text: Chapter 11.3 Measurement of variance in health state valuations in Phnom Penh, Cambodia Ritu Sadana Introduction Initiated in 1992, the Global Burden of Disease (GBD) Study was con- ducted at the request of the World Bank and in collaboration with the World Health Organization (WHO) to develop a set of consistent esti- mates of disease and injury rates for 1990, as well as to develop a com- parative index of the burden of each disease or injury, either from premature mortality or time lived with less than perfect health. This com- parative index is the summary measure of population health, the disabil- ity-adjusted life year (DALY) (Murray and Lopez 1994; WHO 1996; World Bank 1993). By 1998, three volumes of the GBD Study's method- ologies and final results were published on behalf of the World Health Organization and the World Bank (Murray and Lopez 1996a; 1996b; 1998), among other publications highlighting key findings or methods (Murray and Lopez 1996c; 1997a–d). The GBD Study's methods and findings have generated considerable discussion in the literature and in- ternational forums, as well as within the organizations collaborating on the study (for example Anand and Hanson 1997; Barker and Green 1996; Paalman et al. 1998; WHO 1998). The potential normative use of the GBD study's findings by WHO, the World Bank and national governments has raised concerns on the comparability and interpretation of findings across regions, cultures and socioeconomic groups, as well as on the policy rel- evance and implications for resource allocation in different health system contexts. Much of the debate centres on the construction of DALY as a summary measure of population health, in particular the explicit social values in- corporated within DALY. These include social values for severity weights for disability (e.g. disability weights for over 400 different health states partially based on valuations of 22 indicator health states), the discount rate for future health, age-weights across the life cycle, and target expect- ancy of life. This chapter reports on an empirical investigation of (i) 594 Summary Measures of Population Health whether the DALY protocol to elicit valuations for indicator health states may be replicated among non-health professionals in a developing coun- try; (ii) whether differences exist between valuations of health states ob- tained from individuals with different demographic characteristics or health experiences; and (iii) whether differences exist between health and non-health professionals' valuations. Background A severity weight is a quantified valuation of time lived in a less than perfect health state compared to time lived in perfect health. Measuring severity weights makes it technically possible to compare years of life lost due to premature mortality and years of life lived in health states worse than perfect or full health.1 This comparison is necessary in the construc- tion of summary measures of population health as morbidity and mortality are combined in a single index. Several approaches have been used to obtain severity weights for use within summary measures of population health or within cost-effectiveness studies: investigators may assign arbi- trary weights; expert panels may estimate weights; studies may incorpo- rate weights published in the literature; researchers may estimate the revealed (implicit) values based on policies or other social decisions such as current funding or resource allocations and then assign disability weights; or health state valuations may be elicited through primary data collection and severity weights subsequently assigned. Several methodological issues arise in the literature reviewed elsewhere (see Sommerfeld et al. chapter 11.1 in this volume): a few relevant to this study are briefly noted. The first is whose values should be used in the con- struction of severity weights. Empirically there is growing evidence that different groups, such as health care professionals, patients experiencing health states to be valued, lay care givers and the general public, often provide different values for the same health state (Ashby et al. 1994; Nord 1992), akin to differences found in the measurement of health (Pierre et al. 1998). Few discuss why valuations may differ given different socioeco- nomic experiences, health status, asymmetry of information on health, and professional or political agency. A second issue is what valuation method should be selected. A range of methods have been used to elicit valuations of health states, including the visual analogue rating scaling, magnitude estimation, individual trade- off methods such as the standard gamble or time trade-off, willingness- to-pay and social trade-off methods, including the person trade-off (see chapter 9.1 in this volume for details). Different approaches tend to re- flect different disciplinary traditions and applications: for example, the standard gamble approach is preferred by economists as it is based on utility theory, supposedly provides valuations with interval scale proper- ties, and underlines that risk is involved in the decision-making process, whereas the person trade-off method is favoured among those preferring Measurement of variance in health state valuations 595 to use a method that also simulates reality rather than a game, as this method directly asks individuals to allocate scarce resources among people. Although not necessarily providing valuations with interval scale proper- ties, the visual analogue rating scale is the quickest method to obtain valuations and also the most commonly used (Krabbe et al. 1997). All methods assume individuals or groups may provide their preferences for time lived in a less than perfect health state—hypothetical or experienced health states—through a questionnaire, interview or exercise (Shibuya 1999) and that a single valuation exists for each health state. Those de- veloping and applying methods to value health states have not conducted extensive qualitative investigations to provide greater insight on the ac- tual meaning and interpretation of valuations obtained. Not surprisingly, research documents that different methods produce different valuations for the same health state (Dolan et al. 1996; Krabbe et al. 1997). The third issue is how to describe a health state and communicate it to those who will value the health states. Conceptually, what is to be valued needs to be specified. This not only includes the health state, but also what the severity weight should or should not reflect. Empirically, two broad approaches exist: (i) develop a label and short qualitative description specific to each health state; or (ii) develop a classification system based on a series of domains that can be used to describe a broad range of ge- neric or specific health states in a systematic way (see Sadana, chapter 7.1). Table 1 provides examples of these different approaches. Again, not sur- prisingly, research shows that using different methods to describe and com- municate health states may influence the valuations obtained (Llewellyn-Thomas et al. 1984). A fourth issue is that in addition to the specific method2 or description of health states selected, the approach taken may be subject to a wide range of significant biases due to (i) the framing of questions; (ii) heuristic de- vices used by individuals to simplify complex cognitive tasks; and (iii) other details concerning the protocol employed, including the number and range of health states selected to be valued (Tversky and Kahneman 1981). Yet most studies do not discuss if valuations for health states obtained are biased by the overall approach taken. Furthermore, as there is no gold standard for the valuation of health states, the reliability of methods is often tested in lieu of validity—except for convergent validity—similar to the measurement of health status (see Sadana, chapter 7.1). Several have proposed different criteria for severity weights incorpo- rated within summary measures of population health for comparative use across populations. These include that weights should be "non- arbitrary…scientifically measured values" (Richardson 1994); that they should be "invariant over time and invariant between countries" (chap- ter 9.1); and that given that information contained within summary mea- sures of population health may be used towards the social allocation of scarce resources, severity weights should reflect population-based values (Nord 1995). 596 Summary Measures of Population Health Table 1 Standardized health state description approaches and examples Type Example Health state specific label; Breast cancer, second stage, under radiotherapy, qualitative with moderate weakness. Health state classification: I am in the age range of 40–60 years. I have been tired holistic narrative description; and weak. I walk slowly and travel outside the house is generic, qualitative difficult. Much of the day I am alone, lying down in my bedroom. Social contact with my friends is reduced. Health state classification: holistic Age: 40–60 year old taxonomic description; generic, Main activity: employee or housekeeper qualitative Mobility: travel with difficulty Physical role: walk with limitation, perform self-care Social role: social contact reduced Symptom/problem: general tiredness, weakness, weight loss Health state classification: 21322 [corresponding to a health state classification decomposed taxonomic system of 5 domains with 3 levels within each domain, description; generic, quantitative e.g. the EQ5D] Mobility: Level 2: I have some problems walking about Self care: Level 1: I have no problems with selfcare Usual activities: Level 3: I am unable to perform my usual activities Pain/discomfort: Level 2: I have moderate pain or discomfort Anxiety/depression: Level 2: I am moderately anxious or depressed Note: adapted from Llewellyn-Thomas (1984). Objectives In developing countries, the validity and reliability as well as the feasibil- ity and acceptability of implementing different methods and approaches to obtain health state valuations, have neither been systematically inves- tigated