ORIGINAL ARTICLE

Setting priorities in preventative services

Daniela Salzmann & Adele Diederich

Received: 25 February 2013 /Accepted: 25 June 2013# Springer-Verlag Berlin Heidelberg 2013

AbstractAim We investigate opinions regarding which preventativeservices should be given priority funding; the importance ofprimary, secondary and tertiary prevention; and bivariateassociations between the respondents’ sociodemographics,health status and lifestyle and their preferences.Subjects and methods Computer-assisted personal interviews(CAPI) were conducted with participants from a regionalquota sampling by sex, age and socioeconomic status (SES)in Germany. Participants were asked to indicate whether theywould keep the status quo, expand or reduce health-careprovision for eight primary, six secondary and four tertiarypreventative services. Furthermore, they stated the importanceof primary, secondary and tertiary prevention on a four-pointLikert scale. Data were evaluated using contingency analysisand correspondence analyses.Results One hundred and three people completed the survey.The majority of participants opted for expanding non-medicalprimary preventative services like health education andcounselling and for expanding secondary preventative serviceslike cancer screening. For tertiary prevention, like rehabilita-tion, the desired service distribution depends on the specificpreventative services. Therewere few differences in answers tothe questions on the importance of the provision in primary,secondary and tertiary prevention. Bivariate associations be-tween the respondents’ characteristics like age, SES, healthstatus and lifestyle and their preferences could be observed.Conclusion Primary preventative services and disease detec-tion should receive more funds. No consistent pattern could

be detected for tertiary prevention. Respondents expressedsome differences of opinion on the importance of types ofprevention. The differences are related to knowledge, per-sonal circumstances and interests of the respondents.

Keywords Prevention . Priority setting .Citizen preferences .

Germany . Survey

Introduction

Health-care expenditure is increasing worldwide. Aging so-cieties, shifting demographics, changing epidemiology andexpensive medical technology all contribute to the financialburden being experienced by both publicly and privatelyfunded systems. Cross-national comparisons found that in2009, the United States (US) had the highest health-carespending in relation to gross domestic product (GDP). Thisspending was almost twice as high as the spending in En-gland (9.8 %), with Germany spending 11.6 % of its GDP onhealth-care in that year (OECD 2012).

One solution to overcoming financial pressures on healthsystems is to set priorities in the distribution of health ser-vices (Ham 1997; Gibson et al. 2004). In several countriessuch as Norway, New Zealand, the Netherlands and theUnited Kingdom (UK), policy makers have already priori-tized health-care services (Ham 1997; Sabik and Lie 2008).When implementing prioritization, it is expedient first of allto investigate the situation within a clearly defined health-care area such as prevention. Against this background, thisstudy focuses on setting priorities within prevention in Ger-many, where about 4 % of the health-care costs were spent onprevention in 2008 (Gesundheitsberichterstattung des Bundes2010). Preventive measures are commonly classified as prima-ry (preventing diseases from occurring), secondary (screeningof asymptomatic individuals with the aim of early detectionand illness treatment) and tertiary (treatment of patients with a

Electronic supplementary material The online version of this article(doi:10.1007/s10389-013-0581-8) contains supplementary material,which is available to authorized users.

D. Salzmann (*) :A. DiederichSchool of Humanities and Social Sciences, Jacobs University,Campus Ring 1, 28759 Bremen, Germanye-mail: d.salzmann@jacobs-university.de

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focus on rehabilitation and curing or prevention of complica-tions); (Walter and Schwartz 2003).

Research has shown that if priority-setting decisions are tobe accepted, it is important to include the public in thedecision-making process (Ham 1997). The Ljubljana charteron reforming health care in Europe therefore states that“Health care reforms must address citizens’ needs takinginto account, through the democratic process, their expecta-tions about health and health care” (World Health Organiza-tion, WHO 1996). In addition, legitimizing health policydecisions involves including both the healthy and the sick(Fleck 2002; Bruni et al. 2008). However, very little has beenreported from the public’s perspective on setting prioritiesfor various services within the preventative area of healthcare. The current study is a first step in closing this gap.

