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PubMed1996

Reduction of maternal and perinatal mortality in rural and peri-urban settings: what works?

The purpose of this article is two-fold: (i) to lay out conceptual frameworks for programming in the fields of maternal and neonatal health for the reduction of maternal and peri/neonatal mortality; (ii) to describe selected MotherCare demonstration projects in the first 5 years between 1989 and 1993 in Bolivia, Guatemala, Indonesia and Nigeria. In Inquisivi, Bolivia, Save the Children/Bolivia, worked with 50 women's groups in remote rural villages in the Andean mountains. Through a participatory research process, the 'autodiagnosis', actions identified by women's groups included among others: provision of family planning through a local non-governmental organization (NGO), training of community birth attendants, income generating projects. In Quetzaltenango, Guatemala, access was improved through training of traditional birth attendants (TBAs) in timely recognition and referral of pregnancy/delivery/neonatal complications, while quality of care in health facilities was improved through modifying health professionals' attitude towards TBAs and clients, and implementation of management protocols. In Indonesia, the University of Padjadjaran addressed issues of referral and emergency obstetric care in the West-Java subdistrict of Tanjunsari. Birthing homes with radios were established in ten of the 27 villages in the district, where trained nurse/midwives provided maternity care on a regular basis. In Nigeria professional midwives were trained in interpersonal communication and lifesaving obstetric skills, while referral hospitals were refurbished and equipped. While reduction in maternal mortality after such a short implementation period is difficult to demonstrate, all projects showed improvements in referral and in reduction in perinatal mortality.

Bolivia↗
PubMed1992

America's children: economic perspectives and policy options.

American children are worse off than those in the previous generation in several important dimensions of mental, physical, and emotional well-being. During the 1960s cultural changes adversely affected children while their material condition improved substantially. By contrast, material conditions deteriorated in the 1980s, especially among children at the lower end of the income distribution. Public policies to improve the material condition of children require a transfer of resources from households that do not have children to those that do. Government programs such as tax credits and child allowances are more efficient and equitable than employer-mandated programs.

Adult↗
PubMed2004

The effect of cigarette price increase on the cigarette consumption in Taiwan: evidence from the National Health Interview Surveys on cigarette consumption.

BACKGROUND: This study uses cigarette price elasticity to evaluate the effect of a new excise tax increase on cigarette consumption and to investigate responses from various types of smokers. METHODS: Our sample consisted of current smokers between 17 and 69 years old interviewed during an annual face-to-face survey conducted by Taiwan National Health Research Institutes between 2000 to 2003. We used Ordinary Least Squares (OLS) procedure to estimate double logarithmic function of cigarette demand and cigarette price elasticity. RESULTS: In 2002, after Taiwan had enacted the new tax scheme, cigarette price elasticity in Taiwan was found to be -0.5274. The new tax scheme brought about an average annual 13.27 packs/person (10.5%) reduction in cigarette consumption. Using the cigarette price elasticity estimate from -0.309 in 2003, we calculated that if the Health and Welfare Tax were increased by another NT 3 dollars per pack and cigarette producers shifted this increase to the consumers, cigarette consumption would be reduced by 2.47 packs/person (2.2%). The value of the estimated cigarette price elasticity is smaller than one, meaning that the tax will not only reduce cigarette consumption but it will also generate additional tax revenues. Male smokers who had no income or who smoked light cigarettes were found to be more responsive to changes in cigarette price. CONCLUSIONS: An additional tax added to the cost of cigarettes would bring about a reduction in cigarette consumption and increased tax revenues. It would also help reduce incidents smoking-related illnesses. The additional tax revenues generated by the tax increase could be used to offset the current financial deficiency of Taiwan's National Health Insurance program and provide better public services.

Adolescent↗
PubMed2000

Health education leading to community action in Ghana.