across representative samples of populations, nor simply among non-health professionals in any given population. This study therefore set out to provide some empirical evidence concerning the feasibility of ap- plying methods to elicit health state valuations and the reliability of re- sults across different groups of non-health professionals, for indicator conditions in a developing country. Specifically, the objectives of this study are to test (i) whether the DALY protocol to elicit valuations for indicator health states may be replicated among non-health professional women in Phnom Penh, Cambodia; (ii) whether differences exist between valuations of health states obtained from women seeking health services or residing in the community, or by age or number of school years completed; and (iii) whether differences exist between international health professionals' valuations of health states Measurement of variance in health state valuations 597 obtained for the GBD study based on the DALY protocol for measuring severity weights and those obtained from Cambodian women participat- ing in this study. Review of the GBD study protocol to measure severity weights incorporated within DALYs Conceptual framework Disability incorporated within the GBD Study is based on the conceptual framework of impairments (conditions and sequelae), disability (with different levels of severity) and handicap (social and economic conse- quences) found within the 1980 draft of the WHO International Classi- fication of Impairments, Disability and Handicap (ICIDH)3 (WHO 1980). Disability is defined in terms of the impact on the performance of the individual, and handicap in terms of the context of the overall conse- quences which depend on the social environment. The disability in DALY is based on this definition, rather than impairment or handicap (Murray 1994; 1996; Murray and Acharya 1997). The GBD study justifies the conceptual emphasis on disability due to the need for international com- parability requiring the treatment of "like outcomes as like" regardless of the particular context of disability or characteristics of the individual beyond age and sex. However, in practice, the approach implemented to obtain valuations for indicator health states used a construct "somewhere between disability and handicap" (Murray 1996) and the actual interpre- tation of the severity weight is described as the "average level of handi- cap stemming from each condition" that does not take into account age, sex or other characteristics (Murray 1996 pp. 38–39). Nevertheless, the term DALY reflecting disability, rather than HALY reflecting handicap (Evans and Ranson 1995/1996), is retained. Selection and description of health states First, 22 indicator conditions were selected from the 483 disabling sequelae selected for incorporation in the GBD study, in order to cover a wide range of disabilities and severity including those related to physical, mental, social functioning or pain. Short qualitative health state specific labels for each of the 22 indicator conditions are standardized and described for one year duration. For example, severe migraine is described as "imagine a person with a continuous severe migraine for one year. This individual would effectively be bed-ridden and unable to undertake any organized physical or mental activity. This condition is intended to be the proxy indicator for severe pain" or below-the-knee amputation, described as "in an individual without a prosthesis but with the basic aids, such as crude crutches, that are available in all societies" (Murray 1996: p. 94). 598 Summary Measures of Population Health Selection of participants A group of 12 international health professionals (7 men and 5 women) representing each of the six WHO regions, were selected as participants for primary data collection at the World Health Organization. Accord- ing to the GBD study, experts are selected in order to minimize efforts needed to describe and communicate each health state and maintain the focus on severity rather than the prevalence of each condition. Valuation method and approach A formal assessment method to elicit health state valuations for 22 indi- cator conditions using the person trade-off (PTO) method4 was designed that took approximately eight hours to complete for all 22 indicator con- ditions. The specific variant of the PTO method developed was designed to obtain internally consistent valuations, to minimize framing effects, and to promote group consensus (Murray 1996; Murray and Acharya 1997). The PTO method developed, however, is conceptually and cognitively demanding, and requires stamina to sustain interest in completing the exercise for all 22 indicator conditions.5 The facilitator's role is described as "critical", and must provide "constant encouragement" to complete the exercise and to "challenge individuals to search for their own valuations based on careful reflection" (Murray 1996). The study documents a high degree of correlation of health state valuations within the 12 member expert group in Geneva using the PTO protocol, as well as in compari- son with the pooled results of nine other group exercises with health pro- fessionals from different regions of the world (e.g. using the same protocol and facilitators). Although highly consistent ordinal rankings and valua- tions of health states across groups are achieved for the 22 indicator con- ditions, potential differences by age, sex, professional specialization, nationality or other characteristics of the expert participants are not provided. Assigning severity weights Within the GBD study, DALY assigns a value of 1 to years of life lost due to premature mortality, and 0 to perfect health. Time spent in a less than perfect health state is assigned a severity weight between 0 and 1. Health states valued worse than death are not allowed. To assign severity weights to each of the 483 non-fatal health outcomes incorporated within the GBD study, weights were assigned using a two step process. First, severity weights for each of the 22 indicator conditions generated from the Geneva valuation exercise were arbitrarily divided along the spectrum from health to death, into seven classes of severity noted in Table 2. Second, for the 483 conditions and sequelae, magnitude estimation and group consensus are used to estimate their distribution across the seven classes of disabil- ity using the 22 indicator conditions allocated to each class as pegs on the Measurement of variance in health state valuations 599 Table 2 Disability class, severity weights and 22 indicator conditions: DALY protocol Disability class Severity weight Indicator condition 1 0.00–0.02 Vitiligo on face; weight for height less than 2 SDs 2 0.02–0.12 Watery diarrhoea; severe sore throat; severe anemia 3 0.12–0.24 Radius fracture in a stiff cast; infertility; erectile dysfunction; rheumatoid arthritis; angina 4 0.24–0.36 Below-the-knee amputation; deafness 5 0.36–0.50 Recto-vaginal fistual; mild mental retardation; Down syndrome 6 0.50–0.70 Unipolar major depression; blindness; paraplegia 7 0.70–1.00 Active psychosis; dementia; severe migraine; quadriplegia Source: Murray (1996). scale from perfect health to near death by the same 12 international health experts in Geneva. Age-specific severity weights for untreated and treated forms for each of the 483 sequelae were then estimated. No further de- tails on the second step of the methodology are published. Developing and testing methods Conceptual framework One aspect of replicating the DALY protocol was to determine whether local conceptions of the severity of health states overlap with the GBD study's conceptual focus on disability or practical interpretation reflect- ing "somewhere between disability and handicap". Qualitative group dis- cussions (n = 10, with over 100 participants) with women aged 15–54 selected from urban and rural communities, in-depth interviews (n = 33) with women aged 15–54 with reproductive health conditions, physical disabilities or psychiatric conditions, and key informant interviews (n = 15) with male and female modern and traditional health care providers and community leaders, informed the development of a local conceptual frame- work for the burden of illness and disease (Sadana 2001). Based on these qualitative investigations, the severity of health states (i.e. morbidity6 and associated disability) included notions of social or economic consequences and other contextual factors, such as personal attributes, social status, previous illness history, household circumstances and community context, not only pain or physical or cognitive disability. Clearly, this local conceptual framework is broader than disability as conceptually defined within the GBD Study, as it explicitly incorporates notions of handicap. In this study, the conceptual understanding of what is to be valued concerning each health state (and the meaning of the se- verity weight), explicitly incorporates both disability and handicap. 