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PubMed2006

Genetic health technology and economic evaluation: a critical review.

The aim of the review is to establish whether, on the basis of previous published evidence, current accepted guidance for health economic evaluation needs to be adapted to evaluate healthcare based on use of genetic information. Online literature search strategies were designed (using PubMed and the NHS Economic Evaluation Database [NHS EED], among others) to gather papers carrying out or discussing economic evaluation and genetics. Papers meeting the inclusion criteria were obtained and reviewed. The papers purporting to be economic analyses were classified using the criteria of the NHS EED and the British Medical Journal (BMJ) working party on peer review of health economic literature. Of 120 English-language papers that met the criteria for review, only 37 were economic evaluations according to the criteria set out by the NHS EED and BMJ working party on economic evaluations. Of these 37, only 33 papers discussed economic evaluation methodologies in the genetics context. The economic evaluation papers did not seem to tackle any of the problems discussed in the methodological papers. Economic evaluation methods offer a structured approach for evaluation of changes but may need to change in order to assess the new technologies. We have found that such studies have not been widely reported, and that those that have been reported do not depart from current economic methods. We have identified a need for better skills and guidance in health economics within this growing area of research.

Biomedical Technology↗

PubMed1998

Where are we now in British health economics?

Health economics took off in 1970 or thereabouts, just after the take-off date for the economics of education. Although early health economics made use of human capital theory as did the economics of education, it soon took a different route inspired by Arrow's work on medical insurance. The economics of education failed to live up to its promising start in the 1960s and gradually ran out of steam. The economics of health, however, has made steady theoretical and empirical progress since 1970, principally in coming to grips with the implications of supplier-induced demand and the difficulties of evaluating health care outcomes. Some of the best work on British health economics has been in the area of normative welfare economics, defining more precisely what is meant by equity in the delivery of health care and measuring the degree of success in achieving equity. Recent efforts to reform the NHS by the introduction of 'quasi markets' have improved the quantity and quality of health care in Britain. In short, British health economics has been characterised by the use of Pigovian piecemeal rather than Paretian global welfare economics, retaining a distinctive style that sets it apart from American health economics.

Economics, Medical↗

PubMed1983

Health care in the developing world: the role of economists and economics.

This paper does not address itself to high theory or to complex methodologies; nor does it offer any detailed illumination of key economic concepts. Rather, it focuses on the role of economists and economics (not the same thing) in the formulation of health policies, and in influencing an evaluation of health strategies appropriate to the requirements of the developing world. The paper argues that the 'climate' has changed sufficiently in the developing world to promote a close interest in the economics of health and health care. Evidence exists of a growing willingness to employ economists and economic analysis to resource allocation issues within the health sector. Accordingly, a glossary of economic concepts in presented to demonstrate that economics does possess certain ideas, distinct from other disciplines, which can be of considerable value to health planners and health managers alike. The text also sets out, in tabular form, many of the key questions that should be of close interest to policy-makers, and indicates the economic concepts and techniques that can be applied. At the same time, it is noted that there are very real conceptual and methodological problems likely to be faced by those wishing to apply economic reasoning to the health sector. The paper then moves on from analysis to consider implementation, and investigates the political constraints and institutional barriers to the acceptance of economic analysis in the health sector. In the past, the nature of the economics of health has sometimes been considered improper, i.e. views have been expressed that services should be made available to those for whom they may be beneficial, as a matter of right without regard to economics.(ABSTRACT TRUNCATED AT 250 WORDS)

Delivery of Health Care↗

PubMed1993

Economic evaluation of pharmaceuticals: a European perspective.