In rural Ghana, women face a tough time as there is little in the way of health facilities, few health workers, and the women have to farm as well as raise children and keep house. Community male elders and the younger men in the community do not pay much attention to the reproductive health problems faced by women. Providing information and education for health is the key to enable people to realize their needs and initiate joint community actions to achieve better health. However, such information needs to be disseminated in a manner, which is easily accepted by the people. The Planned Parenthood Association of Ghana has taken the approach of utilizing drama performances by their health volunteers, which tackle the real life problems existing in a village, such as a woman troubled by too much childbirth. When information is given in this way, a form rooted in traditional culture, the messages of health education are readily acceptable. Along with the support of village elders and residents, health education becomes a valuable tool to encourage joint community efforts in solving health problems. Changes are occurring. A local steering committee was set up involving all groups, including chiefs, community leaders and CBDAs. Various activities have been initiated and expanded in the community in collaboration and participation with community leaders and the residents. Some of these are home visits by CBDAs, outreach services, environmental sanitation campaigns, and income generating activities and vocational training for women.

Africa↗
PubMed1997

[A drug revolving fund program for rural villages in the Philippines].

In 1994, a community-based drug revolving fund program was introduced in 10 pilot villages in the province of Tarlac, Philippines, as a component of a health project by the provincial health office and Japan International Cooperation Agency (JICA). The purpose of the program was to set up a cooperative drug store in each community in order to regularly provide rural residents with essential drugs at affordable prices. The following are the results and findings during the first two years of operation. 1. Collaboration with a local NGO facilitated implementation and management of the program, when socio-cultural consideration was necessary. Stable and prompt procurement of drugs was secured on a contract with a commercial wholesaler in Manila. 2. Out of the 105 kinds of pharmaceuticals that were sold both in the cooperative and commercial drug stores, 83% were less expensive than the average market price, and 51% were discounted more than 25% of the market price. 3. The levy of premiums was introduced to increase the cooperative fund with the consent of each community. The amount was 0.1-0.2% of the average family income. However, regular collection of premiums was difficult due to various reasons. The practice of the sales on credit was common in all pilot villages. 4. While the knowledge of community health workers, who were in charge drug sales, was improved after training sessions on rational drug use, it was not at a sufficient level yet. 5. When assisting a community-oriented health program, an exterior organization should try to encourage the community to generate its own solutions to operational difficulties, based on the socio-cultural context in the community.

Community Participation↗
PubMed2004

Dietary pattern change and acculturation of Chinese Americans in Pennsylvania.

OBJECTIVE: To obtain information about dietary pattern change of Chinese Americans in Pennsylvania and its relationship with demographic characteristics and acculturation indicators. DESIGN: A cross-sectional self-administered survey. SUBJECTS: A convenience sample of 399 Chinese Americans. Statistical analyses performed t Tests, analysis of variance with Tukey post-hoc tests, Spearman rank correlation, and chi(2) test. RESULTS: After immigration, Chinese Americans increased consumption frequency of all seven food groups (grains, vegetables, fruits, meat/meat alternatives, dairy products, fats/sweets, and beverages) and Western foods while consumption frequency of traditional Chinese foods decreased. Dietary variety also increased after immigration. Higher education and higher income levels were associated with a larger increase in consumption frequency of grains, vegetables, and fruits. Persons who resided in the United States for a longer period of time shared a greater increase in their consumption frequencies of vegetables, fats/sweets, and beverages. Persons with better English proficiency had a greater increase in their consumption frequency of grains, fruits, meat/meat alternatives, and fats/sweets. CONCLUSIONS: This study can help nutrition educators design appropriate educational programs for first-generation Chinese Americans that can facilitate the adoption of more healthful dietary practices. Nutrition educators should consider the dietary changes of Chinese-American participants, such as skipping breakfast and increased consumption frequency of fats, sweets, and soft drinks, which were observed in this study. For example, acculturated first-generation Chinese Americans should be encouraged to decrease fats, sweets, and soft-drink consumption. Less-acculturated persons should be encouraged to maintain their healthful dietary pattern and increase consumption of vegetables and fruits.

Acculturation↗
PubMed1991

Using new electronic information products to fund others.

