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PubMedDate not supplied

Economic evaluation in health care: the point of view of informed physicians.

OBJECTIVES: We investigated health professionals with a solid background in health-care management and economics to get their opinion and attitude on the use of economic evaluation at the policy, organizational, and professional levels of decision-making. METHODS: A 12-item questionnaire was sent to 374 Italian health-care professionals who received training in economic evaluation of health-care programs in the last 10 years at the Bocconi School of Management, Milan, Italy. RESULTS: The response rate was 46.8% (175 questionnaires). All respondents stated that the basics of economic evaluation analysis must be part of the overall knowledge of health-care professionals. The usefulness of economic evaluation for professional activities was rated 3.83 (scale 1-5). Respondents stated that economic evaluation is used more for managerial decisions than for clinical ones (mean 2.89 vs. 2.74, P = 0.09). "Decisions are taken according to a short-term perspective" was the most frequently reported barrier for the actual use of economic evaluation studies, particularly by managers (76.7%). "More training in health economics" was indicated as the incentive to expand its use by the majority of both clinicians and managers (64.6%). Significantly more managers than clinicians (74.4% vs. 54.1%, P = 0.005) considered that the maximum benefits of economic evaluation are reaped at organizational level. CONCLUSIONS: Informed Italian health professionals have a positive attitude toward the principles and the techniques of economic evaluation. They show appreciation of their potential role and report making some use of them in actual decision making.

Adult↗
PubMed2000

Recent economic evaluations of antenatal screening: a systematic review and critique.

A systematic review of recent economic evaluations of antenatal screening was conducted. Relevant studies were identified from a number of sources including computerised databases, bibliographies of economic evaluations, and searches of unpublished manuscripts. Each study identified by the literature searches was categorised on the basis of its title and abstract. Studies considered relevant to the systematic review were obtained from libraries. The methodology, results, and policy implications of studies categorised as economic evaluations upon full review were documented. A total of 566 studies were identified by the literature searches, 41 of which were categorised as economic evaluations upon full review. The economic evaluations covered a range of antenatal screening practices, aimed mainly at the prevention of infectious diseases and fetal anomalies. The review highlighted the poor methodological quality of the bulk of economic evaluations of antenatal screening. The study design, data collection methods, and analysis and interpretation of results frequently violated methodological guidelines adopted by health economists. The review also highlighted the narrow definition of benefits adopted by this body of literature, with most studies reporting outcomes in terms of cases detected, cases of particular disorders prevented or, most often, costs averted. The conclusions arrived at differed by area of antenatal screening. There appeared to be clear economic arguments in favour of some forms of antenatal screening, for example, triple test screening for Down's syndrome. Other economic evaluations pertained to specific locations, which suggests that the results may not necessarily be generalizable to different settings. For all areas of antenatal screening, an updating of published economic evaluations may be required to account for evolving economic, epidemiological, and clinical effectiveness evidence.

Costs and Cost Analysis↗
PubMed1995

Free-riding and the prisoner's dilemma: problems in funding economic analyses of phase III cancer clinical trials.

PURPOSE: Both economic and clinical data on new agents are important to policy-makers who approve pharmaceuticals for widespread use. Randomized clinical trials have been used to evaluate both clinical results and total medical costs associated with new agents. With new expensive pharmaceutical agents, early assessments of economic benefit have taken on greater importance to physicians and patients. Who should provide financial support to these integrated economic and clinical analyses in clinical trials? Here we describe issues that hinder funding of economic analyses and propose potential support mechanisms. RESULTS: The Cancer and Leukemia Group B (CALGB), a large, national cooperative group of academic and community hospitals in the United States, designed a non-small-cell lung cancer (NSCLC) treatment trial to compare two widely used supportive care regimens that varied 20-fold in cost. One important objective of this trial was to compare the cost-effectiveness of the two regimens. While funding for the clinical trial was supported by grants from the National Cancer Institute and the pharmaceutical companies involved in the trial, no specific funding agency was willing and/or able to provide financial support for the economic analyses. After 2 years of planning, the clinical trial was retracted when the funding for the economic analyses could not be secured. The prisoner's dilemma, individual reluctance to support a common social good, explains the lack of funding. CONCLUSION: Economic theory predicts difficulties in evaluating cost-effectiveness of new pharmaceuticals and reluctance to support economic analyses of clinical trials. Economic analyses will require new sources of funds that will not take scarce resources from clinical trials groups. Options for funding include a new federal agency, coordinated work by existing agencies, or academic centers for economic analysis.