In this study, we examined people’s preferences on preven-tative services. The aims of this study were (1) to gatherinformation about the public’s opinion on which preventativeservice should given priority funding; (2) to assess the public’sopinion of the importance of the provision of primary, sec-ondary and tertiary prevention; and (3) to examine bivariateassociations between the respondents’ sociodemographics,health status and lifestyle and their preferences towards andthe importance of preventative services.

Methods

Sampling

A purposive sample of 100 participants was drawn from theregional population of Bremen and the vicinity. Bremen is acity state of Germany (about 600,000 inhabitants) but shouldnot be considered as a representative sample of the entirepopulation of Germany. A newspaper advertisement andflyers in public places and public offices invited citizens aged18 and above to participate in the study. Since both theadvertisements and the flyers only resulted in a small numberof responses frommen “≤45 years”, citizens were additionallyaddressed directly. Respondents were selected according tothe criteria sex, age groups and socioeconomic status (SES).The target was to recruit about the same number of men andwomen. The distribution of the respondents’ age was in agegroups that were in line with the distribution in the Germanpopulation; thus, 44 % people needed to be 45 years oryounger (Bundesministerium für Arbeit und Soziales 2009).SES was measured using academic and professional educa-tion, monthly household income after taxation and current orlast employment status. The target was to recruit roughly 20%of respondents with a low SES, 55 % with a moderate SESand 30 % with a high SES (Knopf et al. 1999).

The interviews were carried out at Jacobs University andat the University of Bremen. Where respondents had been

directly recruited, the interviews were conducted in the in-stitutions where the recruitment took place. Data were col-lected between May and August 2010 using computer-assisted personal interviews (CAPI). At the beginning ofthe interview, respondents consented orally to the interview.Respondents were not paid for their participation but wereoffered free drinks and biscuits during the interviews.

Questionnaire

The preferences of the public towards preventative serviceswere investigated using a questionnaire. The topics addressedin the questionnaire were based on results obtained from anexplorative interview study on prioritizing health with 45members of six different stakeholder groups (Heil et al.2010) and from questions asked in a population survey inGermany about views and preferences on priority setting(Diederich and Schreier 2010). The questionnaire consistedof seven sections: (1) personal experience with prevention, (2)preferences about the distribution of preventative services, (3)preferred prioritization according to patient groups, (4) prior-itization of types of prevention, (5) prioritization in specialcases, (6) financing of preventative services, and (7) decision-makers in the allocation of preventative services. Responseswere measured on categorical scales (binary, multi-nominal,and ordinal). Response options “don’t know” or “responserefused” were offered only when mentioned by the respon-dents themselves. The questionnaire closed with questions onsocio-demographics (e.g. sex, age, and SES), questions ondisease status and self-reported health behaviours (heightand weight to determine the body mass index, BMI), physicalactivity, smoking and alcohol consumption).

To answer the research questions, this paper followsDiederich’s work but focuses only on the second section‘questions about preferences relating to the distribution ofpreventative services’. For this survey, four pertinent questionswere asked. The first three questions were used to determinepreferences for particular preventative services. These ques-tions addressed certain primary, secondary and tertiary preven-tative services that are currently financed by public healthinsurances. Participants were instructed to indicate whether, ifthey could decide, they would (1) expand, (2) reduce, or (3)maintain the services as they are (for verbatim instructions andphrasing, see electronic supplementary material, ESM). Thefourth question was related to the importance of prioritizing.

The first question focused on primary preventative ser-vices. The participants responded to the question, “What doyou think? Which of those services should be expanded,which should be reduced and which should be maintainedthe same?” for eight preventative services: (1) vaccinations,(2) courses in dieting, (3) courses in physical activity, (4)courses in dehabituation, (5) courses in stress relief, (6) work-place health promotion (WHP), (7) health projects in spheres

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such as schools and retirement homes, (8) health educationand counselling.

The second question addressed secondary prevention.Respondents were asked to indicate whether they wouldkeep the status quo, expand or reduce the following sixsecondary preventative services: (1) medical check-ups, (2)cancer screening, (3) pediatric examinations, (4) youthhealth examinations, (5) prenatal care, (6) dental prevention.