Small medical libraries can, with a planned approach, respond positively to extra user demands generated by new information products, such as CD-ROM databases, by taking the initiative to raise, through fee-based services, income which can be used to fund other products.

Budgets↗
PubMed1984

Who will pay for medical education in our teaching hospitals?

Although most medical educators believe that education, research, and patient care are inseparable and essential to their academic mission, the educational component of this triad has never been given adequate, earmarked support. To fund educational programs, medical centers first relied on research grants and later on third-party payments intended for patient care. However, research money has long since ceased to be available for other purposes and recent federal cost containment measures have started to reduce payments for patient care. Teaching hospitals are threatened with loss of support not only for education, but for their capital improvements and care of the poor. Many institutions are now hoping to generate new income through business deals with for-profit health care corporations, but this effort probably will also fail and may compromise professional traditions. Teaching hospitals serve the public interest and will have to depend, at least in part, on public subsidy of their unavoidable extra costs.

Costs and Cost Analysis↗
PubMed2004

[The expanded enrollment form in the Brazilian Family Health Program as a management tool for diagnosis of living and health conditions].

As a consequence of the introduction of the Family Health Program in the city of Sao Paulo, Brazil, a pilot experiment was conducted with an expanded enrollment form for gathering information on families at two school health services. The aim of the study was to analyze this enrollment form as a management tool capable of identifying differences and inequities in each area. The collected data provided the basis for generating six related indicators: time of residence in the area, family members per bedroom, per capita family income, number of children as a percentage of total family members, schooling, and health insurance coverage. A compound indicator was constructed, called the Mean Living Standard Score, in addition to another indicator -- Mean Score/ Basic Health Care Information System -- from the three indicators existing in form A of the Basic Health Care Information System. The results identified contiguous geographic areas with different living standards. The two scores showed similar discriminatory power. In conclusion, it is possible to differentiate and discriminate sub-areas, thereby highlighting the need to organize different health actions for each sub-area.

Brazil↗
PubMed2003

Emergence of resistance and resistance management in field populations of tropical Culex quinquefasciatus to the microbial control agent Bacillus sphaericus.

In recent years, highly potent mosquitocidal strains of the microbial agent Bacillus sphaericus (Bsph) have been isolated and developed for the control of mosquito larvae around the world. Laboratory selection experiments with the most active strains and their use in large-scale operational mosquito control programs resulted in the emergence of resistance in larvae of the Culex pipiens complex. This generated great concern among vector control agencies around the world, who feared reduced efficacy of this highly active larvicidal agent. To address this issue, the current studies were started to find practical strategies for controlling resistant mosquitoes and more importantly to develop resistance management strategies that would prevent or delay development of resistance. We initiated field studies in 3 low-income communities in Nonthaburi Province, Thailand. In 1 of the communities, larvae of Culex quinquefasciatus that were highly resistant (>125,000-fold) to Bsph strain 2362 were successfully controlled with applications of Bacillus thuringiensis var. israelensis (Bti) alone or in combination with Bsph. To prevent or delay resistance to Bsph, 2 other sites were selected, 1 treated with Bsph 2362 alone and the other treated with a mixture of Bsph 2362 and Bti. Mosquitoes treated with Bsph 2362 alone showed some resistance by the 9th treatment and almost complete failure of control occurred by the 17th treatment. After 9 treatments with the mixture over a 9-month period at another site, no noticeable change in susceptibility to Bsph was detected. During this period, the site treated with Bsph alone required 19 treatments, whereas the site treated with mixtures took only 9 treatments because of slower resurgence of larvae at the site treated with the mixture than at the site treated with Bsph alone. This is the 1st field evidence for delay or prevention of resistance to microbial agents in larval Cx. quinquefasciatus by using mixtures of Bti and Bsph. Further studies on the use of mixtures for the management of field resistance are warranted.

Animals↗
PubMed1976

Issues in national health insurance.