Carcinoma, Non-Small-Cell Lung↗
PubMed2005

Effects of economic status and education level on the height and weight of community adolescents in Nepal.

There is scarce information on the relative importance of socio-economic factors in determining the adolescent anthropometric measurements. The objective of this study was to examine the effects of economic status, education level, and food consumption on the height and weight of community adolescents in Nepal. The study was done in the communities of the Kathmandu Valley area in Nepal. All together 426 unmarried adolescent girls aged 14-19 y were selected. The adolescents were interviewed regarding socioeconomic background (education, occupation and property possessions) and frequency of foods consumption. Height and weight were determined and BMI was calculated. Z-scores of height-for-age and weight-for-age were calculated based on the WHO/NCHS standard to avoid bias by age. The adolescents participating in the survey were categorized into three groups using the various indicators of economic status: Low Economic Status (LES) group, Middle Economic Status (MES) group and High Economic Status (HES) group. The Z-scores of height and weight were significantly lower in the LES group than in the MES and HES groups (p<0.05). The Z-score of height was significantly increased with education level even under the condition of controlling economic level (p<0.05). Since the frequency of milk consumption was significantly related not only with height (p<0.05), but also with economic (chi2=31.6, df=4, p<0.001) and education levels (chi2=22.4, df=6, p<0.01), the increased height in the groups of the better economic status or the better education level was interpreted to be due to the outcome of the higher frequency of milk consumption. This study indicated that education was a more important factor affecting the height of the adolescents via improved food habits even under adverse economic conditions.

Adolescent↗
PubMed1999

Savings obtained using an oxygen economizer device: a cost-minimization analysis.

As liquid oxygen represents a relevant burden on healthcare systems, different methods have been developed to reduce oxygen consumption, including economizers. The aims of the study were: 1) to evaluate the efficacy of an economizer device (Companion 5 Oxygen Saver) in a significant sample of patients, and 2) to perform cost-minimization analysis of the possible savings to be obtained using the device. The study was designed as an open, prospective clinical trial in which equivalence in haemoglobin saturation with and without the economizer device was demonstrated, preliminary to cost-minimization analysis in patients affected by restrictive and obstructive lung disease. Patients were to use their usual O2 flow, provided it was able to guarantee a saturation of > or = 90% and an arterial oxygen tension (Pa,O2) of > or = 8.0 kPa (60 mmHg) during rest, sleep and exercise with and without the economizer (mean value and different saturation ranges compared by means of parametric or nonparametric tests where appropriate). The average unit cost was calculated with and without the economizer, based on the average unit O2 consumption, and cost-minimization analysis was performed. In 29 patients enrolled, the mean (+/- SD) O2 flow in L.min-1 was 1.5 +/- 0.6 during sleep, 1.4 +/- 0.6 during rest and 2.3 +/- 1.1 during exercise. The mean oxygen saturation during sleep was 91.2 +/- 19.5% without and 97.2 +/- 3.9% with the economizer device (p = 0.09), the mean saturation during rest was 88.8 +/- 22.7% without and 92.1 +/- 14.9% with the economizer device (p = 0.42), and the mean saturation during exercise was 84.7 +/- 19.3% without and 91.8 +/- 15.9% with the economizer device (p = 0.04). The total daily O2 consumption was significantly lower using the economizer device (2,384 +/- 950.3 versus 93.0 +/- 482.9 L, p < 0.001). The potential savings, estimated per patient per year, were 530,114 +/- 184,233 L, corresponding to US$2,492 +/- 866. During the first year the total unit savings would be US$1,892. The savings, consistently relevant alongside the whole range of variation explored by sensitivity analysis both during the first and the following years, justify considering the adoption of similar economizers on a larger scale, although further studies should be performed to evaluate whether or not liquid oxygen really represents the most cost-effective method of treating hypoxaemic patients.