In recent years there has been a large increase in the number of economic evaluations of pharmaceuticals. Many of these studies have been commissioned by individual pharmaceutical companies, in support of new or existing products. In 2 countries, Australia and Canada (in the province of Ontario), draft guidelines issued by the government have outlined the requirements for economic evaluations to be submitted in support of requests for reimbursement (government subsidy) of particular products. One consequence of the guidelines is that they clarify what is required, and in specifying the procedure for submission of dossiers, identify a clear audience for the economic evaluation. In contrast, the situation in Europe is diverse. A wide range of healthcare systems exist, including national health services and more liberal systems, involving a wide range of insurers and providers. European countries also differ widely in their approach to the pricing and reimbursement of pharmaceuticals. Because of this diversity, the nature, conduct and impact of economic evaluation in Europe is not clear. It is therefore difficult for pharmaceutical companies to develop appropriate strategies for economic evaluation and for analysts to decide on appropriate study methodology. This article reviews the nature of any official guidance or requirements for economic evaluation, the potential for use of economic evaluation, the range of studies carried out and the identifiable impacts. There is currently no official guidance in any country, although some countries are considering issuing guidelines. In some countries there is official encouragement to pharmaceutical companies to undertake studies, and where economic data have been presented they have been considered by the relevant committees. The potential uses of economic evaluation vary widely from country to country. These can be classified in terms of a potential role in undertaking national price negotiations, deciding on reimbursement status or copayment level, deciding on inclusion in local formularies or in treatment guidelines, or in improving prescribing decisions. Approximately 80 economic evaluations of pharmaceutical products have been conducted to date in Europe, covering a wide range of clinical areas. There are relatively few examples of identifiable effects of such studies. In part this is because it is often difficult to assess the part played by various items of data. Nevertheless, the overriding conclusion is that economic evaluation of medicines is likely to be more relevant in Europe in the future. The problem for the pharmaceutical industry is in determining when and how.

Drug Industry↗

PubMed2002

Socio-economic differences in health risk behaviour and attitudes towards health risk behaviour among Slovak adolescents.

OBJECTIVES: Socio-economic differences in the frequency of smoking, alcohol consumption, drug use, physical exercise, and attitudes toward smoking were explored in a sample of Slovak adolescents (1,370 boys, 1,246 girls, mean age 15 years). METHODS: Identification of socio-economic status was based on three indicators: the highest educational level of parents, the highest occupational class of parents, and the type of school the adolescents attended. RESULTS: Health risk behaviour was strongly related to socio-economic status based on all three socio-economic indicators, although there were some exceptions mostly related to education as indicator of socio-economic status and to alcohol consumption experience and drug use experience. The pattern of socio-economic differences was unfavourable for lower socio-economic groups of adolescents, except for differences in frequency of alcohol consumption among females when highest education of parents was used as an indicator of socio-economic status. CONCLUSIONS: There are socio-economic differences in health risk behaviour. Lower socio-economic groups of adolescents behave risky more frequently than higher socio-economic groups of adolescents.

Adolescent↗

PubMed2000

Can economic evaluation guidelines improve efficiency in resource allocation? The cases of Portugal, The Netherlands, Finland, and the United Kingdom.

The use of economic evaluation in decision making appears to have increased over the past few years and economic evaluation is looked upon as another measure to help contain costs and improve efficiency in an evidence-based decision-making environment. Following the examples of Australia and the Canadian Province of Ontario, four European Union (EU) countries (Finland, the Netherlands, Portugal, and the United Kingdom) have recently introduced economic evaluation guidelines. In addition to the Australian and Canadian guidelines, which constitute a hurdle to reimbursement, the paradigm that seems to be evolving in the four EU countries follows a similar route. Finland and the Netherlands seem to be moving toward the notion of a fourth hurdle to reimbursement, whereas the National Institute for Clinical Excellence in England and Wales was in principle meant to influence practice, although in reality this essentially acts as a hurdle to reimbursement, requiring a different data set to that used by regulatory authorities. Whereas the Portuguese guidelines were developed to assist in preparing economic submissions to support reimbursement decisions, they are unclear about when such evidence will be required and also discuss the dissemination of economic evidence to broader audiences. The introduction of these guidelines poses a number of challenges to policy makers, the implications of which are analyzed in the paper: a) to ensure that economic evaluations are carried out scientifically without industrial or political bias; b) to define an acceptable methodology that would increase their credibility; and c) to address certain practical issues ranging from deciding how to use economic evaluations in policy making to setting up new institutions or improving the coordination and dissemination of evidence. The variation in the use of economic evaluation guidelines in the four EU countries highlights the differences in national pharmaceutical policies and is in line with policy makers' continuous attempts to contain costs. While the paper critically discusses the guidelines, it also points out that a series of methodologic issues need to be addressed if economic criteria are to be introduced in policy making with the aim to improve resource allocation. The paper concludes that economic evaluation as a discipline is beginning to impact on policy, whereas the consistent use of economic evaluation results is, in principle, being adopted by policy makers but needs to go a step further to reach practitioners.

Drug Therapy↗

PubMed2006

Multiple socio-economic circumstances and healthy food habits.