Health insurance, by reducing net price to the consumer and increasing the opportunities for revenue to the provider, has profound effects, among other things, on the volume, content and distribution of services, their prices, and the capacity of providers to produce them. The magnitude and nature of these effects depend, partly, on the design of insurance benefits and, partly, on the nature of the health care system, particularly its current and potential capacity and the methods it uses to pay providers. Those who believe that the unique aim of insurance is to protect against unpredictable expenses attempt to suppress these effects, mainly by imposing financial disincentives to utilization which, in turn, reduce protection for those who need it most. Those who wish to reform the system have a broader range of objectives which include protective efficacy, cost control, quantitative adequacy, qualitative adequacy, efficiency of production, efficiency of allocation, equity, and redistribution of capacity. An analysis of the effects of insurance in the light of these objectives reveals favorable as well as unfavorable consequences. The provision of comprehensive benefits generates the necessity for a fundamental change in the organization of health services, if the advantages are to be fully realized and the disadvantages minimized.

Deductibles and Coinsurance↗
PubMed2005

The economic effect of a tertiary hospital-based heart failure program.

OBJECTIVES: This study was designed to determine the economic effect of a tertiary heart failure (HF) program at an academic medical center. BACKGROUND: Most hospitals use cross-sectional financial models to analyze the economic contribution of clinical programs for a budget period. We estimated the incremental value of a tertiary hospital HF program on the basis of the longitudinal utilization of a sample of HF patients. METHODS: The primary data source was a sample of 82 HF patients referred for cardiac transplant evaluation at an academic medical center during calendar years 2000 to 2001. Cumulative recurrent rates of utilization, cost, and reimbursement for hospital services were computed as functions of time using reliability models. The economic contribution of patients transplanted was contrasted with those not transplanted. RESULTS: Mean hospitalizations and outpatient encounters per patient at the end of the first year of follow-up for those transplanted were 2.1 (95% confidence interval [CI] 1.6 to 2.7) and 11.9 (95% CI 9.2 to 15.4), compared with 1.1 (95% CI 0.8 to 1.6) and 6.0 (95% CI 4.8 to 7.6), respectively, for those not transplanted. Mean revenue and direct cost per patient were 194,470 dollars (95% CI 136,683 dollars to 276,689 dollars) and 146,623 dollars (95% CI 96,377 dollars to 233,065 dollars), respectively, for transplanted patients and 43,587 dollars (95% CI 28,149 dollars to 67,503 dollars) and 33,424 dollars (95% CI 21,584 dollars to 51,760 dollars), respectively, for non-transplanted patients. The point estimates of first-year contribution margins per patient for transplanted and non-transplanted patients were 47,847 dollars and 10,163 dollars, respectively. CONCLUSIONS: Newly evaluated patients for cardiac transplantation at an academic medical center generated substantial incident demands for inpatient and outpatient services over a two-year follow-up period. The estimated contribution margin associated with these services was positive. Hospitals without cardiac transplantation that serve high-acuity HF patients may generate favorable long-term contribution margins, on the basis of the results for the non-transplant group.

Academic Medical Centers↗
PubMed2006

Developing a family-based depression prevention program in urban community mental health clinics: a qualitative investigation.

Extensive research documents that children of depressed mothers are at a significantly higher risk for developing a variety of socioemotional difficulties than children of nondepressed mothers. Yet, little prevention research has been conducted for this population, and low-income, minority, and urban families are rarely included. To address this deficit, we are developing the Protecting Families Program (PFP), a family-based multicomponent depression prevention program for mothers in treatment at urban community mental health agencies and their school-aged children. To inform intervention development and begin relationship building with the agencies, patient and staff focus groups were conducted in the participating agencies. Eighteen mothers with depression participated, and eight major themes were identified: (1) depression symptoms, (2) generational legacy, (3) parenting difficulties, (4) child problems, (5) social support, (6) stressful life events, (7) therapy and other helpful activities, and (8) desired treatment. In the focus groups with 10 mental health providers, the five major themes identified were parenting difficulties, lack of social support, life stress, current mental health practices, and intervention development. The findings support the multicomponent design of PFP, which focuses on increasing knowledge of depression, enhancing social support, and improving parenting skills. The study helped clarify many of the challenges of conducting research in a community mental health system.