Aged↗
PubMed1989

The demographics of macro-economic-demographic models.

A number of macro-economic-demographic models have been created for developing countries during the decades of the 1970s and 1980s. Such models purport to simulate relationships between demographic variables and the process of socioeconomic development in the particular country, with the dual purposes of enhancing our knowledge of the process in particular settings and, by examining alternative scenarios, providing useful information to policy makers on the selection of demographic and economic policies to enhance economic development and improve human welfare. This paper 1st reviews the antecedents and then focuses on assessing the demographic functions (fertility, mortality, and internal migration rates) used in the 2 families of models which have had perhaps the largest number of applications in developing countries--the Bachue models, originating at the International Labour Office (Geneva), and the ESCAP models, originating at the Economic and Social Commission for Asia and the Pacific (Bangkok). Each has been applied, with significant variations, in at least 3 countries. Economic-demographic functions are defined as endogenous (and substantively meaningful, from the points of view of this paper) whenever there is an effect of economic growth or change in economic structure on the particular demographic function. The bulk of this paper assesses the realism and endogeneity of the fertility, mortality, and migration functions used in the Bachue and ESCAP models, noting, where possible, both the apparent and prima facie behavioral relationships and those that are actually important on the dynamic simulation. Shortcomings are described, including the lack of government expenditure functions with effects on demographic variables. The paper concludes more positively, noting areas of congruence and appealing endogenous relationships and functional forms specified in certain country models. It also suggests further development of, on the 1 hand, both simpler and more realistic planning models (focusing on particular behavioral relationships or sectors of importance to the country), which will be easier for country planners to understand and hence use, and, on the other hand, more complex research models aimed at enhancing our understanding of fundamental, dynamic relationships between economic factors, government policies and fertility, mortality and migration rates during the course of socioeconomic change.

Demography↗
PubMed2026

Longitudinal Relations among Perceived Economic Stress, Teacher-Student Relationships, and Cybervictimization: Exploring Within-Person Links.

Family economic hardship has been identified as a risk factor for adolescents' cybervictimization. Nevertheless, existing studies have primarily focused on objective economic conditions, and little is known about the within-person association between perceived economic stress and adolescents' cybervictimization and the mediating mechanisms underlying this association. To fill these gaps, the random intercept cross-lagged model was employed to examine the dynamic relations among perceived economic stress, teacher-student relationships, and cybervictimization. The data were obtained from a sample of 2407 Chinese adolescents (Mage = 12.75, SD = 0.58, 50.23% girls at baseline) recruited from seven schools and assessed at three time points over one year. At the between-person level, there were no significant associations among perceived economic stress, teacher-student relationships, and cybervictimization. At the within-person level, perceived economic stress positively predicted later cybervictimization over time, and this effect was unidirectional. The bidirectional relations between perceived economic stress and teacher-student relationships remained stable over time. Cybervictimization significantly and negatively predicted subsequent teacher-student relationships across time, indicating a unidirectional predictive effect. Additionally, perceived economic stress indirectly predicted cybervictimization through teacher-student relationships. The findings highlight the importance of distinguishing within-person from between-person processes and shed light on the longitudinal role of teacher-student relationships in the association between perceived economic stress and cybervictimization.

Humans↗
PubMed1998

Economic values in broiler breeding.