600 Summary Measures of Population Health Selection of indicator conditions and description of health states The original goal was to use all 22 indicator conditions from the DALY protocol and some 5 additional reproductive health state indicators7, iden- tified by individuals participating in the qualitative phase of the study. Through pretest group and individual exercises with women aged 15–45, all 22 indicator health state conditions and some 20 additional reproduc- tive health states were tested. The selection of indicator conditions for this study in Cambodia was guided by the following criteria: (i) whether stan- dardized qualitative health state specific labels as developed for the DALY protocol were understood easily by non-health professional participants; (ii) if not all 22 indicator health state conditions from the DALY proto- col are selected, at least one indicator condition from each of the seven classes of disability is selected; (iii) indicator conditions that represent a broad range of health states including a range of severity covering physi- cal disability, cognitive function, mental health, pain and discomfort as well as conditions with complex social responses; (iv) inclusion of two anchor conditions, representing potentially the worst and best health states as defined locally; and (v) less than 30 total indicator conditions, consid- ered the maximum number manageable for a group or individual valua- tion exercise. Based on these criteria, 11 of the original 22 GBD indicator conditions were selected, along with an additional 15 reproductive health indicators, noted in Table 3. Twenty-six hypothetical health states plus the individual's own health state were therefore selected for valuation. Identical health state descriptions are used for the 11 indicator condi- tions from the DALY protocol with the exception of also adding the Khmer lay term for each condition in an effort to improve communication of the health state to non-health professionals. Similar qualitative health state specific labels are used to describe the 15 reproductive health indicator conditions. For death, the potential worst state, most participants during the pretest asked what type of death.8 In order to provide consistent re- sponses by the facilitators, maternal death was noted as the cause of death. The qualitative label for the best health state anchor was "bright skin/ regular period/good understanding within the family", which corre- sponded to the local definition of a woman in the best health state. The duration for each condition, except for death, is stressed as one year, al- though most women in the pretest found this difficult to believe or under- stand conceptually. This is especially problematic, not surprisingly, for mild conditions and relatively short events. Selection of valuation method and approach The original goal was to use the PTO method as described within the DALY protocol, to elicit health state valuations. Through pretest group and individual exercises with non-health professional women aged 18–45, Measurement of variance in health state valuations 601 Table 3 Health state indicator conditions, Cambodian reproductive health study 11 of the 22 15 reproductive health Type of indicator conditions and illness indicator conditions indicator condition from DALY protocol specific to this study Physical disability Below-the-knee amputation; blindness; deafness; quadriplegia Cognitive function Dementia Mental health Active psychosis; unipolar Toas (post-partum chills/weakness/ major depression sadness) Complex social problem Infertility; recto-vaginal fistula; AIDS; severe pain during sexual vitiligo on face intercourse Pain/discomfort Moderate pelvic cramps and low (continuous, from back pain during menstruation; exertion, intermittent, moderate dizziness; prolapse; debilitating) STD with foul discharge and extreme pain (PID) Reproductive illness, Severe anaemia Abortion at 3 months with events, situations haemorrhage and sepsis; miscarriage at 3 months with no complications; fetal death at 7 months; no suitable contraceptive method available; severe eclampsia; unable to breastfeed Potential best and Bright skin/regular period/good worst anchors understanding in family; death (maternal) the PTO method, as well as a version of the standard gamble method, were unsuccessfully implemented. Person trade-off method. For the PTO, the DALY protocol specifying both PTO1 (quantity of life of healthy versus disabled individuals) and PTO2 (quantity of life of healthy versus improved quality of life for dis- abled individuals) frames were attempted both as group and individual ex- ercises. Five of the 22 indicator conditions were attempted, including blindness, infertility, below-the-knee amputation, severe headache and unipolar major depression. Almost all women selected from the commu- nity were reluctant to conduct either PTO1 or PTO2 in the urban pretest group aged 25–38 (8 out of 10 women) or in the rural pretest group aged 18–27 (10 out of 11 women). Almost all women seeking care from urban health care facilities aged 36–45 were reluctant to conduct either PTO frames in individual interviews (10 out of 12 women). Locally appropri- ate visual aids, such as a balance commonly used to weigh goods in the market, facilitated the comprehension of the trade-off. However, most women were unwilling to trade off lives, as found in other studies (Fowler et al. 1995): several women noted "…the choice is up to Buddha." Even though most women seemed to understand the trade-off, it is the author's 602 Summary Measures of Population Health opinion that many simply stated "I don't know" or "I don't understand" in an effort to avoid being forced to give an answer. Standard gamble method. Given the unsuccessful implementation of the PTO, an alternative method that supposedly provides valuations on an interval scale was attempted. For the standard gamble, three chronic health states were attempted: blindness, infertility and severe anaemia. The spe- cific frame was a gamble between a certain choice A, of 100 people being blind, or an uncertain choice B, of 100 people with the probability (1 – p) of dying immediately. Normally, the probability combinations are varied in a high/low fashion and the final valuation is achieved when the partici- pant is indifferent between choice A and choice B. Although a commonly used visual aid, a board with a wheel for probability combinations for healthy (p) or dead (1 – p) was used, and analogies to other forms of gam- bling and betting were described, no one in the pretest groups or individual interviews understood or completed a standard gamble. Although in Cambodia gambling is socially unacceptable for women to participate in, it is the author's opinion that this was not an obstacle in completing the standard gamble exercise. Visual analogue scale method. In the pretest, the category rating scale using a visual analogue scale (VAS) was successfully implemented. In the pretest, all women in group discussions and individual interviews com- pleted consistent ordinal rankings and category ratings for the five indi- cator conditions attempted: blindness, infertility, below-the-knee amputation, severe headache and unipolar major depression. The visual aids of a 100 mm horizontal VAS with 100 equal-appearing division lines, a pointer, and index cards with each health state label and standardized descriptions in Khmer, were used. The top anchor of the scale was labelled "the most desirable health state, only positive consequences and no bur- den" while the bottom anchor of the scale was labelled "death". Partici- pants were instructed that the rating should "best reflect the value of the burden (e.g. conceptually understood as both disability and handicap) that an average person with that health state for one year in Cambodia will experience". Each step on the scale is described as an equal interval (i.e. the distance between 15 and 20 is the same as between 70 and 75). Par- ticipants are also instructed that ties, clusters and the unequal spacing of health states along the VAS is allowed, given other studies' findings on the use of the VAS. For hypothetical health states, lucky numbers, such as 40 or 70 in Cambodia, were not selected more often, although this was ini- tially observed when women valued their own health. As many women wanted to value some hypothetical health states worse than death, the label for the bottom anchor of the scale was changed to "the least desirable health state, worst negative consequences and heaviest burden". Deliberative approach Although the DALY protocol calls to challenge participants "with the implications of their valuations" within a deliberative approach of Measurement of variance in health state valuations 603 "a group exercise which allows for substantial exchange and revision", in practice, such a format was inappropriate among semi-literate and lit- erate Cambodian women participating in the pretest. This was so as even in relatively homogenous groups, women with the highest social status or literally the strongest voice set the model for others to follow. Also, many semi-literate women relied on or simply copied others in order to keep up with the group's pace. By observation, several individuals' views were therefore marginalized in the pretest groups. Hence for this study, indi- vidual reflection was chosen in lieu of group deliberation. Final study methods Valuation method and approach As noted, local concepts of disability and handicap formed the conceptual basis of what should be valued or disvalued associated with each health state. Individual interviews were designed so that women valued their own health state in isolation early on in the interview using a visual analogue scale. Women participants then subsequently ranked 26 hypothetical health states, ranked their own health state within the 26 ranked states, and then values were elicited for all 27 health states using a visual ana- logue scale. Facilitators read the full description of each health state and gave each woman a set of printed cards in Khmer with 26 hypothetical health state labels and short description, plus one card stating in Khmer "your health today and its burden (disability and handicap)". The facili- tators engaged in discussions with each woman on what she understood as each health state, her own health, the value or disvalue attached to these different health states, and the implications of her values given the potential use of the information to compare levels of health across or within popu- lations or to distribute scarce social resources. Women were not forced to change "irrational values"—i.e. one individual ranked and valued death as the best state9—but were required to provide internally consistent valu- ations (between ordinal ranking and VAS valuation of health states). As noted, some women ranked and valued a few health states worse than death, as found in other studies (Patrick et al. 1994), and the revised VAS accommodated women's views even though this was not consistent with the DALY protocol where death has a severity weight equivalent to 1.0 and all other health states are less than 1.0. Overall, the deliberation process en- couraged individuals to defend their views in a non-threatening way, rather than forcing agreement with the facilitator through debate or pressure. Along with the author, the facilitators included two Cambodian female lecturers from the Department of Psychology, Royal University of Phnom Penh, with substantial experience in conducting interviews and group dis- cussions with women in rural and urban communities and within health services facilities. All discussions, interviews and exercises were conducted in Khmer, with explicit informed consent obtained from all individuals. 