The third question focused on tertiary prevention. Hererespondents were offered four items: (1) rehabilitation, e.g. acourse of treatment, (2) self-help groups, (3) disease man-agement programs (DMPs) for the chronically ill, e.g.Curaplan from the German public health insurance company(AOK) for diabetes, (4) training courses for those sufferingfrom different illnesses, e.g. the skin disease neurodermatitis.

The last question was used to determine the importanceattached to the provision of preventative services in primary,secondary and tertiary prevention in general. Participants wereinstructed to indicate the importance of the provision of each typeof prevention (for verbatim instructions and phrasing, see ESM).

Respondents to the question “How important is it for youthat priorities are set in the provision of the following typesof prevention?” were given three types of prevention: (1)services for diseases prevention, (2) services for early dis-ease detection and (3) services for preventing complications.The importance of the provision could be indicated on a four-point Likert scale ranging from ‘very important’ to ‘notimportant’.

Statistical analysis

The data was analyzed using SPSS.We conducted exploratorycontingency analysis to investigate the association betweenthe respondents’ age, sex, SES, health status and lifestyle andtheir preferences towards preventative services. To uncoverpatterns in the preventative services, a correspondence analy-sis was conducted on the results of the first three questions.Correspondence analysis enables us to explore the structure ofcategorical variables included in two-way and multiple-waytables and allows us to visualize the associations between thelevels of the categories. Correspondence analysis is similar toprincipal component analysis, but applies to categorical data,i.e., contingency tables rather than to continuous data (formore details see e.g. Greenacre 2007). People who chose the“don’t know” or “response refused” option were excludedfrom the correspondence analyses.

The SES was measured using the Winkler Index, whichconsists of three socioeconomic indicators: academic and pro-fessional education, monthly household income after taxationand current or last employment status. Every indicator rangesfrom one to seven points. One point represents the lowest andseven points the highest SES. The Winkler Index thus rangesfrom 3 to 21 points. The first group (3–8 points) represents low

SES, the second (9–14 points) the middle SES and the third(15–21 points) the high SES (Lampert and Kroll 2006).

Health behaviour was classified using a lifestyle index(Diederich et al. 2012). The lifestyle index is based on theindicators smoking (non-smokers vs. smokers), alcohol-consumption (no/little, moderate, heavy), BMI (normal weight,BMI: 18.5–24.99; overweight, BMI: 25–29.99; obese, BMI≥30), physical activity (often, three or more times a week;moderate, one or two times a week; and never/seldom). Eachcategory value was assigned one, two and three points, whereone point represents behavior that presumably does not affecthealth negatively, and three points represents behavior thatpresumably negatively affects health the most. A lifestyle indexwas determined by adding the points. The lifestyle categorywas defined on the basis of this index: healthy (4–5 points),average (6–7 points), and unhealthy (8–12 points). Note that thecategories for non-smoking and smoking received one andthree points, respectively (Diederich et al. 2012).

Results

Demographics

Of the sample, 53 respondents (51.5 %) were female and 50respondents male. Participants’ ages ranged from 19–79 years(mean=46.37 years; SD=16.35). According to the WinklerIndex, 50.5 % of the respondents belonged to the middle SES,30.1 % to the low SES and 19.4 % to the high SES class. Athird (34.0 %) of the sample reported suffering from a chronicdisease; two thirds (66.0 %) reported having no chronic dis-ease. Of all respondents, 35 % reported drinking no or just alittle alcohol, 71.8 % drinking moderately and 1.9 % drinkinga lot of alcohol. The majority (76.7 %) of the survey-population were non-smoking and 23.3 % smoked. Withrespect to physical exercise, 18.4 % of the respondents report-ed being seldom or never physically active, 46.5 % weremoderately physically active and 35 % were very often phys-ically active. Almost half of the respondents (46.0 %) could beclassified as overweight (BMI: 25.0–29.9), followed by thosewith normal weight (36.5 %) (BMI≤25.0), and 17.5 % wereobese (BMI ≥30.0). According to the lifestyle index, 15.5 %of the sample led a healthy lifestyle, 55.3 % had an averagehealth lifestyle, and 29.1 % had an unhealthy lifestyle.