OBJECTIVE: To examine associations between seven indicators of socio-economic circumstances and healthy food habits, while taking into account assumed temporal order between these socio-economic indicators. DESIGN AND SETTING: Data were derived from cross-sectional postal questionnaires in 2000-2002. Socio-economic circumstances were assessed by parental education, childhood economic difficulties, own education, occupational class, household income, home ownership and current economic difficulties. Healthy food habits were measured by an index consisting of consumption of fresh vegetables, fruit or berries, rye bread, fish and choosing vegetable fats on bread and oil in cooking. Sequential logistic regression models were used, adjusting for age and marital status. PARTICIPANTS: Employees of the City of Helsinki, Finland (n=8960, aged 40-60 years). RESULTS: Healthy food habits were reported by 28% of women and by 17% of men. Own education, occupational class, household income, home ownership and current economic difficulties were associated with healthy food habits. These associations were attenuated but mainly remained after mutual adjustments for the socio-economic indicators. Among women, a pathway was found suggesting that part of the effects of education on food habits were mediated through occupational class. CONCLUSIONS: Employees in higher and lower socio-economic positions differ in their food habits, and those in lower positions and economically disadvantaged are less likely to report healthy food habits. Health promotion programmes and food policies should encourage healthier food choices among those in lower socio-economic positions and among those with economic difficulties in particular.

Adult↗

PubMed2005

Derivation of economic values for productive and reproductive traits of Bombyx mori (Lepidoptera: Bombycidae) from profit equation.

Using a deterministic model of profit equation compatible to cocoon production system in Iran, equations for estimating economic values of cocoon weight, shell weight, shell percentage, fecundity, fertility, and hatchability of three commercial varieties of silkworm Bombyx mori (L.) were derived. Economic values of these traits as well as their relative economic importance (REI) compared with cocoon weight were estimated. Estimates of economic value of a given trait differed among the varieties. Cocoon weight, shell weight, and shell percentage had the highest economic value in variety 107. The highest economic value for fecundity, fertility, and hatchability was estimated in variety 110. Shell weight and shell percentage were the most important production traits, and fecundity was the most important reproduction trait. The REI values of shell weight and shell percentage were higher than that of cocoon weight. The sensitivity of estimated economic values to principal factors of production system was studied by altering cocoon weight, shell percentage, fecundity, variable costs, and cocoon price by +/- 10%. The traits varied in the rate of sensitivity of their economic values to changes in production factors. Economic values of cocoon weight, fecundity, fertility, and hatchability had the most sensitivity to the changes in shell percentage. The most important factor affecting economic values of shell weight and shell percentage was the grade 1 cocoon price. Economic value equations provided in this study can help silkworm breeders to concentrate on the most important factors in predicting the future. Furthermore, when these factors change, silkworm breeders will be able to determine to what extent breeding goals have to change.

Animals↗

PubMed2004

Economic evaluations and randomized trials in spinal disorders: principles and methods.

STUDY DESIGN: Descriptive methodologic recommendations. OBJECTIVE: To help researchers designing, conducting, and reporting economic evaluations in the field of back and neck pain. SUMMARY OF BACKGROUND DATA: Economic evaluations of both existing and new therapeutic interventions are becoming increasingly important. There is a need to improve the methods of economic evaluations in the field of spinal disorders. MATERIALS AND METHODS: To improve the methods of economic evaluations in the field of spinal disorders, this article describes the various steps in an economic evaluation, using as example a study on the cost-effectiveness of manual therapy, physiotherapy, and usual care provided by the general practitioner for patients with neck pain. RESULTS: An economic evaluation is a study in which two or more interventions are systematically compared with regard to both costs and effects. There are four types of economic evaluations, based on analysis of: (1) cost-effectiveness, (2) cost-utility, (3) cost-minimization, and (4) cost-benefit. The cost-utility analysis is a special case of cost-effectiveness analysis. The first step in all these economic evaluations is to identify the perspective of the study. The choice of the perspective will have consequences for the identification of costs and effects. Secondly, the alternatives that will be compared should be identified. Thirdly, the relevant costs and effects should be identified. Economic evaluations are usually performed from a societal perspective and include consequently direct health care costs, direct nonhealth care costs, and indirect costs. Fourthly, effect data are collected by means of questionnaires or interviews, and relevant cost data with regard to effect measures and health care utilization, work absenteeism, travel expenses, use of over-the-counter medication, and help from family and friends, are collected by means of cost diaries, questionnaires, or (telephone) interviews. Fifthly, real costs are calculated, or the costs are estimated on the basis of real costs, guideline prices, or tariffs. Finally, in the statistical analysis the mean direct, indirect, and total costs of the alternatives are compared, using bootstrapping techniques. Incremental cost-effectiveness ratios are graphically presented on a cost-effectiveness plane and acceptability curves are calculated. CONCLUSION: Economic evaluations require specific methods. These recommendations may be helpful in improving the quality of economic evaluations of new and existing therapeutic interventions in the field of spinal disorders.