Adult↗
PubMed1988

The paradox of psychiatric deinstitutionalization: historical perspective and policy implications.

Deinstitutionalization has, in effect, resulted in the creation of new forms of asylum for the mentally ill. Rather than being generated in a planful, humanitarian manner, the reduction in the census of state hospitals has been governed by federal health and welfare programs not designed for the mentally ill. By relying upon Medicaid and SSI, states were able to shift their financial burden for the mentally ill to the federal government. Reliance upon Medicaid has resulted in nursing homes playing a major role in psychiatric care. SSI stipends are not adequate to cover rising housing costs--even in low-income areas. As a result, large numbers of the mentally ill are among the populations of homeless persons in the United States.

Deinstitutionalization↗
PubMedDate not supplied

Intergenerational health disparities: socioeconomic status, women's health conditions, and child behavior problems.

OBJECTIVE: Relatively little is known about the intergenerational mechanisms that lead to social disparities in child health. We examined whether the association between low socioeconomic status (SES) and child behavior problems is mediated by maternal health conditions and behavior. METHODS: Prospective cohort data (1979-1998) on 2,677 children and their mothers were obtained from the National Longitudinal Survey of Youth. SES, the Child Behavior Problems Index (BPI), and maternal smoking, depressive symptoms, and alcohol use before, during, and after pregnancy were examined. RESULTS: Lower income and lower maternal education were associated with increased child BPI scores. Adjustment for maternal smoking, depressive symptoms, and alcohol use attenuated the associations between SES and child BPI by 26% to 49%. These maternal health conditions often occurred together, persisted over time, and were associated with the mother's own childhood SES and pre-pregnancy health. CONCLUSIONS: Social disparities in women's health conditions may help shape the likelihood of behavior problems in the subsequent generation. Improved public health programs and services for disadvantaged women across the lifecourse may not only address their own urgent health needs, but reduce social disparities in the health and well-being of their children.

Adolescent↗
PubMed2006

Heat or eat: the Low Income Home Energy Assistance Program and nutritional and health risks among children less than 3 years of age.