Preferred prioritization according to the three levelsof prevention

The majority of respondents indicated that specific primary,secondary and tertiary preventative services should be ex-tended. Respondents desired an expansion of the following:(1) setting projects in spheres such as schools and retirementhomes (81.6 %); (2) cancer screening (71.8 %); (3) health

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education and counseling (70.9 %); (4) WHP (68.9 %); (5)courses in physical activity (68.0 %); (6) courses in dieting(65.0 %); (7) medical check-ups (63.1 %); and (8) youthhealth examinations (55.3 %). The majority of respondentswere satisfied with the currently offered services for vaccina-tions (62.1%), dental care (58.3 %) and prenatal care (52.4 %).There was no clear majority for expanding or maintaining thestatus quo for pediatric examinations, DMPs, rehabilitation(e.g. a course of treatment) and courses in stress relief. Therewas a wide range in responses regarding expanding, reducingor maintaining the funds for courses in dehabituation and self-help groups. However, in the opinion of the majority, none ofthe preventative services should be reduced. To illustrate theseresults, a correspondence analysis was conducted (see Figs. 1,2, and 3 for details; the summary statistics are found in theelectronic supplementary material, ESM).

Respondents especially wanted an expansion of non-medical primary prevention and most measures for diseasedetection (secondary prevention measures). No consistent pat-tern could be detected for tertiary preventative services. Onlythose preventative services associated with personal responsi-bility such as self-help groups and courses for dehabituation,were rated differently.

An exploratory contingency analysis showed that therewere bivariate associations between some respondents’ char-acteristics and preferences for some preventative services(see Table 1 for details).

Associations between respondents’ characteristics andtheir preference with respect to preventive services

& Participants of the younger age group more often stated apreference for reducing ‘prenatal care’ while participantsof the older age group preferred to expand ‘prenatal care’.

& Respondents with a low SES more often stated a prefer-ence for maintaining the current level of service for‘courses in physical activity’ than did respondents witha high SES. People with a low SES preferred to expand‘pediatric examination’ more often than did people witha moderate or high SES. People with a moderate SESprefer to maintain the status quo in ‘pediatric examina-tion’ while people with a high SES prefer to reduceservices in this area.

& Participants with a chronic disease opted for expanding‘courses for stress relief’, ‘DMP’ and ‘training courses fordifferent illnesses’ more often than did people without achronic disease. People without a chronic disease pre-ferred more often to maintain the present level for thesepreventative services.

& People with an unhealthy lifestyle wished to expand ‘can-cer screening’ more than those with a healthy or averagelifestyle.

& The gender of the respondents did not cause significantdifferences between the groups (see Table 1 for details).

The answers to the fourth question show that, overall, therewere few differences in the importance placed on the provi-sion of primary, secondary and tertiary prevention servicesgenerally. However, it could be seen that ‘services for earlydisease detection’, was given the highest importance, follow-ed by ‘services for preventing complications’ and ‘services fordiseases prevention’. Additionally, the results of the contin-gency analysis show that women and older age groups statedmore often than men or younger age groups that tertiaryprevention is ‘very important’. People with a high SES statedmore often than people with a low or moderate SES thatsecondary prevention is ‘rather important’. Characteristics like

Fig. 1 Biplot for primarypreventative services andresponse categories: Dimension1 accounts for 80.2 % of the11.4 % of the variance explainedby the model

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chronic disease and lifestyle could not be associated with therespondents’ preferences (see Table 2 for details).

Discussion

This study allows a first insight into the public’s opinion of theprioritization of various preventative services. The studyassessed the general public’s opinions about which preventa-tive services should be given priority funding. In addition, thepreferred types of prevention were tested as potential criteriafor prioritizing different services in this area. This information

provides an initial basis for making informed decisions aboutthe funding and availability of different preventative services.

