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statistical modellina. In: Dean K, ed. Population IteaIth retearch: linkina theory and methods. London: Sase, 1993: 16G-80. 9 Nesselroade JR. Hershberger SLĀ ...
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N CET THE I_~~f\~ Volume 343, Number 8895

Population health looking upstream In 1985, Smithl bemoaned the lack of distinctive theory in modem epidemiology and likened the products of the discipline to "a vast stock-pile of almost surgically clean data untouched by human thought". Research on the health of populations is still dominated by experimental designs based on simplistic notions of causality that try to remove the variation and complexity of real-life health and disease processes. Smith's epidemiological vacuum has also resulted in an exaggerated focus on risk factors-"any suggested positive or inverse association" with the outcome under study2-and in the equation of risk with causation. Attribution of causal status to risk factors defined in this way has led to wasteful investment of public money in large intervention trials that are incapable of achieving their stated aims. Despite these reservations, epidemiology has much to offer. While the necessary theoretical developments are taking place, even superficial shifts could add substantially to its effectiveness. Examples include the need for research directed towards exposures rather than outcomes-what diets are least likely to causediseaserather than how cholesterol affects the hean-and examination of the relations betWeen proposed pathogens and allcause rather than, say, heart disease mortality. Nevertheless, development of a knowledge base adequate to sustain research and action in public health well into the next century will require a breadth and depth of vision hitherto lacking in those parts of universities and health services where work on the health of populations is funded, researched, taught, and acted upon. These themes formed the basis of an international multidisciplinary workshop organised last year by the Nuffield Institute for Health, University of Leeds, in collaboration with the World Health Organization (WHO) Regional Office for Europe and Yorkshire Health.) One product of this workshop was the Leeds Declaration,' launched at a follow-up conference in November, 1993, "in the expectation that it will be used' as a focus for discussion and debate in the widest arena". The first of the Declaration's ten principles for action on population health research and practice

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refers to the urgent need to refocus "upstteam"-a

reference to me metaphor about me villagers who devised ever more complex technologies to save people from drowning, rather man looking up-river to see who was pushing mem in.' There is a need to move away from me almost exclusive focus of research on individual risk, toward the social structures and processes within which ill-health originates, and which will often be more amenable to modification." Several of the principles emphasise me limitations of experimental and other current quantitative research models of population health. This discussion deserves attention from several linked perspectives. First, we now recognise the importance of interdisciplinary resear~h that integrates meory and methods and that builds on new analytical models.7 Examples include me value of graphical interaction statistical techniques for modelling the complexity of causal processes,' and psychological research on intraindividual variability for illuminating distortions in health status measurement.. Second, the potential contribution of qualitative methods to population health research

remains seriouslyundervalued.10,11 Appropriateness of the methods is crucial to effectivenessin research. Both in essential upstteam work (eg, on unhealthy public policy" or the social causation and patterning of disease12)and in downstream areas (the cultural influences that shape the way that risk and illness are expressed, recognised, and dealt with I') qualitative approaches such as ethnographic interviewing, participant observation, case-studies, and focus groups are commonly methods of choice. In many instances the best approach is a combined study design-application of qualitative techniques to provide funher insight into the meaning of quantitative findings, or use of quantitative methods to improve the generalisability and inferential strength of qualitative results. Often the value added by qualitative research is the addition of substantive to statistical significance." Most imponant, qualitative research is in principle just as hard, rigorous, and self-critical as quantitative research. The Leeds Declaration separately emphasisesthe imponance of lay knowledge and perspectives to

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public health research. Despite widespread recognition of the importance of the subjective domain in health, epidemiologists often profess that culture distorts "natural" behaviour and that there must be some underlying health reality that can be measured objectively. Yet lay perspectives and knowledge cannot be ignored. In participatory research,'4lay people work alongside the experts in undertaking hypothesis generation, study design, research implementation, and policy development. WHO has recommended that "research should provide ample opponunities for the people affected by the studies to take part in defining their aims, conducting the investigations and using the results". I' The Declaration also calls for research to explore the factors that keep some people healthy despite the most adverse circumstances. In a world where the persistence of health inequalities remains one of the few certaintiesl2 this is an important area for study. The focus required here is on salutogenesisl6-the causation of health rather than of disease-and on the development of an epidem-

iology of health17 to study the population aspects. Both are long overdue.