The objectives of this study were to derive economic values in broiler breeding and to determine their relationship with production circumstances. Economic values were derived using a deterministic economic model based on profit equations with a fixed amount of broiler meat output of the production system. Nonintegrated and the integrated broiler production systems were studied. The difference between these originates from different definitions of cost components and scaling aspects. For each stage of an nonintegrated system, the model calculated the profit margin; for an integrated system, (total) cost prices per unit of product at each stage were calculated. The Dutch broiler performance data and prices were input into the model as the representative situation. For all traits, in the nonintegrated system, economic values were derived, expressed as Dutch guilders (Dfl) per unit of product, where the unit of product depends on the stage of the production system and equals an egg for the multiplier breeder, a day-old chick for the hatchery, and a marketable broiler for the commercial grower and processor. Resulting levels of economic values were illustrated by showing underlying cost or profit changes in the production system. For the integrated system, economic values were expressed as Dfl x marketable broiler(-1) x unit(-1). Economic values of traits in the integrated system were also derived for situations where technical parameters or prices of productive factors were changed (20% increase or decrease). A general conclusion from these sensitivity analyses is that the economic values are sensitive to production levels, product prices and feed prices; there are both linear and nonlinear relationships between economic values and production circumstances.

Agriculture↗
PubMed1999

How to use the results of an economic evaluation.

BACKGROUND: Given the high costs of delivering care to critically ill patients, practitioners and policymakers are beginning to scrutinize the costs and outcomes associated with intensive care. Health economics is a discipline concerned with determining the best way of using resources to maximize the health of the community. This involves addressing questions such as which procedure, test, therapy, or program should be provided, and to whom, given available resources. PURPOSE: The purpose of this article is to review general economic principles that will help intensivists to better interpret published economic evaluations. DATA SOURCES: Selected articles from the health economics and critical care literature. RESULTS: In this article, we use an economic evaluation that examines sedation strategies in critically ill patients. We discuss how learning to critically appraise an economic evaluation is only part of the task for end users. Determining whether and how to apply the results of economic evaluations to local settings presents bigger challenges and remains largely a matter of judgment. CONCLUSIONS: Economic evaluations use analytic techniques to systematically consider all possible costs and consequences of clinical actions. Although they should never form the sole basis for clinical decisions for individual patients, economic evaluations offer potentially useful information at different levels of decision-making.

Cost-Benefit Analysis↗
PubMed2005

The economic value of an improved malaria treatment programme in Zambia: results from a contingent valuation survey.

BACKGROUND: Zambia is facing a double crisis of increasing malaria burden and dwindling capacity to deal with the endemic malaria burden. The pursuit of sustainable but equity mechanisms for financing malaria programmes is a subject of crucial policy discussion. This requires that comprehensive accounting of the economic impact of the various malaria programmes. Information on the economic value of programmes is essential in soliciting appropriate funding allocations for malaria control. AIMS AND OBJECTIVES: This paper specifically seeks to elicit a measure of the economic benefits of an improved malaria treatment programme in Zambia. The paper also studies the equity implications in malaria treatment given that demand or malaria treatment is determined by household socio-economic status. METHODS: A contingent valuation survey of about 300 Zambian households was conducted in four districts. Willingness-to-pay (WTP) was elicited for an improved treatment programme for malaria in order to generate a measure of the economic benefits of the programme. The payment card method was used in eliciting WTP bids. FINDINGS: The study reports that malaria treatment has significant economic benefits to society. The total economic benefits of an improved treatment programme were estimated at an equivalent of USD 77 million per annum, representing about 1.8% of Zambia's GDP. The study also reports the theoretically anticipated association between WTP and several socio-economic factors. Our income elasticity of demand is positive and similar in magnitude to estimates reported in similar studies. Finally, from an equity standpoint, the constraints imposed by income and socio-economic status are discussed.

Adult↗
PubMed1999

The economic impact of foot and mouth disease and its control in South-East Asia: a preliminary assessment with special reference to Thailand.