Overall, for many preventative services, the majority rat-ed to expand the resources. This may reflect the fact that thepublic perceive there to be too few resources devoted to thesepreventative services.

In addition, the results show that the public perceived thelargest gap in non-medical primary prevention and diseasedetection measures. One explanation for this would be thatpeople realized that these preventative services reduce mor-bidity and prevent suffering. No consistent pattern could bedetected for tertiary preventative services.

Fig. 2 Biplot for secondarypreventative services andresponse categories: Dimension1 accounts for 85.3 % of the7.9 % of the variance explainedby the model

Fig. 3 Biplot for tertiarypreventative services andresponse categories: Dimension1 accounts for 85.6 % of the7.1 % of the variance explainedby the model

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Interestingly, the respondents voted to maintain the samelevel of services for ‘vaccinations’ and ‘dental care’ althoughvaccinations have been given clear priority in the national andinternational literature (Mak et al. 2011; Müller and Groß2009; Heginbotham 1993; Liedtke 2009). It is possible thatthe provision of vaccinations has reached a satisfactory levelin Germany. This result also shows that the public reflects thecurrent state of provision and would not necessarily extend allpreventative services. A high level of acceptance of personalresponsibility principally affected the fact that some respon-dents voted to reduce the services ‘courses in dehabituation’and ‘self-help groups’.

However, it was found that the survey population had somedifferences in their priorities, in particular in relation to age, SES,

disease status and lifestyle. Surprisingly, only the old age groupswanted to expand ‘prenatal care’. In particular, people with ahigh SES desired an expansion of resources for ‘courses inphysical activity’. Interestingly, people with a low SES werethe most likely to answer that ‘pediatric examination’ should beexpanded. This is probably due to the fact that people with a highSES know that many diseases can be avoided with regularphysical activity. Furthermore, it is possible that people with anunhealthy lifestyle are aware of their higher risk of falling ill, andthey therefore want to expand services for ‘cancer screening’.Respondents with chronic diseases desired an expansion of the‘courses for stress relief’, ‘DMP’ and ‘training courses for dif-ferent illnesses’. These results suggest that the importance ofthese preventative services depends on personal circumstances

Table 1 Bivariate associations of respondents’ characteristics on preventive services

Expand Reduce Maintain No data χ2 p-value

Bivariate association ofage on ‘prenatal care’

Age < 45 years 19.6 7.8 54.9 17.6 7.998 0.040

> 45 years 38.5 0 50.0 11.5

Bivariate association of SESon ‘courses in physical activity’

SES Low 51,6 0 45.2 3.2 10.984 0.049

Moderate 69.2 3.8 25.0 1.9

High 90.0 0 10.0 0

Bivariate association of SESon ‘pediatric examination’

SES Low 74.2 0 22.6 3.2 28.466 0.000

Moderate 40.4 0 59.6 0

High 30.0 5.0 45.0 20,0

Bivariate association of healthstatus on ‘courses in stress relief’

Health status Chronically ill 71.4 5.7 20.0 2.9 11.464 0.002

Healthy 47.1 1.5 51,5 0

Bivariate association of health statuson ‘DMPs’

Health status Chronically ill 62.9 0.0 34.3 2.9 6.469 0.043

Healthy 36.8 0.0 55.9 7.4

Bivariate association of health status‘training courses for different illnesses’

Health status Chronically ill 74.3 5.7 20.0 0.0 7.598 0.033

Healthy 52.9 1.5 42.6 2.9

Bivariate association of lifestyle on‘cancer screening’

Life style Healthy 68.8 0 31.3 0.0 9.308 0.025

Average 64.9 1.8 33.3 0.0

Unhealthy 86.7 6.7 6.7 0.0

Proportion (in percent) of the distribution expand, reduce, maintain, and no data regarding the item: “What do you think, which of those servicesshould be expanded, which should be reduced and which should maintain the same?” differentiated by significant respondents’ characteristics. Theother variables were not significant

DMP Disease Management Program

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and interests. However, future studies on the topic of settingpriorities, especially for prevention, are recommended. It isimportant to know how the public perceives the importanceof preventative measures and services because this will deter-mine their acceptability, usage, and impact.