604 Summary Measures of Population Health Selection of participants A sample of female non-health professionals (n = 40) aged 15–54 years were selected as participants within this study. Half of these women were randomly selected from three urban districts in Phnom Penh, while the other half were randomly selected from individuals seeking health services for either mild or serious reproductive health problems, or psychological/ psychiatric conditions from two private reproductive health clinics and two large public hospitals in Phnom Penh. Age quotas ensured that women were selected across age groups. Although this study represents a small number of participants, the sample size is more than three times the num- ber of participants that were included within the Geneva exercise with international health experts. Table 4 details participants' background characteristics by sample group. Analysis of data collected Valuations using a 100 mm visual analogue scale with 100 equivalent to the best health state and 0 equivalent to the worst possible health state (as two states were valued worse than death), were transformed to a 1–0 severity scale, with 1 equivalent a valuation of 0 and 0 equivalent to a valuation of 100. For the 26 indicator conditions, Spearman's rank order correlation coefficients (for ordinal ranks) and Pearson's correlation co- efficients (for cardinal values) were calculated in order to estimate the similarity of each group's ranking and valuation of health states, by sam- pling design (community or seeking services and by type of health prob- lem), age group (15–24; 25–34; 35–44; 45–54 years) and years of education (0–3; 4–6; 7–10; 11 or greater). Results For the overall sample, the average VAS valuation, standard deviation, and severity weight associated with each of the 26 hypothetical health states are presented in Table 5. At the mild end, the best anchor "bright skin/ Table 4 Sample characteristics by group selection, Phnom Penh, Females Characteristic Community (n = 20) Seeking care (n = 20) Mean age (range) 34 (17–54) 32.7 (19–51) Currently married 65% 75% Participating in income generating activities 60% 55% Residing in female headed households 25% 25% Mean household size 5.8 5.2 ≤ 6 school years completed 25% 50% Currently pregnant 10% 20% Children ever born 2.3 2.6 Measurement of variance in health state valuations 605 regular period/good relations within the family" has a weight of .015. At the worst end, rather than "death", two states are on average valued worse than death, AIDS (.936) and psychosis (.909). Standard deviations are greater for health states in the middle to mild portion of the spectrum. As expected given the use of the VAS, the disability weights associated with the array of 26 health states are fairly evenly spaced across the range of possible values between 0 and 1, except for states at both ends of the spectrum, as noted in Figure 1. Table 5 VAS valuations, standard deviation, and severity weights for 26 indicator conditions, Cambodia study and severity weights from GBD study for 11 overlapping indicator conditionsa Severity weights (1–0) Health state Valuation (0 –100) SD Cambodia GBD AIDS 6.4 11.9 0.936 Active psychosis 9.1 10.8 0.909 0.722 Maternal death 9.4 18.7 0.906 Blindness 18.2 10.8 0.818 0.642 Quadriplegia 20.0 12.1 0.800 0.895 Dementia 24.3 19.7 0.757 0.762 Deaf 30.4 22.1 0.696 0.333 Infertility 35.0 26.7 0.650 0.191 Severe eclampsia 35.3 20.7 0.647 Below-the-knee amputation 36.8 15.6 0.632 0.281 Prolapse 39.6 17.2 0.604 Recto-vaginal fistula 42.3 21.1 0.577 0.373 Severe pain during sex 43.3 23.6 0.567 Vitiligo on face 46.4 25.9 0.536 0.020 Fetal death at 7 months 51.3 17.2 0.487 Severe anaemia 51.8 22.0 0.482 0.111 Unipolar depression 54.9 19.0 0.451 0.619 STD w/symptoms 56.3 22.4 0.437 Abortion at 3 months w/hem/sepsis 58.1 19.6 0.419 Sad/chills/weak post-natal 58.4 18.6 0.416 No satisfactory contraception 61.0 23.9 0.390 Miscarriage at 3 months 65.6 19.3 0.344 Unable to breastfeed 71.6 19.7 0.284 Moderate cramps/period 71.8 20.2 0.282 Moderate dizziness 81.3 17.8 0.187 Bright skin — regular period 98.5 6.5 0.015 a overlapping indicator conditions in bold. Final column: Murray (1996). Figure 1 Severity weights associated with 26 hypothetical health states, based on VAS valuations, n = 40, Phnom Penh, Cambodia 606 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 Severity weight (0 best, 1 worst) 0.1 0 S is th d f l os ia n s is al n s d d ss d D os ea in gia ntia ea tility psia tion pse tula sex acia D a s AI h d Bl iple e m em ssio tom eps -nat ptio 3mo tfee erio ine erio e p e yc al d r e m fer lam puta rol al fi ring go f th 7 ana P /s st c e e ps n D In in i a e pr ym em po as s/p dizz r p la e er ua e ec am ag du itel de er de /s ha k nt ra riag r br mp te gu Q er ee V re A c tiv Mat ev kn o -v pain t al Sev ajor D w w/ wea s co isca le to cra era d S ct re Fe m e M b te o — e- ar ST mo ills/ tabl h i na era M ki n -th Re eve ol 3 U d w S p n ss/c su o ts lo ni io e o M igh Be U rt n N Br A bo Sad Health state Summary Measures of Population Health Measurement of variance in health state valuations 607 The similarity of ranking and valuation of health states for the 26 in- dicator conditions across sample groups and by age group or number of school years is remarkably high within this study. Table 6 notes that both the Spearman's rank order correlation and Pearson's correlation coeffi- cients are .95 or higher between the community and seeking health ser- vices group, and between those seeking mild or serious reproductive health services. Across age and school year groups, these correlations are almost all above .90. The lowest correlations (.76/.81) are found between the group with the lowest number of school years completed (0–3) and high- est number of school years completed (≥ 11). Although numbers are small within each group, a closer look at the sig- nificant differences between the lowest and highest education group may generate some hypotheses concerning the source of variance. Table 7 notes health states with severity weights of at least .150 more or less severe based on the average valuations of the lowest versus highest education group. Table 6 Correlationsa of average health state valuations, 26 indicator conditions, across sample group, type of service, age and school years Group Seeking services (n = 20) Community (n = 20) .96/.98 Type of service Mild RH Serious RH Psych Mild RH (n = 8) — Serious RH (n = 7) .95/.95 — Psych (n = 5) .83/.87 .88/.90 — Age 15–24 25–34 35–44 45–54 15–24 (n = 10) — 25–34 (n = 13) .93/.93 — 35–44 (n = 9) .93/.93 .97/.96 — 45–54 (n = 8) .91/.92 .90/.93 .89/.94 — School years 0–3 4–6 7–10 ≥ 11 0–3 (n = 4) — 4–6 (n = 11) .90/.88 — 7–10 (n = 19) .92/.93 .96/.97 — ≥ 11 (n = 6) .76/.81 .89/.90 .89/.91 — a. Spearman's Rank Order Correlation Coefficient/Pearson's Correlation Coefficient. 608 Summary Measures of Population Health Table 7 Health states with a difference in severity weights at least .150, based on health state valuations of individuals with 0–3 (n = 4) and ≥ 11 (n = 6) school years Health state 0–3 years ≥ 11 years A. Health states valued at least .150 points more severe by individuals with 0–3 school years than ≥ 11 HIV+/AIDS .982 .823 Quadriplegia .920 .752 Infertility .760 .580 Vitiligo on face .715 .325 Severe pain during sexual intercourse .635 .378 No suitable contraceptive .445 .285 B. Health states valued at least .150 points more severe by individuals with ≥ 11 school years than 0–3 Deafness .557 .787 Fetal death at 7 months .347 .598 Abortion w/ haemorrhage & sepsis at 3 months .232 .510 Sad/chills/weak post-natal .245 .478 Health states valued significantly more severe by the lowest education group include quadriplegia, infertility, vitiligo on the face, AIDS, severe pain during sexual intercourse and no suitable contraceptive. Health states valued significantly more severe by the highest education group include deafness, fetal death at 7 months, abortion with haemorrhage and sepsis at 3 months, and toas, a locally named post-natal condition where a women is sad, has chills and is weak. Concerning the valuation of own health state, Table 8 lists the sever- ity weight associated with the first trial when women valued their own health state in isolation, before being exposed to any of the indicator health conditions or discussing the meaning and implications of the valuation (ad hoc frame), and the second trial when women valued their own health state, after ranking the 26 indicator health states and discussed the impli- cations of their valuations (deliberative frame). Women sampled from the community, with mild or serious reproductive health conditions, or in younger age groups, tend to value their health as more severe within the ad hoc frame, in comparison to the deliberative frame. The reverse is noted for women seeking services for psychological problems, in the oldest age group, or with least education, as these women tend to value their health less severe within the ad hoc frame, in comparison to the deliberative frame. The severity weights for the 11 indicator conditions that overlap be- tween the DALY protocol and this study are in bold in Table 5. Of these 11 health states, the severity weights based on the DALY protocol imple- mented in Geneva with international health experts are listed in the final Measurement of variance in health state valuations 609 Table 8 Comparison of severity weight of own health state, based on first (ad hoc) and second (deliberative) valuation trial Second severity weight similar to First Second p ≤ .05 Direction