Results

Table 1 shows the 10 most important disease categories ranked according to their share of total PYLLs in the canton. Cardiovascular diseases appear as the top priority health problem for men and women in Geneva, followed by breast cancer for women and AIDS for men. Overall violent deaths including traffic accidents, other accidents and suicide accumulate a high proportion of premature deaths (24%).

Table 2 presents the list of the 15 most important health problems ranked by their contribution to total DALYs per year in the canton, and shows the relative importance of mortality (YLL) and morbidity (YLD). Ischaemic heart disease appears as the single most important priority, followed by unipolar major depression, AIDS, and alcohol abuse. Neuropsychiatric disorders appear in six of the 15 priority problems, accounting for 20.9% of DALYs. HIV/AIDS is the third contributor to DALYs in Geneva. Suicide and other self inflicted injuries account for more DALYs than road traffic accidents and falls. Breast cancer ranks fourth in women (13th position in overall ranking). Respiratory cancer ranks seventh.

Table 3 shows the 10 health problems and five determinants chosen as priority issues by the five Delphi panels, and the summary results from all panels. Depression and cardiovascular disease rank as the top two priority issues. AIDS appears again as the third issue, and breast cancer as the fourth. A high rank was given to “violence in the family” presented, overall, as the fifth priority issue. Some interesting differences emerge between panels with regard to AIDS (rated as a high priority by community leaders but given a lower priority ranking by politicians), breast cancer, and hypertension (rated relatively low by the community and NGO panel, whereas it is given high priority by the two “medical” panels). Alcohol and tobacco abuse are seen as the most important health determinants to be tackled, with the notable exception of the community group who ranks tobacco abuse comparatively low. With regard to the interventions proposed for each priority, they mainly relate to primary and secondary prevention and include a range of legal, social, environmental and medical measures.

Several health conditions are unanimously selected by all three methods as top priorities: cardiovascular diseases, AIDS, respiratory cancer, breast cancer, suicide and unintentional injuries including traffic accidents (fig 1). Alcohol abuse, given priority by the DALY and Delphi method, can be closely linked to liver cirrhosis in the PYLL analysis. Similarly tobacco abuse, identified as an important health determinant through the Delphi survey is closely linked to respiratory cancer. The DALY analysis and Delphi study coincide in the identification of unipolar major depression as a high priority, while it is entirely missing in the PYLL analysis. Two health problems that appear solely in the Delphi study—chronic back pain and hypertension—can be linked to results of the DALY analysis. Hypertension leads to cardiovascular and cerebrovascular diseases, and chronic back pain may have some relation with osteoarthritis.

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Figure 1

Overlap in health priorities identified through each method.

Finally, the Delphi survey adds several elements that would have been missed by the two quantitative methods. Violence in the family has been given high priority by all panels. The importance given by participants in the Delphi survey to this issue was further corroborated by the high ranking of a deteriorated family environment in choosing priority health determinants. Although social determinants such as a deteriorated family environment, unemployment and social exclusion, are not directly identifiable through the two quantitative methods, they may be linked with the broader category of mental disorders.

Discussion

The final choice of health priorities (table 4) for the Canton of Geneva was guided by a three step approach.

(1) All six health problems unanimously identified by the three methods plus those two for which a clear conceptual link could be established between the three methods (alcohol and tobacco abuse) were chosen. By doing so we incorporated cardiovascular diseases, AIDS, breast cancer, suicide, unintentional injuries (traffic accidents, falls, other accidents), alcohol abuse and tobacco abuse. However, respiratory cancer was not included in the final list considering it more a consequence of tobacco abuse than a prime priority. In fact, all interventions proposed by the respondents in the Delphi survey to improve the situation with regard to respiratory cancer were linked to tobacco abuse.

(2) Clear links between priorities identified through the DALY and the Delphi method lead to further inclusion of chronic back pain, instead of osteoarthritis, and depression. These decisions were supported by data currently available for the canton of Geneva. In 1993, 9.4% of women and 5.6% of men reported a medically diagnosed depression during a population-based survey. This was considerably higher than the Swiss average (5.4% and 2.5% respectively).44 In addition, 36% of women and 31% of men considered themselves to be in bad mental health. In the same survey a quarter of the respondents said they had suffered from joint problems or acute back pain in the preceding month. In addition, bone and joint disease (mainly back problems) are the main cause for attributing an invalidity pension to men.

(3) Finally, the three main social determinants solely identified through the Delphi survey (violence in the family, unemployment, social exclusion) were included as they were consistently considered important by professionals and the lay public alike. Regarding violence in the family, data on physical abuse of children, including sexual abuse, are still very patchy. We know, however, that physical abuse of children is pervasive in Switzerland,45 and that a third of school aged girls and 10% of boys in Geneva have suffered from some type of sexual abuse.46 The first study on domestic violence against women was carried out in Switzerland in 1996, showing that during their life time 20% of women had been physically and 40% psychologically abused by their partner(s).47 Having included violence in the family as a priority, we discarded a “deteriorated family environment” in the list of determinants. Unemployment and social exclusion were both considered important though broad and “indirect” health determinants. Participants in the survey had pointed to the frequency and recent increase of these phenomena and their important impact on health, often referring to a vicious cycle, including several of the determinants (that is, unemployment can lead to a deteriorated family environment, to additional stress, to alcohol abuse and social exclusion). In fact, the unemployment rate has tripled in Geneva since the beginning of the 1990s and in particular, long term unemployment (more than one year) has increased 20-fold. Some local studies have shown the severe impact of unemployment on health status.48 49

Moving from the results of the PYLL analysis to those of the DALY study to those of the Delphi survey, we found convergence on certain priorities, and that each subsequent method also broadens and enriches the argument. Obviously the concept inherent in each method “drives” the result. The limitations of the premature mortality analysis in setting priorities in low mortality populations stems from the fact that it excludes all non-fatal consequences of acute and chronic conditions and that deaths occurring after age 75 are not considered a loss. The DALY method circumvents these problems, but in turn is unable to identify psychosocial and socioeconomic health conditions and determinants perceived by the population as important issues. The Delphi method provides the broadest view on health, but may be dependent on the selection, responsiveness and quality of the participants. Two advantages of this method are that it portrays the perceived importance of health problems and their determinants, and that it allows to elicit opinions on the most effective interventions to tackle them. It thus takes into account social preferences and points to actions that are seen as feasible and acceptable.

The main limitation of this approach is that each method uses by design a different classification of health problems thus leading to a certain subjectivity in the comparison of results and the final choice. However, based on our findings, we believe that health priorities, and by extension health care priorities, may benefit from using a mix of quantitative and qualitative research methods. Qualitative results alone, however valuable, would most probably not be agreeable if they were not supported by epidemiological data and analyses, such as the burden of disease. The triangulation of results allows for a broader perspective, makes the final choice socially more acceptable and improves consensus on the choice of priorities. This may be particularly important as the priorities selected for the canton of Geneva incorporate broader social issues that have traditionally been left out when setting health priorities. As demonstrated by the responses to the Delphi survey resolving these problems will require inter-sectoral collaboration rather than relying on health care services as the unique response, thus implying a strong commitment of all parties concerned.