Back Pain↗

PubMed2002

Socio-economic mortality differentials in Sydney over a quarter of a century, 1970-94.

OBJECTIVE: To examine trends in socio-economic differentials in all-cause mortality in Sydney over a 25-year period (1970-94). METHODS: Five measures of single indicators (two for occupation, two for education and one for income) and a composite measure of socio-economic disadvantage based on Census data (the Australian Bureau of Statistics' Index of Relative Socio-Economic Disadvantage) were used as indicators of socio-economic status by local govemment area. The relationship between mortality and socio-economic status was examined using quintiles based on these six measures of socio-economic status. RESULTS: Socio-economic differentials in mortality were evident for males and females for all periods, and over the 25-year period the relative socio-economic differentials did not decline. For males, the socio-economic status differential in mortality widened, irrespective of socio-economic status indicator used, whereas for females it widened only when certain socio-economic indicators were used: occupation (unemployment measure) and income, but was not significant for the other single indicators or for the composite indicator. CONCLUSIONS: Sydney trends of widening inequalities are generally similar to those reported for Britain and for other industrialised countries, suggesting that this is a common phenomenon and that policies to reduce health inequalities over the past quarter of a century have not been effective.

Adolescent↗

PubMedDate not supplied

[Evaluation of the quality of the websites of pharmacoeconomics and health economics centers through a validated questionnaire].

OBJECTIVES: To evaluate the quality of websites of pharmacoeconomics centers and organizations in the countries of the European Union, the United States and Canada through a validated system with explicit criteria. METHODS: The websites of institutions and centers related to pharmacoeconomics and health economics in the 24 countries of the Organization for Economic Cooperation and Development (OECD) were identified through browsers. Twenty-four predetermined key words were used. A questionnaire on the quality of the information on health was designed and validated according to standards established in literature. Using this questionnaire, we evaluated the quality of the pharmacoeconomics and health economics centers. RESULTS: In 23 of the 26 items of the validated questionnaire, Cochran's Q was statistically significant. The coefficient of reliability obtained in the questionnaire was 0.90 and the value obtained in Pearson's correlation was 0.812. The 33 pharmacoeconomics and health economics centers evaluated were divided into three subgroups according to the scores obtained on the questionnaire: centers of high quality, average quality (the majority), and low quality. The centers in the high-quality subgroup were: the Leonard Davis Institute of Health Economics, the Centre for Health Economics, the Agency for Healthcare Research and Quality, the Health Economics Research Unit, the Institute of Health Economics and the Health Economics Resource Center. CONCLUSIONS: The criteria included in the questionnaire used to evaluate the quality of websites on health were: credibility, content, description, links, design, interactivity and safeguards. The quality of the websites of centers related to pharmacoeconomics and health economics analyzed in this study using the criteria established in the questionnaire varied from 30.4% to 79.8%. A validated system with explicit criteria is required to evaluate the quality of information on health available on the Internet.

Economics, Medical↗

PubMed1999

Agriculture sector resource and environmental policy analysis: an economic and biophysical approach.

Agricultural pollution of the environment is jointly determined by economic decisions driving land use, production practices, and stochastic biophysical processes associated with agricultural production, land and climate characteristics. It follows that environmental and economic statistics, traditionally collected independently of each other, offer little insight into non-point pollutant loadings. We argue that effective policy development would be facilitated by integrating environmental and economic data gathering, combined with simulation modelling linking economic and biophysical components. Integrated data collection links economics, land use, production methods and environmental loadings. An integrated economic/biophysical modelling framework facilitates policy analysis because monetary incentives to reduce pollution can be evaluated in the context of market costs and returns that influence land use and production activity. This allows prediction of environmental and economic outcomes from alternative policies to solve environmental problems. We highlight steps taken to merge economic and biophysical modelling for policy analysis within the Economic Research Service of the United States Department of Agriculture. An example analysis of a policy to reduce agricultural nitrogen pollution is presented, with the economic and environmental results illustrating the value of linked economic and biophysical analysis.