indicator health state Group Community 0.305 0.256 • Better Moderate cramps/low back pain, moderate dizziness Seeking care 0.401 0.397 Better No suitable contraception Type of service Mild RH 0.328 0.280 • Better Moderate cramps/low back pain/ period Serious RH 0.507 0.474 • Better Severe anaemia, fetal death 7 mos Psychological 0.370 0.476 • Worse Unipolar major depression Age 15–24 0.262 0.224 • Better Moderate dizziness 25–34 0.451 0.414 • Better Toas post–natal 35–44 0.331 0.279 • Better Moderate cramps/low back pain 45–54 0.331 0.366 • Worse No suitable contraception School years 0–3 0.462 0.600 • Worse Prolapse 4–6 0.452 0.333 • Better Miscarriage 3 mos 7–10 0.311 0.289 Better Unable to breastfeed ≥ 11 0.233 0.250 Worse Moderate cramps/low back pain, moderate dizziness column and are generally much lower for eight conditions (particularly vitiligo on face, severe anaemia, infertility, below-the-knee amputation and deafness), higher for two conditions (depression and quadriplegia), and almost the same for one condition (dementia). Figure 2 is a scatter plot of the severity weights for health states common to both studies. Discussion Given the objectives of the study, three areas are briefly discussed: (i) the feasibility and acceptability to replicate the DALY protocol to measure severity weights with non-health professionals among women in Phnom Penh, Cambodia and the potential validity of the approach taken instead; (ii) variation within Cambodia; and (iii) variation between international health experts' and Cambodian women's valuations for the same health states. 610 Summary Measures of Population Health Figure 2 Comparison of severity weights for 11 overlapping indicator conditions, person trade-off (PTO) with international health experts in Geneva and Visual Analogue Scale (VAS) with non-health professional women, Phnom Penh 1.0 0.9 Quadriplegia 0.8 Active Dementia psychosis 0.7 PTO, Geneva, n = 12 Blindness Unipolar depression 0.6 0.5 0.4 Recto-vaginal fistula Deafness 0.3 Below-the-knee amputation 0.2 Infertility 0.1 Severe anaemia Vitiligo 0 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 VAS, Phnom Penh, n = 40 Feasibility of DALY protocol and validity of approach developed This study found that the DALY protocol to value health states and assign severity weights to indicator conditions could not be replicated "as is" among non-health professional women in Phnom Penh, Cambodia. Not all women understood all 22 indicator conditions' labels or their qualita- tive descriptions. For a few indicator conditions, this was not surprising: for example, the description of angina states that when assessing the se- verity of pain "do not take into consideration your clinical judgment that someone with this degree of angina may have an increased risk of death", or the label "2 standard deviations below weight/height". For a health state to be understood by non-health professionals, how the state is described using non-technical language seemed more important than familiarity with the health state. Although not explicitly tested within this study, further development of standardized health state descriptions that include labels along with a classification system based on the conceptual understanding of health (see Table 1 for examples) may improve description and com- munication to non-health professionals. Concerning the valuation method, most individuals were reluctant to conduct any variant of the person trade-off approach. Although not in the DALY protocol, given the level of abstraction required, it is not surpris- Measurement of variance in health state valuations 611 ing that no one completed a valuation based on the standard gamble. It is important to note that during the pretest, facilitators discussed that they could have "forced" women to use these methods and provide answers. However, it was their belief that the valuations obtained would neither reflect what women actually believed nor would they as researchers be able to defend the results. All women were able to complete valuations based on the VAS and facilitators believed that these values corresponded to the study participants' ideas reflected through in-depth discussions. This is so even if the VAS may be considered less "rigorous" in terms of achieving interval scale properties or theoretical grounding. This is not to argue that the valuation method selected and the deliberative process should neces- sarily be "easy" to implement, as making choices concerning scarce re- sources that will affect people's lives is a difficult process. Critics of the VAS claim that the severity associated with mild states may be over-estimated, given the even spreading out of states across the full range of the scale. Given that individuals appear to place the available health states across the entire 100 mm scale, the inclusion of a sufficient range of health states in terms of severity that cover different types of health problems, as recommended within the DALY protocol, is good advice. Others have suggested using a log scale for the first ten points as one means to "deflate" the value attached to milder states.10 However, valuations obtained from altered scales or from transformations of val- ues based on estimated relationships to other valuation methods, should be evaluated for validity, i.e. do these still reflect the ideas of the people providing valuations? Concerning the approach, individual interviews gave equal voice to each participant and ensured greater understanding of the valuation task, par- ticularly for semi-literate women who generally required more time to complete the exercise. However, this choice placed all of the responsibility on the facilitator to raise questions in a non-threatening fashion with each participant, in order to resolve inconsistencies between ordinal rankings and VAS valuations, and discuss the implications of valuations made. Neutrality was very important: given the differences in power and agency between facilitators and participants, it was not uncommon that partici- pants wanted to please the facilitator or avoid confrontation. Even with this understanding, differences in social status and authority between female participants and facilitators could not be removed, and may have never- theless influenced the deliberative process and outcome of the exercise. This and other factors concerning the validity of valuations obtained, raises the question of whether one can judge and defend one set of valu- ations based on in-depth deliberation and clarification of views versus an- other set of valuations that reflect a change from an individual's original views to fit potentially some target view, irrespective of the method used. If reflection on complex choices leads to shifts in values, evidence from this study suggests that despite simplifying the DALY protocol and con- ducting individual exercises, women shifted their valuations of their own 612 Summary Measures of Population Health health state in a defensible manner, as they incorporated information on the range of hypothetical health states over the course of the exercise. This finding bodes well for population-based surveys using simplified methods. Two pieces of evidence exist. First, it appears that the ad hoc valuation of one's own health state may reflect some of the same biases associated with the self-report of morbid- ity or health that limit comparability across groups or populations status (see Sadana et al., chapter 8.1, and Murray et al., chapter 8.3). As Table 8 notes, the direction of change from the ad hoc to more deliberative valu- ation of one's own health state, for most subgroups suggests that by plac- ing one's own health state in context of a range of health states, and discussing the meaning of the valuation, the direction of change indicates a greater understanding of the possible range of health states. For example, women in the community gave a better valuation of their health status, as did women with mild health problems or in younger age groups, dur- ing the second trial. It is possible that the ad hoc isolated valuation was an "over estimation" of the severity associated with their health state. The reverse is so for women with psychological problems, in the oldest age groups, or with the least amount of education, as their ad hoc valuations may have been an "under estimation" of the severity associated with their health state. Although these results are based on small numbers, similar "validity checks" may be useful to incorporate within population-based studies eliciting health state valuations. Given that clarification of values should occur from the ad hoc to deliberative trial, reliability in this case is not desirable. Furthermore, values appear consistent between the valuation of one's own health state and the hypothetical health states included, given aver- age severity weights for subgroups. The final column in Table 8 provides some guidelines on how to interpret the severity weights associated with valuations of one's own health state based on the second trial, in compari- son with the severity weights generated for the hypothetical indicator conditions. For example, the average severity weight of their own health state associated with women seeking services for serious reproductive conditions (.474), is closest to the severity weights associated with the hypothetical health states of severe anaemia (.482) and fetal death at 7 months (.487). Developing similar approaches to improve the meaning and interpretation of valuations obtained in population based surveys may evaluate the validity of methods employed and enhance the credibility of results. Variation within Cambodia Based on the correlation coefficients reported in Table 6, variance of health state valuations within the sample is minimal for hypothetical states irre- spective of demographic background or use of health services. For the sub- groups where the correlation is weakest (among lowest and highest education groups), one hypothesis to explain the difference in severity Measurement of variance in health state valuations 613 weights of the same health state (see