A pilot study of the economic impact of foot and mouth disease (FMD) in the countries and region of South-East Asia is described. Previous economic impact assessments are reviewed and summarised and a synthesis of these contributions is constructed. A framework for the future economic impact of the disease is then developed, incorporating analyses at the sectoral (production system), national and regional levels. Data requirements for such studies are also identified. Integrated epidemiological and economic models for impact assessment were developed and applied to the case study country of Thailand. The models were used to evaluate the economic viability of FMD control programmes in the country. Scenarios evaluated include the effect of improving vaccination coverage and thus reducing productivity losses, and the effect of eventual eradication of the disease. The results indicate that economic returns to the high expenditures incurred in FMD control could be achieved in the short term if greater international trade in pork products was made possible and export prices higher than those in the domestic market could be attained. If FMD were to be eradicated from Thailand in 2010, the eradication would be economically viable, even without exports, with a predicted benefit-cost ratio of 3.73. With additional exports, the economic justification for control becomes much stronger with a benefit-cost ratio of up to 15:1 being achieved. If eradication is not achieved until 2020, returns remain positive without exports, but at a lower rate. The authors propose that the integrated epidemiological and economic models developed be applied to other countries of the region to gain a more accurate insight into the future benefits of FMD control and eradication in the region.

Animals↗
PubMed2004

Ex-ante economic analysis of animal disease surveillance.

This paper provides an ex-ante economic analysis comparing four alternative intervention strategies for the control and eradication of rinderpest against a scenario of no intervention in a cattle population similar in size to that of Ethiopia. The interventions were three different coverage levels of mass vaccination and one surveillance-based programme where vaccination targeted infected sub-populations. For each scenario, the disease impact was estimated using an open-population, state-transition SEIR ('susceptible', 'exposed', 'infectious', 'recovered') disease transmission model with parameter estimates developed for lineage 1 rinderpest virus. Projected economic surplus gains and costs estimated from the rinderpest eradication programme in Ethiopia were analysed using benefit-cost methods. Social net present values (NPVs) and benefit-cost ratios (BCRs) were calculated. Although the economic model found that BCRs were greater than one for all interventions examined, the scenarios of intensive mass vaccination (75% vaccination coverage) and surveillance with targeted vaccination were economically preferable. The BCRs for these strategies were 5.08 and 3.68, respectively. Sensitivity analysis revealed that an increase in market prices for beef and milk increased the value of economic loss, the economic surplus and returns to investments in terms of NPVs and BCRs. An increase in demand and supply elasticities for beef and milk decreased the value of economic losses. This also had a negative effect on economic surplus and NPVs. The effect of an increase in the discount rate reduced returns to investments, with lower NPVs and BCRs. The authors note that 75% mass vaccination coverage was attempted in Ethiopia in the early 1990s, but failed to eradicate rinderpest because the approach was logistically too difficult to implement in practice. Subsequently, an effective surveillance and epidemiologically targeted vaccination programme was developed and has apparently resulted in the eradication of rinderpest from Ethiopia (the last case was recorded in 1996). The authors conclude that epidemio-surveillance with targeted vaccination is both an economically viable and realistic strategy and offers benefits that extend beyond rinderpest eradication.

Animals↗
PubMed1983

Mortality and economic instability: detailed analyses for Britain and comparative analyses for selected industrialized countries.

This paper discusses a first-stage analysis of the link of unemployment rates, as well as other economic, social and environmental health risk factors, to mortality rates in postwar Britain. The results presented represent part of an international study of the impact of economic change on mortality patterns in industrialized countries. The mortality patterns examined include total and infant mortality and (by cause) cardiovascular (total), cerebrovascular and heart disease, cirrhosis of the liver, and suicide, homicide and motor vehicle accidents. Among the most prominent factors that beneficially influence postwar mortality patterns in England/Wales and Scotland are economic growth and stability and health service availability. A principal detrimental factor to health is a high rate of unemployment. Additional factors that have an adverse influence on mortality rates are cigarette consumption and heavy alcohol use and unusually cold winter temperatures (especially in Scotland). The model of mortality that includes both economic changes and behavioral and environmental risk factors was successfully applied to infant mortality rates in the interwar period. In addition, the "simple" economic change model of mortality (using only economic indicators) was applied to other industrialized countries. In Canada, the United States, the United Kingdom, and Sweden, the simple version of the economic change model could be successfully applied only if the analysis was begun before World War II; for analysis beginning in the postwar era, the more sophisticated economic change model, including behavioral and environmental risk factors, was required. In France, West Germany, Italy, and Spain, by contrast, some success was achieved using the simple economic change model.