Agriculture↗

PubMed2005

Health economic research on vaccinations and immunisation practices--an introductory primer.

The economic importance of vaccines lies partly in the burden of disease that can be avoided and partly in the competition for resources between vaccines and other interventions. Up to the 1980s only few economic evaluations had been carried out. Since then the confrontation of most countries with escalating health care costs and tighter budgets have awakened the interest in pharmacoeconomic analysis. Resources used to provide health care are vast but not limitless. When clinicians are asked to participate in decisions for large groups of patients (in a managed care context, in an institution, or at the level of local health authorities), the balance between consumption of resources and the benefits of an intervention is important. Clinicians may use cost-effectiveness and cost-benefit studies to inform such decisions (but not to make them). Because of differences in methods, the presentation of results, and country-specific parameters, economic evaluations of the same vaccination strategy by different groups may have divergent results. Vaccines differ from classical medicines in at least three ways: firstly, there is a longer tradition of economic evaluations for vaccines than for medicines. Some of the most earliest economic studies were carried out in the field of vaccines in the public health arena. Secondly, comparatively fewer central decision makers need to be convinced as compared to drugs. The reason for this being a more centralised process of recommending vaccines and vaccination policies. Thirdly, externalities are more relevant in the field of vaccines. Such externalities may be positive or negative. Positive externalities are present in the case where herd immunity prevents the spread of the disease in the community. We are now undoubtedly in an era of assessment and accountability for all new technologies in healthcare. However, sufficient economic data are still lacking to support the formulation of health policy and a particular challenge for the future is to conduct further health economic research on immunisation. Specific areas for such study include: effectiveness under field conditions (i.e., not under the conditions of a randomised controlled trial); the real value of economic production losses; the conditions for implementing novel immunization programmes; cost estimates for more ambitious immunization programmes; the economic benefits of combination vaccines. From this research, it will be important to disseminate the data and to adapt the findings to other countries. Nevertheless, the source of funding for research and its application in clinical trials programmes represent some of the practical problems faced by medical economics today within academia and the industry.

Adult↗

PubMed1984

[Rehabilitation of the handicapped caught between content programming and economic justification].

Notwithstanding the wide socio-cultural scope of theoretical social policy, those, at any rate, who are involved in practical social policy making time and again face the task of providing an economic justification for their respective programmes; the field of rehabilitation of the disabled is no exception to this rule. An economic justification of rehabilitation service provision would however imply their flexibility within economic development: content programming continuity and economic justification will clash as the economic situation changes. Maintaining, or honouring, present rehabilitation service programming will jeopardize economic justification, whereas orientation of rehabilitation practice toward economic justifiability would imply the need to abandon redemption of present content programming. This entails a normative dilemma between rehabilitation content programming, or goal-setting, on the one hand, and its economic-functional, theoretical justification as reflecting given economic circumstances on the other. This normative dilemma gives rise to critically re-consider current practice in, and the rank accorded to, economic justification in rehabilitation service provision.

Cost-Benefit Analysis↗

PubMed2005

Can economic evaluations be made more transferable?

Several commentators have identified the lack of generalisability and transferability of economic evaluation results. The aims of this study were: (a) to develop a checklist to assess the level of generalisability and transferability of economic evaluations; (b) to assess the generalisability and transferability of economic evaluations between the UK and France using the checklist; (c) to identify reasons for any lack of transferability and generalisability; (d) to assess how the transferability and generalisability of economic evaluations can be improved; and (e) to outline ways in which databases of economic evaluations and journals can assist in this area. The checklist was developed using previous work and the templates of the NHS EED and CODECS databases. A sub-checklist of essential items was then derived. Validation of the two checklists was undertaken with Health Economists participating in the EURONHEED project. Economic evaluations involving the UK and France were then located and assessed using the checklist. A summary score for each study was calculated based on the percentage of correctly reported (applicable) points, and the results in the empirical analysis compared to identify differences. The extended checklist includes 42 items, and the sub-checklist 16 items. Twenty-five economic evaluations met the inclusion criteria for the empirical analysis. In the extended checklist the mean score was 66.9+/-13.6%. The results for the sub-checklist were very similar. The analysis revealed that costing, assessments of generalisability by the author(s), assessment of data variability, discounting, study population, and the reporting of effectiveness are areas that need more attention. Differences in cost-effectiveness results are often accounted for by price or organisational differences. The developed checklists are useful in assessing the generalisability and transferability of economic evaluations. In order to improve the generalisability and transferability of economic evaluations authors need to be more explicit and detailed in describing and reporting their studies. If they are to provide added value to their users, international databases of economic evaluations should systematically assess the generalisability and transferability of studies. Further research is in progress on producing a weighted version of the checklist.