Table 7) is that for women with least education, states that were associated with stigma or shame were valued as more severe, while for the more educated group, avoidable or negative reproductive outcomes were valued as more severe. Although based on small numbers, these results suggest that population-based valuations of health states may be consistent, but that potential differences by socioeco- nomic level, particularly for the most vulnerable or marginalized popula- tions, should be reported and discussed. This is important as the means to calculate summary measures should investigate and reflect different perspectives in a particular setting, even if population averages are ulti- mately used in the end. Variation between international health experts' and Cambodian women's valuations. Not surprisingly, different conceptual basis, valuation method, range of health states, participants, deliberative approach and context, produce different severity weights for the 11 indicator conditions common to both protocols (see Table 9 summarizing differences in methods). Another limi- tation in the comparison is that men were excluded in the Cambodian sample. Nevertheless, a recognizable pattern exists: valuations for the more severe health states are more similar, while health states associated with stigma and shame, are much more severely disvalued by Cambodian women than by experts in Geneva. These differences may not simply be explained away by differences in methods, e.g. in particular, infertility (.650 in this study, .191 by Geneva experts). These findings cannot determine whose values are more valid or more narrowly which valuation approach is more valid. The answers to these Table 9 Differences in methods between Cambodian study and GBD DALY protocol to elicit health state valuations Study Quantifying Reproductive Health Global Burden of Disease and Illness Location Cambodia: participants' homes Geneva: World Health & health services' locations Organization Participants Cambodian women, non-health International health professionals, professionals, n = 40 40% women, 60% men, n = 12 Valuation method VAS PTO Facilitators Cambodian female psychologists GBD study team Deliberative process Individual reflection Group discussion Severity weight Disability & handicap Between disability & handicap interpretation No. of indicator states 26 22 Average time 2 hours 8–10 hours 614 Summary Measures of Population Health questions may vary depending on the intended use of the severity weights and more generally of summary measures of population health. However, if social values are to be explicitly incorporated within summary measures of population health, what does seem clear is that differences or similari- ties in health state valuations should be documented within and across populations and openly discussed. Concluding remarks Further development and testing of methods to value health states should provide support for methods that are acceptable and reflect the way non- health experts think about health. Economist Jose-Luis Pinto Prades ar- gues rationally that if participants in valuation exercises "cannot use the response mode most convenient to investigators, then investigators must find a response mode that works" for the participants (Pinto-Prades 1997, p. 78). It is also possible that no one magic question or approach exists to elicit health state valuations. More generally, open discussion of the development and interpretation of health indicators that explicitly take into account social values is im- portant, as social acceptance is not based solely on the technical sound- ness of a methodology—health policy is not simply a technocratic exercise. In fact the inclusion of population representative values may be as impor- tant as the technical debates on specific approaches to measurement. Concerning health state valuations, on one hand, improving the validity and reliability of severity weights should not be pursued at the expense of suppressing different perspectives. On the other hand, although efforts should be expended to improve valuation methods, researchers should not lose focus that the ultimate goal is to improve health, not the measurement of severity weights. Acknowledgements In addition to the individuals who consented to participate, I thank Kruy Kim Hourn and Sek Sisokhom, from the Department of Psychology, Royal University of Phnom Penh, for their persistence and insights during the field work in Cambodia; Carla AbouZahr, from the World Health Orga- nization, Geneva, for being specifically interested in severity weights for reproductive health; and Christopher JL Murray, at the time of fieldwork, from the Department of Population and International Health, Harvard School of Public Health, for providing details of the GBD study protocol. Earlier versions of this chapter were presented in 1998 at the Eighth Annual Public Health Forum: Reforming Health Sectors held at the Lon- don School of Hygiene & Tropical Medicine, and at an Informal Consul- tation on DALYs and Reproductive Health, organized by the Reproductive Health Technical Support Unit, World Health Organization, Geneva. Measurement of variance in health state valuations 615 Notes 1 The need for a non-monetary value of a good did not originate within the health field, but environment sector. The disvalue associated with various types and levels of environmental pollution, in comparison with a clean environment led to the development of valuation methods. From a social perspective, a clean environment and a healthy population may be considered as public goods. 2 Biases specific to different methods, such as valuations of the severity of health states being confounded by time preference or risk aversion. 3 The draft ICIDH has now been recently finalized and renamed to the Interna- tional Classification of Functioning, Disability and Health. The conceptual framework has also been modified (see WHO 2001). 4 Briefly, individuals completed two person trade-off (PTO) exercises. PTO1 is a trade between the life extension of healthy individuals versus the life extension of individuals in a given health state i. PTO2 is a trade between raising quality of life of those in health state i to perfect health for 1 year versus extending life for healthy individuals for one year. The exercise ends when individuals are indifferent between the trade-off. Both PTO exercises were conducted for each of the 22 indicator conditions, resulting usually in two health state valuations for each condition. Two PTOs are conducted to reveal to individuals their own inconsistencies. Individuals were then requested to resolve inconsistencies between the two valuations per condition, deliberate within the group, and revise in private. Each of the 22 indicator conditions were also ranked by severity and these ordinal rankings are compared with the rankings based on the final person trade-off valuation for each indicator condition. 5 Personal communication to the author by three of the participants in the Geneva expert group. 6 The range of morbidity was not limited to bio-medical disease labels or sequelae, but also indigenously named illnesses, conditions or events, that may be shaped by social norms and rituals, that depend on the individual's family or life cycle phase, or that reflect historical changes in social and political expectations for health. This knowledge informed the types of health states added as indicator conditions within this study. 7 Beyond the scope of this paper, these additional states were to include reproductive events or sequelae excluded from the estimation of disease burden within the GBD Study. For example, within the GBD study, by design many events or episodes are assigned a disability weight of .000 if it is assumed no subsequent disability results due to these problems. Within reproductive health—the focus of the larger study that this feasibility study was nested within—episodes of maternal haemorrhage, maternal sepsis and obstructed labour, among others, are assigned a disability weight of .000 within the GBD Study. Only selected sequelae resulting from one of these episodes, such as Sheehan's syndrome (.093) or severe anaemia (.065) following maternal haemorrhage; infertility (.180) following maternal sepsis; or stress inconti- nence (.025) or recto-vaginal fistula (.430) following obstructed labour, are given the indicated disability weights for the 15–44 year age group irrespective of treatment classification. 616 Summary Measures of Population Health 8 This may reflect that cause of death contributes to the valuation of death; however, this hypothesis was not tested within this study. 9 This participant explained that "if a woman died after giving birth, in her next life she will be a man and will then be much better off…she'll avoid a lot of misery". 