Adolescent↗
PubMed1984

The economics of parasitic diseases: research priorities.

Parasitic diseases are primarily diseases of poverty. At serious risk are individuals, communities and countries least able to afford the costs of treatment or prevention. In turn, economic development projects which aim to increase income levels may lead to negative results because of increased transmission of parasitic diseases often results. In attempting to analyse the economic consequences of parasitic diseases and the economics of their control, economists have usually relied on the tools of cost-benefit analysis, cost-effectiveness analysis and financial analysis. These efforts are briefly reviewed in the paper. The results have been subject to considerable criticism because of conceptual and methodological problems. For example, most studies have not taken into account the epidemiology and natural history of the disease in estimating the associated economic losses, thereby leading to inappropriate conclusions. The UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases through its Social and Economic Research Scientific Working Group (SER-SWG) is promoting research on the economics of parasitic diseases. In an attempt to improve the usefulness and reliability of such studies, conceptual and methodological approaches have been suggested which are reported on here. To improve the research design of these projects, a conceptual framework is proposed which consists of four components: (1) baseline social, cultural and economic conditions influencing disease transmission; (2) resources already invested in the health system and investments in other related sectors such as agriculture, housing, water supply and sanitation; (3) health consequences resulting from (1) and (2); and (4) social and economic consequences resulting from (3). A key concern in relation to the framework is to determine the most useful basis for linking results from studies of one component to another so as to analyse more systematically the impacts of disease on individuals and society. Such studies are inherently interdisciplinary and close collaboration of economists with medical scientists and disease control programme staff is needed to ensure completeness and reliability of input data and results. Results from these studies could be used to inform national decision-makers about the social and economic consequences of the parasitic diseases and their control and, thus, should strengthen support for increased investment to reduce the parasitic disease burden in developing countries.

Communicable Disease Control↗
PubMed2004

Design, execution, interpretation, and reporting of economic evaluation studies in obstetrics.

OBJECTIVE: The purpose of this article was to propose guidelines for the design, execution, interpretation, and reporting of economic evaluation studies in obstetrics. Study design We performed a PubMed search of economic evaluation articles to identify those articles that deal with the quality of published economic evaluation studies, the development of guidelines, and the development of checklists/guidelines for the reporting of economic evaluation studies. All other articles were excluded from the review. RESULTS: We identified 160 articles. We included 8 articles in our review that reported on the quality of published economic analyses, 12 articles that reported on guidelines, and 3 articles that reported on checklists/guidelines that are used by journals. There were 2 articles that dealt with the quality of published economic evaluations in obstetrics and gynecology, both of which showed less than optimal quality. There were only 4 articles that provided some general guidelines for the reporting of economic evaluations in obstetrics and gynecology. We found no articles on any checklist/guidelines for the reporting of economic evaluation studies in obstetrics and gynecology. CONCLUSION: There is a need to improve the design, execution, interpretation, and reporting of economic evaluation studies in obstetrics.

Cost-Benefit Analysis↗
PubMed2004

Economic analysis of eating and physical activity: a next step for research and policy change.