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Smith A. The epidemiological basis of community medicine. In: Smith A, ed. Recenl advances in community medicine 3. Edinburgh: Churchill Livingstone, 1985: 1-10. Hopkins PN, Williams RR. A survey of 246 SuggeSledcoronary risk facton. Athm>sderosis1981; 40: I-52. !.Dna AF. Undentandina health and disease:towards a knowledge base for public health action. Leeds: Nuffield Instirute for Health, Univenity of Leeds, 1993. Di~ons for health: new approaches to population health research and practice. The ueds Declaration. Ueds: Nuffield Institute for Health, Univenity ofUed., 1993. McKinlay JB. A case for refocusing upstream: the political economy of illness. Proceedings of American Hun Association Conference on Applying Behavioural Science to Cardiovscular Risk. Seattle: American Hun Association, 1914. McKinlay lB. The promotion of health through planned sociopolitical change: challenges for research and policy. Sac Sa Mtd 1993; 36: 109-11. Dean K. Integrating theoty and methods in population health research. In: Dean K, ed. Population health research: linking theoty and methods. !.Dndon: Sage, 1993: 9-36.

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What are the overall implications of this new approach? The upstreamers are not merely calling for the development of new theory and practice in epidemiology. The upstream way also acknowledges the contribution of social sciences and other disciplines in collaborative research and in the knowledge-base for public health. Indicators of success in the adoption of this pluralist approach must be monitored. They include the staffing of academic departments and public health research units; the change in focus of national and regional research and development funding; and above all, the quality of research into prevailing causes of ill health.

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8 Whittam I. Graphicalinteractionmodels:a newapproachfor statistical modellina. In: Dean K, ed. Population IteaIth retearch: linkina theory and methods. London: Sase, 1993: 16G-80. 9 Nesselroade JR. Hershberger SL Inuaindividual variability: methodological issuesfor population health research. In: Dean K, ed. Population health research: linking theory and methods. l.Dndon: Sage, 1993: 74-94. 10 Pope C, Mays N. Opening the black box: an encounter in the corridon oflteaIth servicesresearch. BA{JI992; 306: 31~20. II Chaput de Saintonge M, PosesRM. Health serVicesresearch. 8MJ 1993; 306: 797. 12 Townsend P, Davidson N, Whitehead M, eds.lnequalities in health: the Black repon and the health divide. 3rd rev ed. Harmondswonh: Pensuin, 1992. 13 Davison C, Smith GD, Frankel S. Lay epidemiology and the prevention paradox: the implications of coronary candidacy for health education. SociolH.aJth i11nas1991; 13: 1-19, 14 Starrin B, SvenssonPG. Panicipatory research: a complementary research approach in public health. Er J Publ H.aJth 1991; 1: 29-35. 15 World Health Organization, ReIionaI Office for Europe. Priority research for health for all. Copenhagen: WHO, 1988. 16 AntonOYlky A. A call for a new question-.alutogenesis-and a proposed answer-tbe senseof coherence.J Pm1 p,ycIIol1984; 2: 1-13. 17 Brown VA. Towards an epidemiolocy of health: a basis for planning community health programs. H.aJth Po/iey 1985; 4: 331-40.

In 1992 in the light of the two highly publicised cases (of Cox and Bland), the House of Lords established a Select Committee with special reference to euthanasia and treatments regarding the end of life. The Committee's repon was published this week.' The Committee was immediately faced with several dilemmas. As medical science advances, treatment decisions become more complex for all involved. For competent patients, making a decision has its difficulties; for those who care for incompetent patients, the decisions are even harder. Since competent patients are encouraged to exercise their autonomy and to be an integral pan of the decision-making process, the Committee commended the use of advance directives for assisting healthcare teams in making decisions about appropriate treatment. However, the Committee concluded that legislation was not required but suggested instead that the colleges and faculties develop a code of practice so that doctors are suitably informed. While advance directives can be beneficial, the Committee was aware that they are not without complications themselves. With regard to incompetent patients, attention was focused on the case of Tony Bland, who was in a persistent vegetative state for three years. The Committee was concerned that decisions about treatment should always be governed by the best interest of the patient. Doctors and nurses should consider the balance of burdens and benefits in order to facilitate the decision as to whether a

Vol 343. FtbNarv 19. 1994