10 Salomon J, personal communication. References Anand S, Hanson K (1995) Disability-adjusted life years: a critical review. Harvard Center for Population and Development Studies. (Working paper no 95/06.) Harvard Center for Population and Development Studies, Cambridge, MA. Ashby J, O'Hanlon M, Buxton MJ (1994) The time trade-off technique: how do the valuations of breast cancer patients compare to those of other groups? Quality of Life Research, 3(4):257–265. Barker C, Green A (1996) Opening the debate on DALYs. Health Policy and Planning, 11(2):179–183. Dolan P, Gudex C, Kind P, Williams A (1996) Valuing health states: a comparison of methods. Journal of Health Economics, 15(2):209–231. Evans TG, Ranson MK (1995) The global burden of trachomatous visual impair- ment: II. Assessing burden. International Ophtamology, 19(5):271–280. Fowler FJ, Cleary PD, Massagli MP, et al. (1995) The role of reluctance to give up life in the measurement of the values of health states. Medical Decision-making, 15(3):195–200. Krabbe PFM, Essink-Bot ML, Bonsel GJ (1997) The comparability and reliability of five health-state valuation methods. Social Science and Medicine, 45(11):1641– 1652. Llewellyn-Thomas H, Sutherland HJ, Tibshirani R, Ciampi A, Till JE, Boyd NF (1984) Describing health states: methodologic issues in obtaining values for health states. Medical Care, 22(6):543–552. Murray CJL (1994) Quantifying the burden of disease: the technical basis for disability-adjusted life years. In: Global comparative assessments in the health sector. Murray CJL, Lopez AD, eds. World Health Organization, Geneva. Murray CJL (1996) Rethinking DALYs. In: The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. The Global Burden of Disease and Injury, Vol. 1. Murray CJL, Lopez AD, eds. Harvard School of Public Health on behalf of WHO, Cambridge, MA. Murray CJL, Acharya AK (1997) Understanding DALYs. Journal of Health Economics, 16:703–730. Murray CJL, Lopez AD, eds. (1994) Global comparative assessments in the health sector: disease burden, expenditures and intervention packages: collected re- prints from the Bulletin of the World Health Organization. World Health Organization, Geneva. Measurement of variance in health state valuations 617 Murray CJL, Lopez AD (1996c) Evidence-based health policy: lessons from the global burden of disease study. Science, 274(5288):740–743. Murray CJL, Lopez AD, eds. (1996b) Global health statistics: a compendium of incidence, prevalence and mortality estimates for over 200 conditions. Global Burden of Disease and Injury, Vol 2. Harvard School of Public Health on behalf of WHO, Cambridge, MA. Murray CJL, Lopez AD, eds. (1996a) The global burden of disease: a comprehen- sive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Global Burden of Disease and Injury, Vol. 1. Harvard School of Public Health on behalf of WHO, Cambridge, MA. Murray CJL, Lopez AD (1997a) Alternative projections of mortality and disability by cause 1990–2020: global burden of disease study. Lancet, 349(9064):1498– 1504. Murray CJL, Lopez AD (1997b) Global mortality, disability and the contribution of risk factors: global burden of disease study. Lancet, 349(9063):1436–1442. Murray CJL, Lopez AD (1997c) Mortality by cause for eight regions of the world: global burden of disease study. Lancet, 349(9061):1269–1276. Murray CJL, Lopez AD (1997d) Regional patterns of disability-free life expectany and disability-adjusted life expectancy: global burden of disease study. Lancet, 349(9062):1347–1352. Murray CJL, Lopez AD, eds. (1998) Health dimensions of sex and reproduction: the global burden of sexually transmitted diseases, HIV, maternal conditions, perinatal disorders, and congenital anomalies. Global Burden of Disease and Injury, Vol 3. Harvard School of Public Health on behalf of WHO, Cambridge, MA. Nord E (1995) The person-trade off approach to valuing health care programs. Medical Decision-making, 15(3):201–208. Nord EM (1992) Methods for quality adjustment of life years. Social Science and Medicine, 34(5):559–569. Paalman M, Bekedam H, Hawken L, et al. (1998) A critical review of priority setting in the health sector: the methodology of the 1993 World Development Report. Health Policy and Planning, 13 (1):13–31. Patrick DL, Starks HE, Cain KC, Uhlmann RF, Pearlman RA (1994) Measuring preferences for health states worse than death. Medical Decision-making, 14(1):9–18. Pierre U, Wood-Dauphinee S, Korner-Bitensky N, Gayton D, Hanley J (1998) Proxy use of the Canadian SF-36 in rating health status of the disabled elderly. Journal of Clinical Epidemiology, 51 (11):983–990. Pinto-Prades JL (1997) Is the person trade-off a valid method for allocating health care resources. Health Economics, 6(1):71–81. Richardson J (1994) Cost-utility analysis: what should be measured? Social Science and Medicine, 39(1):7–21. 618 Summary Measures of Population Health Sadana R (2001) Social discourses and individual narratives: contexts, meanings and embodied experiences of reproductive health and illness in Cambodia. In: Quantifying reproductive health and illness. Doctoral dissertation. Harvard School of Public Health, Boston, MA. Shibuya K (1999) Quantifying the economic impact and health consequences of smoking. Doctoral dissertation. Harvard School of Public Health, Boston, MA. Tversky A, Kahneman D (1981) The framing of decisions and the psychology of choice. Science, 211(4481):453–458. WHO (1980) International classification of impairments, disabilities, and handi- caps: a manual of classification relating to the consequences of disease. World Health Organization, Geneva. (Reprint 1993) WHO (1996) Investing in health research and development. (Report of the Ad Hoc Committee on Health Research Priorities.) World Health Organization, Geneva. WHO (1998) DALYs and reproductive health: report of an informal consultation. WHO/RHT/98.28. World Health Organizaton/Division of Reproductive Health, Geneva. WHO (2001) International classification of functioning, disability and health (ICF). World Health Organization, Geneva. World Bank (1993) World development report: investing in health. Oxford University Press, New York.


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Carnival goers donned their wellies - and some even flung theirs away - at a damp but otherwise successful Dove Holes Carnival on Saturday.
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staff did everything possible to accommodate the needs of guests - Carry luggage up 4 flights of stairs, wake up call by knocking at my door at 0600 as scheduled. Fixing the safe on the spot,...etc. Very good service. - Anonymous
I liked the location of the hotel. It is very close to Amsterdam Central Station. Also, the beds were very comfortable in the room. The hotel staff was very polite and good. - Alican
The staff were wonderful and the hotel is centrally located. The room was clean and well equipped. - Katharine
The staff were extremely friendly and helpful. Our room we had was simple but very clean and nice. The shower and toliet was always clean and tidy. Overal we enjoyed our time in the hotel and would stay again. - Laura
very good experience from clean room, plenty of hot water to friendly staff. good breakfast from caring cook, who is a most interesting fellow. you will feel safe and looked out for here. - Anonymous
Very freiednly staff, good breakfast, clean room, great location! (Nearlarge supermarket, Dam Square, laundry, post office, atm machines) - Anonymous
Room is modern and very clean. New comfortable furniture and sheets which are very important for me. Spacious bathroom and shower. My single room has view of a silverbirch tree which is relaxing and quiet. Staff are helpful in giving directions. Tram is in front of hotel. There is someone to help with your bags and please do tip them as the stairs are very steep! - Anonymous
Nadia Hotel is in the perfect location. Just a stroll away from all the main attractions with a nice view across to where Anne Frank House is. The staff there are so friendly. A big special mention to Hazem who was so attentive and helpful to us. We are on a long extended holiday so have very heavy luggage. Hazem was more than happy to carry our suitcases up the very steep stairs of Nadia and bring them back down again on our departure. He really made our stay at Nadia so memorable with his - Anonymous
Room clean, cosy and comfy. Location fantastic, right next to Dam square, could not be more central. Staff really helpful. Price excellent for location and quality. - Anonymous
Fantastic value for money. Nice sized rooms with breakfast included. The hotel is in a great central location, really easy to find and is close to the main tram routes, supermarket and post office as well as popular attractions. I would definately stay there again. - Anonymous
Exellent ubication, clean, awsome view from the room and specially the staff was very helpfull with directions and places to go. Very important since i was there by myself - Pilar
I thought Hotel Ajax was a fantastic place to stay, Always had clean towels and sheets + toilet was cleaned regular within the 5 days i stayed here. Staff were extremely friendly...... From other reviews i had came across saying infested with rats and all that other complete bull that is all lies. Would stay here again, value for money. Thanks again Hotal Ajax + Staff - Anonymous
I stayed here with a group of friends.we got a room with canal-view.in d evening,there's street performers at d boulevard in front of the hotel.we enjoyed it so much.very lively place.not to forget d location is very strategic.near Dam Square n Central Station. - Anonymous
Good location - centre of the city and beautiful view to the canal - Natalija
It was a big risk to book a two stars hotel but I took it based on the high customer review. I was right. Location was perfect, within walking distance to everything, very clean, breakfast was ok, and staff are very friendly. We booked the family suite and it was two super large rooms and a very spacious and modern bathroom. The room furniture was good. We wanted to stay in an old style hotel and this was a perfect one for us. Some reviews complained from the narrow and steep stairs. We st - Anonymous


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2 Easy Moves to Work Your Abs and Backside
Description:We love the versatility of the exercise ball and decided to share our two favorite moves with you: learn how to work your abs without crunches and your backside without squats. Remember size does matter! It's best to work with a ball appropriately for you, so check out this chart to see what dimension best fits. (1:17)
Source: PopSugar Fitness
Tags: 2 Easy Moves to Work Your Abs and Backside , abs workout , backside workout , easy workout moves


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License & Identifications
A medical license is required for a doctor to practice medicine in a particular state. Requirements vary by state but most require, at a minimum, post-graduate training in the doctor's specific specialty. An NPI number is a national identifier unique to an individual health care provider and is managed by the Center for Medicare & Medicaid Services (CMS).
Learn more about Dr. Tiron Pechet:
View the full profile to get information on:
- Qualifications
- What's important to you
View full profile
Patient Reviews
The overall average patient rating of Dr. Tiron Pechet is Poor.