Poor nutrition and physical inactivity are among the leading causes of morbidity and mortality in the United States, and widespread behavior modification is needed to improve health now and in the future. There is growing evidence that modifications in the physical environment and in social policies will be required to accomplish this goal. There is also growing recognition that economic factors have contributed to current eating and physical activity patterns, and that economic factors need to be considered when developing strategies for improving these behaviors. Identifying where economic and public health priorities converge could suggest new avenues for sustainable policy changes, which will, in turn, promote healthy choices on both an individual and population-wide level. To review the effect that economics has on eating and physical activity behaviors, the Partnership to Promote Healthy Eating and Active Living convened an Economic Analysis Forum. Two working groups were formed-one focusing on eating behaviors and one on physical activity, and both with equal representation from health-related and economic disciplines. The groups examined how economics has contributed to present eating and physical activity patterns and how economics could be used to develop interventions to improve these patterns. This article describes the challenges the groups faced in their work, the way in which the public health and economic approaches were integrated, and the questions left unanswered.

Cost-Benefit Analysis↗
PubMed2006

Regional economic impacts of Grand Canyon river runners.

Economic impact analysis (EIA) of outdoor recreation can provide critical social information concerning the utilization of natural resources. Outdoor recreation and other non-consumptive uses of resources are viewed as environmentally friendly alternatives to extractive-type industries. While outdoor recreation can be an appropriate use of resources, it generates both beneficial and adverse socioeconomic impacts on rural communities. The authors used EIA to assess the regional economic impacts of rafting in Grand Canyon National Park. The Grand Canyon region of northern Arizona represents a rural US economy that is highly dependent upon tourism and recreational expenditures. The purpose of this research is twofold. The first is to ascertain the previously unknown regional economic impacts of Grand Canyon river runners. The second purpose is to examine attributes of these economic impacts in terms of regional multipliers, leakage, and types of employment created. Most of the literature on economic impacts of outdoor recreation has focused strictly on the positive economic impacts, failing to illuminate the coinciding adverse and constraining economic impacts. Examining the attributes of economic impacts can highlight deficiencies and constraints that limit the economic benefits of recreation and tourism. Regional expenditure information was obtained by surveying non-commercial boaters and commercial outfitters. The authors used IMPLAN input-output modeling to assess direct, indirect, and induced effects of Grand Canyon river runners. Multipliers were calculated for output, employment, and income. Over 22,000 people rafted on the Colorado River through Grand Canyon National Park in 2001, resulting in an estimated $21,100,000 of regional expenditures to the greater Grand Canyon economy. However, over 50% of all rafting-related expenditures were not captured by the regional economy and many of the jobs created by the rafting industry are lower-wage and seasonal. Policy recommendations are given for increasing the regional retention of rafting expenditures and for understanding both the beneficial and adverse impacts that accompany outdoor recreation in rural areas.

Arizona↗
PubMedDate not supplied

[Problems and proposals for improvement in the health care of economic immigrants].

OBJECTIVES: To analyse existing problems in health care to economic immigrants from the point of view of health and social professionals, health authorities and economic immigrants and to know which will be their proposals and priorities to improve economic immigrants's health assistance. METHODS: Qualitative approach study made in Majorca island. (Spain). Three focus groups and three nominal groups with health and social workers from primary health care and hospital services were carried out as well as two partially structured interviews to health authorities, one Autonomic Authority and one Governmental Authority, and twelve partially structured interviews to economic immigrants identified trough key informants. RESULTS: Health and social workers perceive the increase in the number of economic immigrants as a massive arrival. The main problems identified are: access restrictions to public health services for economic immigrants, the follow-up of these patients and diagnostic difficulties because lack of training in tropical medicine. Health and social workers's first proposal for improving this situation is their own training in tropical medicine. Autonomic Authority priorities are to guarantee access to public health services for all immigrants and to look actively for health problems in these population. Governmental Authority, instead, holds the legalization for all. In fact, economic immigrants are not concerned on health care because legalization and housing problems. CONCLUSIONS: The main barriers identified by health and social workers in health care to economic immigrants are: access restrictions, follow-up and lack of training in tropical medicine. Health and social first proposal to improve this situation is their own training in tropical medicine while Autonomic and Central Authorities's priorities are not the same. For economic immigrants, health assistance is not their biggest concern.

Delivery of Health Care↗