes to compre-hensively evaluate its worth as a screen-ing tool.Marteau’s study 1 also raises interest-ing questions about what representsQOL/psychosocial outcomes. Althoughconsensus on QOL/psychosocial mea-surement is limited, most evaluationsinclude some component of emotionaland social functioning with a measureof perceived health or physical function-ing sometimes also included. Marteau 1 reports only perceived health (SAH).The finding that SAH is poorer afterscreening in the group with screendetected aortic aneurysms is not at allsurprising. The purpose of screening isto identify people at increased risk of disease and inform them of their status. As such, the finding that a person ratestheir health as poorer after an abnormalscreening result is an inevitable conse-quence of screening, and perhaps maybe viewed as an indication that a personhas understood their test result, ratherthan a measure of psychosocial well-being.This brings us to Marteau’s 1 findingthat SAH was poorer before screening inmen who subsequently had aneurysmsfound, predicting AAA even afteradjustment for known risk factors. Thisis a puzzling finding—why should aperson’s perception of their health sta-tus predict whether they have anasymptomatic condition? It could bethat the results are explained by thefailure to measure smoking at baselineand adjust for it appropriately. However, Subjects eleigble for screening randomised to be invited to screening or not Screening group1 Baseline measures of psychosocial wellbeing3 Follow up measures of psychosocialwellbeing on all who were randomisedScreening:early detection and treatment of asymptomatic diseaseUsual care group2 Baseline measures of psychosocial wellbeing4 Follow up measures of psychosocialwellbeing on all who were randomisedUsual care:Diagnosis and treatment of symptomatic disease Figure 1  Design of randomised trials for valid estimation of the psychosocial impact of screening. EDITORIALS  969 www.jech.com  on 8 August 2005  jech.bmjjournals.comDownloaded from 
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