Specialties & Research
Dr. Tiron Pechet, MD is board certified in Diagnostic Radiology.
Dr. Pechet has 5 hospital affiliations:
- U Mass Memorial Med Ctr - Memorial Campus
- Newton-Wellesley Hospital
Similar doctors nearby
- Additional Information
- Dr. Tiron C M Pechet MD is a male Diagnostic Radiologist, has 21 years of experience and practices in Diagnostic Radiology.
- Where does Dr. Tiron C. Pechet practice?
- Dr. Tiron Pechet has 1 office location.
Dr. Tiron Pechet practices Diagnostic Radiology near Brockton, MA.
See Brockton Radiologists.


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OSI-Approved Open Source (248)
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E/AS E/AS (E/AS Automation Solutions) is open source software system for help automate any informational solution.
1 weekly downloads -
MediaCore Video Platform MediaDrop is an open source video platform written in Python. It makes distributing media on any website easy and is capable of delivering video in HTML5 and Flash. NOTICE: MediaCore CE is now known as MediaDrop. See the announcement http://mediadrop.net/blog/2013/mediacore-ce-is-now-mediadrop.html
12 weekly downloads -
MegaGlest Cross-platform real-time strategy game (3D)
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Java Micro Benchmark (Desktop/Server) Java Micro Benchmark - control tasks required to determine the comparative performance characteristics of the computer system on different platforms. Can be used to determine the effect of different software on the performance of a computer system.
10 weekly downloads -
my-fm-ve-de File manager, internal viewer, internal editor, desktop environment. Console and X Window modes.
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MeganetSpy Слежение и оповещение о статусе игроков сервера http://la2.meganet.org.ua
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IServerd There are many people, who search server that support several protos and can work as corporate internet connection-independent ICQ gate.
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dirsave Dirsave is graphical utility for intellectually generaty senteces urls from you link (example: pic01,pic02 or pic1,pic2). After generate with 2 clicks (paste & generate) you execute program and wget download this files:)
1 weekly downloads -
Millennium BSA Millennium Business Suite Anywhere (BSA) is web based ERP/CRM solution with integrated BPM. Millennium BSA automates resources' planning (MRPII), distribution, inventory, payroll, HR, purchase, sales. Millennium BSA is distributed under GPL V2.
32 weekly downloads -
UTL(Universal Template Library) UTL - Universal Template Library UTL::PTL - Patterns Template Library This is a library that implements the design patterns in generic overview.
0 weekly downloads -
xBird CMS xBird CMS is a freeware content management system. Minimal system reqipments - Apache Web Server, MySQL/PGSQL, PHP > 5.1.4 (5.2.x best for it).
0 weekly downloads -
emker web-application framework Yet another web framework for easier development and deployment object-oriented web-application within a SOHO environment.
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mJournal mJournal developing and support project. Addons, skins and hacks store for mJournal
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PHP-Blah! A complete open source bulletin board system. Supports over 10 different languages. Unlimited forums and topics, who's online features, ultra easy skinning system, a full blown administrative control panel, and many more features.
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EasyPortal CMS system for small/medium PHP-based hostings.
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mod_dynamic_vhost mod_dynamic_vhost is an Apache HTTP-server module that dynamically adds/removes/updates virtual hosts from LDAP database without server restart.
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OTUPYACHIVATEL Configurable text processor for the http://upyachka.ru web site.
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MVDsv MVDSV (MultiView Demo Server) - most popular QuakeWorld Server in the world with it's ability to record every player's point of view in a server side demo. Includes: mvdsv, qwdtools (demo tools), qwdplayer (client - removed, use http://ezquake.sf.net).
1 weekly downloads -
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aSe Suite Common and specific purpose C/C++ library as addon and advance of standart C libs and STL. Toolkit with warious shell utilites (FreeBSD /usr/ports/INDEX parser to HTML, DNS zone generator, Linux-like service command, e.t.c.)
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NEW YORK (AP) -- Oprah Winfrey says creating her new cable network has turned out to be a steep climb.
CommentsGREENSBORO, N.C. (AP) -- Three of Chris Daughtry's former bandmates are suing him, claiming he defrauded them out of proceeds from four songs that included music and lyrics they wrote together.
CommentsLAS VEGAS (AP) -- A year after the Muscular Dystrophy Association telethon split with comedian and longtime host Jerry Lewis, the Labor Day weekend show is leaving Las Vegas.
CommentsLOS ANGELES (AP) -- There's a hint of mature romance - or at least hot sex involving older folks - in the latest sequel to "American Pie."
CommentsMEXICO CITY (AP) -- An art and photo show focusing on the trade in firearms and their deadly effects in Mexico may soon be going to the United States, the same place where many of the weapons come from.
CommentsLOS ANGELES (AP) -- Matt Lauer is sticking with NBC's "Today," ending speculation that the top-rated show might have to face ABC's rising "Good Morning America" without him.
CommentsLOS ANGELES (AP) -- The Weinstein Co. said Thursday an edited version of the film "Bully" will be released across the U.S. on April 13 with a PG-13 rating.


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Reuters AlertNet
2069 days ago Article ID# 34169 Original URL
LONDON, U K (Reuters AlertNet) - Sri Lanka's Manik Farm is a camp that shelters nearly 200,000 displaced people. Thousands of families cannot go home despite the recent end of the country's civil war. To help support the refugees, AmeriCares sent relief workers to the former conflict zone to provide emergency aid and assess health care needs. In response, two emergency airlifts of additional medicines, medical supplies and humanitarian aid will soon be delivered. One emergency airlift will depart from AmeriCares U.S. headquarters and the other from AmeriCares India in Mumbai. The vital deliveries include medicines, surgical equipment and medical supplies to treat pain, infections, injuries and wounds. AmeriCares relief workers in the field report that many civilians were wounded in the fighting or injured during their escape. The need for medical treatment is great. Earlier this week, AmeriCares staff donated medical and humanitarian aid to the Vavuniya Hospital and other health clinics within the former conflict zone. "The hospital was overwhelming. Their maximum capacity is 400 patients, but there were over 2,000 the day we visited. Patients were waiting on the floors outside, without food, and many without clothes," reported one AmeriCares relief worker. "They looked shell-shocked, many had injuries from the bombings – their eyes vacant and traumatized. Luckily through our donations, 500 families in the children's unit received some much-needed supplies. "The health clinics were heart-wrenching. A poor widow lay listless in the dirt waiting for help; she was suffering from fever and malnutrition. Her three small, frightened children surrounded her," the aid worker shared. "We were quickly able to negotiate transportation for her to the local hospital so she could receive urgent care. At that moment, it re-affirmed what AmeriCares is all about - helping vulnerable people in their dire time of need." AmeriCares has worked extensively in Sri Lanka since the Southeast Asian tsunami in 2004. Many of the areas on the eastern coast that were devastated by the tsunami have also been impacted by the conflict and have provided refuge for families fleeing the war zone. Since fighting escalated during the last months of the decades-long conflict, AmeriCares has delivered over $16 million worth of lifesaving medical aid to communities in war-torn Sri Lanka.
Copyright 2015 Reuters AlertNet (Copyright Terms) Updated 2069 days ago Article ID# 34169
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LONDON, U K - In May 2014, AmeriCares responded to an emergency in Honduras with an air shipment of laboratory supplies. Through our partner in Honduras, the ...
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"It is lovely. I would; however, put the Star of David on the left rather than the right as it makes the letter look a little unbalanced with a stamp in the right corner and nothing much going on in the left corner"
"These labels are so adorable. The background is a little darker than I had expected, but there is still enough contrast between the text and background to make it easy to read. I am very pleased with the order and how easy the editing process was."


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A Zeppelin is a type of rigid airship pioneered by the German Count Ferdinand von Zeppelin in the early 20th century. It was based on designs he had outlined in 1874 and detailed in 1893. His plans were reviewed by committee in 1894 and patented in the United States on 14 March 1899. Given the outstanding success of the Zeppelin design, the term zeppelin in casual use came to refer to all rigid airships. Zeppelins were first flown commercially in 1910 by Deutsche Luftschiffahrts-AG, the world's first airline in revenue service.
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7,403 kohler Bath Design Photos
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