OBJECTIVES: Public funding for the Low Income Home Energy Assistance Program has never been sufficient to serve more than a small minority of income-eligible households. Low Income Home Energy Assistance Program funding has not increased with recent rapidly rising energy costs, harsh winter conditions, or higher child poverty rates. Although a national performance goal for the Low Income Home Energy Assistance Program is to increase the percentage of recipient households having > or = 1 member < or = 5 years of age, the association of income-eligible households' receipt of the Low Income Home Energy Assistance Program with indicators of well-being in young children has not been evaluated previously. The goal of the current study was to evaluate the association between a family's participation or nonparticipation in the Low Income Home Energy Assistance Program and the anthropometric status and health of their young children. METHODS: In the ongoing Children's Sentinel Nutrition Assessment Project from June 1998 through December 2004, caregivers with children < 3 years of age in 2 emergency departments and 3 primary care clinics in 5 urban sites participated in cross-sectional surveys regarding household demographics, child's lifetime history of hospitalizations, and, for the past 12 months, household public assistance program participation and household food insecurity, measured by the US Food Security Scale. This scale, in accordance with established procedures, classifies households as food insecure if they report that they cannot afford enough nutritious food for all of the members to lead active, healthy lives. On the day of the interview, children's weight, length, and whether the children were admitted acutely to the hospital from the emergency departments were documented. The study sample consisted only of Low Income Home Energy Assistance Program income-eligible renter households without private insurance who also participated in > or = 1 other means-tested program. RESULTS: In this sample of 7074 caregivers, 16% of families received the Low Income Home Energy Assistance Program, similar to the national rate of 17%. Caregivers who received the Low Income Home Energy Assistance Program were more likely to be single (63% vs 54%), US born (77% vs 68%), and older (mother's mean age: 28.1 vs 26.7 years) but were less likely to be employed (44% vs 47%). Households who received the Low Income Home Energy Assistance Program were more likely to receive Supplemental Nutrition Program for Women, Infants, and Children (85% vs 80%), Supplemental Security Income (13% vs 9%), Temporary Assistance for Needy Families (38% vs 23%), and food stamps (59% vs 37%) and to live in subsidized housing (38% vs 19%) compared with nonrecipients. Children in families participating in the Low Income Home Energy Assistance Program were older than children in nonparticipating families (13.6 vs 12.5 months), were less likely to be uninsured (5% vs 9%), and were more likely to have had a low birth weight < or = 2500 g (17% vs 14%). Families participating in the Low Income Home Energy Assistance Program reported more household food insecurity (24% vs 20%) There were no significant group differences between recipients and nonrecipients in caregiver's education or child's gender. After controlling for these potentially confounding variables, including receipt of other means-tested programs, compared with children in recipient households, those in nonrecipient households had greater adjusted odds of being at aggregate nutritional risk for growth problems, defined as children with weight-for-age below the 5th percentile or weight-for-height below the 10th percentile, with significantly lower mean weight-for-age z scores calculated from age- and gender-specific values from the Centers for Disease Control and Prevention 2000 reference data. However, in adjusted analyses, children aged 2 to 3 years in recipient households were not more likely to be overweight (BMI > 95th percentile) than those in nonrecipient households. Rates of age-adjusted lifetime hospitalization excluding birth and the day of the interview did not differ between Low Income Home Energy Assistance Program recipient groups. Among the 4445 of 7074 children evaluated in the 2 emergency departments, children from eligible households not receiving the Low Income Home Energy Assistance Program had greater adjusted odds than those in recipient households of acute hospital admission on the day of the interview. CONCLUSIONS: Even within a low-income renter sample, Low Income Home Energy Assistance Program benefits seem to reach families at the highest social and medical risk with more food insecurity and higher rates of low birth-weight children. Nevertheless, after adjustment for differences in background risk, living in a household receiving the Low Income Home Energy Assistance Program is associated with less anthropometric evidence of undernutrition, no evidence of increased overweight, and lower odds of acute hospitalization from an emergency department visit among young children in low-income renter households compared with children in comparable households not receiving the Low Income Home Energy Assistance Program. The Low Income Home Energy Assistance Program in many states shuts down early each winter when their funding is exhausted. From a clinical perspective, pediatric health providers caring for children from impoverished families should consider encouraging families of these children to apply for the Low Income Home Energy Assistance Program early in the season before funding is depleted. From a public policy perspective, although this cross-sectional study design can only demonstrate associations and not causation, these findings suggest that, particularly as fuel costs and children's poverty rates increase, expanding the Low Income Home Energy Assistance Program funding and meeting the national Low Income Home Energy Assistance Program performance goal of increasing the percentage of recipient households with young children might potentially benefit such children's growth and health.

Child, Preschool↗
PubMed1997

An economic profile of American older women.

This literature review examines the economic status of American women age 65 and older in view of their longevity, employment patterns, sources of income, income levels, potential for poverty, and their economic stake in current public policy debates and actions regarding Social Security, Medicare, Medicaid, and SSI. Although women live longer and therefore must stretch their financial resources further than men, longevity is not the sole cause of their economic vulnerability. Rather, it is associated with historical patterns of economic dependence on men; with sporadic, often low-wage or nonexistent employment histories; and with public policies and programs that place undue financial pressures on older women. Living alone is a major risk factor for poverty, and women of color are doubly at risk, with the highest poverty rates of all the elderly. Middle-class women face the possibility of "cycling into poverty" after widowhood, especially if their husbands suffered long, costly illnesses or spousal pensions shrink or disappear. While women's improving educational and work opportunities are likely to result in improved financial circumstances for future generations of older women, it will be necessary to move beyond their personal efforts to the public policy arena for solutions to the often devastating effects of uninsured health care costs, pension inequities, and other pressing economic concerns for older women.

Aged↗