Cost-Benefit Analysis↗

PubMed2004

Malaria incidence in rural Benin: does economics matter in endemic area?

Malaria represents a major health problem with over 1 million annual deaths in Africa alone. There are a limited number of policies tackling the health problems of people at greater risk, namely the poor and rural communities. This is partly due to the lack of evidence available on the range of factors affecting their health status. Despite endemic malarial situations, there is still little understanding of the relative importance of economic factors that contribute to people acquiring malaria. This paper examines the socio-economic and economic factors that affect the incidence of malaria in rural community households in Benin, where malaria is endemic. A sample of 1585 households was determined to collect information on socio-economic characteristics and the presence of malaria symptoms. Probit estimation techniques were used to assess the impact of socio-demographic and socio-economic factors on the incidence of malaria, comparing households with and without malaria patients. Predisposing characteristics of the household head such as age, knowledge of malaria, education and the size of the household significantly affect the incidence of malaria as anticipated by economic theory. Enabling factors reflecting higher economic status, measured by monthly expenditure and a socio-economic index, have a statistically significant and positive impact on the incidence of malaria. This could reflect that better-off have improved case reporting and are likely to seek treatment. Variations in socio-economic and economic characteristics are significant in explaining the incidence of malaria, even in an endemic malarial setting.

Adolescent↗

PubMed2003

Socio-economic differences in the utilisation of health services in Belgium.

OBJECTIVE: To investigate socio-economic differences in the use of health services in Belgium and to explore to what extent eventual socio-economic inequalities are explained by differences in demographic determinants and health needs. DESIGN: Data was obtained from the 1997 Belgian national Health Interview Survey. In this survey information was collected on the health status, the life style and the medical consumption of a representative sample of the Belgian non-institutionalised population consisting of 8560 Belgian inhabitants aged 15 years and over. RESULTS: Lower socio-economic groups make more often use of the general practitioner and nursing care at home and are more often admitted to hospital than persons with a high socio-economical status. There is, however, no socio-economic gradient when the health status is taken into account. On the opposite, persons with a higher socio-economic status report more often a visit to a specialist, a physiotherapist or a dentist. For the health services for which this was investigated no association was found between socio-economic status and the volume of the use of health services. CONCLUSIONS: There are in Belgium still important socio-economic gradients in the use of some health services. These differences may be due to socio-economic inequities but could also indicate that the existing health facilities are not always used in an optimal way. Patient factors may be more important than supply factors in explaining the differential use of health services. Further research needs to focus on socio-economic differences in the reasons, the outcome and the quality of the provided care.

Adolescent↗

PubMed2002

Household economic strategies and nutritional anthropometry of women in American Samoa and highland Bolivia.

This study compares findings from research projects involving different genetic, environmental, and cultural contexts: a study of lifestyle and health from American Samoa (ASLS) and the Bolivian project. Reproduction and Ecology in Provincia Aroma (REPA). This paper presents analyses of varying economic strategies and their association with nutritional status indicators in each population. The ASLS sample includes 66 Samoan women and the REPA sample includes 210 Aymara women. Principle components analysis of household economic resources within each sample extracted two significant factors: one represents modernizing influences including education and occupational status, and the other represents ethnographically salient traditional economic behavior. The traditional pattern includes adding household members in Samoa and selling agricultural products in Bolivia. This analysis places each woman along two continua, traditional and modern, based on her household mobilization of economic resources, permitting an understanding of the patterns underlying household economic behavior that is not possible in univariate analyses of socioeconomic variables. For the Bolivian women the strategy involving more education and higher occupational status was associated with higher measures of several nutritional status indicators, including body mass index, arm muscle area, and peripheral skinfolds. But among the Samoan women, where substantial obesity was the norm, there were no significant differences in anthropometric measurements based on economic strategies. These data argue for the importance of directly measuring the potential consequences of variation in household economic strategies rather than merely inferring such, and of assessing ethnographically relevant aspects of household economic production rather than limiting analyses to non-context-specific economic indicators such as income. This focus on household strategy is likely to be fruitful especially where economic and nutritional conditions are marginal. The findings from Bolivia also support efforts in developing countries to improve girls' education, and thereby occupational prospects, as a means to improve their health status as women.

Adult↗