International studies on how the public would prefer health-care services to be allocated show that prevention is a health-care area that, in comparison with other health-care areas, isclearly prioritized (Kneeshaw 1997; Mossialos and King 1999;Ryynänen et al. 1999). Prevention is rated highly with littleinconsistent response behavior, even when different questionsor question types are used (Kneeshaw 1997). In different inter-national studies, prevention is assessed higher than the otherlisted areas of care (Müller andGroß 2009; Heginbotham 1993)or respondents opted for spending a greater value of the health-care fund on prevention rather than treatment (Johannesson andJohansson 1997; Ubel et al. 1998). However, as far as we know,little research has been done on explicitly examining people’spreferences for different types of prevention.

Etter (2009) examined the public’s options on prioritizingthe distribution of health-care funds to several arbitrary healthproblems in 1996 and 2006 in Switzerland. The study containsmore concrete preventative services than this study, makingcomparability partially restricted. In that study, in third place,the prevention of tobacco smoking rated relatively high.Mammography screening was rated comparatively low. Anddiet and lack of physical activity received the lowest priority.

This study was conducted to gather views of members ofthe general public on prevention and preferences for differenttypes of prevention services within the German statutoryhealth insurance. The study focuses on one clearly definedhealth-care area: prevention. The results show preferencesfor prevention from the public’s view.

The respondents had to decide on the expansion, reduc-tion or laissez-faire of several preventative services offered

by the statutory health insurance. The aim was to gatherinformation about the public’s opinions regarding whichpreventative service should be given funds as a priority. Asa result of the research, it was possible to detect gaps inpreventative service provisions (e.g. setting projects inspheres such as schools and retirement homes) and observepreventative services where provision has reached a satisfac-tory level (e.g. vaccinations) from the public’s point of view.

This study has several limitations relating to sample sizeand survey questions. The sample was not representative ofthe German population, and the results thus provide only aninsight into the views of the public regarding the preferencesof preventative services of statutory health insurance. Oneway to overcome this problem would be to increase thesample size. The questionnaire items were developed for thissurvey and have not been validated, e.g. with test–retestreliability. When people were asked to assess which primary,secondary and tertiary preventative services they thoughtshould be extended, stay the same or be reduced, mostpeople stated a preference to expand resources for preventa-tive services. This does not seem too surprising when real-izing that no budget constraints were given and respondentswere not asked for out-of-pocket payments for additionalservices. Future research should use such questions withina scenario, whereby not everything can receive funding andthen respondents would have to set priorities themselves.

Additionally, when asked with a priority-setting question(the fourth question) to rate the importance of each type ofprevention, most of the respondents stated that all wereimportant. Further research should use discrete choice ex-periments (DCE) to prevent such an answer as this and thusreceive results of more value for policy decision-makers.DCEs require respondents to make value judgments aidedby choosing the type of prevention they would prefer, andthese choices in turn reflect how real decisions are made.

Table 2 Bivariate associations of respondents’ characteristics on importance of types of prevention

Very important Rather important Rather not important No Data χ2 p-value

Bivariate association of age on ‘services for preventing complications’

Age < 45 years 33.3 56.9 7.8 2.0 15.432 0.000

> 45 years 71.2 29.9 1.9 0.0

Bivariate association of gender on ‘services for preventing complications’

Gender female 64.2 30.2 3.8 1.9 7.563 0.031

Male 40.0 54.0 6.0 0.0

Bivariate association of SES on ‘services for early disease detection’

SES Low 71.0 25.8 3.2 8.037 0.035

Moderate 61.5 30.8 7.7

High 35.0 60.0 5.0

Proportion (in percent) of the distribution very important, rather important, rather not important and not important concerning the item: ‘Howimportant is it for you that there are set priorities in the provision of the following types of prevention?’ differentiated by significant respondents’characteristics. The other variables were not significant

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Acknowledgements The research was supported by the German Re-search Foundation (DFG) DI 506 10–2 granted to the second author.

Conflict of interests The authors declare that they have no conflict ofinterest.

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