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PubMed2002

Preparing for change in the secondary prevention of coronary heart disease: a qualitative evaluation of cardiac rehabilitation within a region of Scotland.

BACKGROUND: Secondary prevention of Coronary Heart Disease (CHD) is often poorly managed and its benefits attained in only a minority of those with CHD. Guidelines developed in the United Kingdom and North America suggest that in future cardiac rehabilitation programmes should provide services through individualized programmes that cater for a wide range of conditions associated with CHD. This will involve substantial and costly changes to current programmes that are mostly standardized and for postmyocardial infarction patients. Based on change theory, this study examined the dynamics, strengths and weaknesses of an existing programme in a Scottish region which was due to undergo the changes suggested by guidelines. AIM: To examine the perceived provision of secondary prevention services for CHD from the perspectives of health professionals within one region in the West of Scotland. METHODS: A purposive sample of 14 health professionals (eight primary and six secondary care health professionals) was selected to cover a range of professional roles including both specialists and generalists. Separate focus group discussions (2) were held with primary care and secondary care professionals. FINDINGS: Whilst the health professionals were enthusiastic about CHD prevention and their involvement, they perceived barriers to the success of the existing service as being complex and multifactorial, including patient, social and service-related factors. Although both groups identified motivation as the most influential personal factor, secondary care staff tended to focus on the importance of patient factors in influencing motivation to change, whereas the primary care staff referred more to the cumulative effects of social and cultural factors. Professionals highlighted weaknesses in the transition between hospital and community-based services with regard to the information flow between primary and secondary care. CONCLUSIONS: Although the study has immediate relevance for the local area, it highlighted issues of more general relevance to cardiac rehabilitation programme development and intersectoral working, such as communications and role perceptions in multi-professional working and the need to adapt services to local socio-economic conditions.

Communication↗
PubMed2002

A model of traffic crashes in New Zealand.

The aim of this study was to examine the changes in the trend and seasonal patterns in fatal crashes in New Zealand in relation to changes in economic conditions between 1970 and 1994. The Harvey and Durbin (Journal of the Royal Statistical Society 149 (3) (1986) 187-227) structural time series model (STSM), an 'unobserved components' class of model, was used to estimate models for quarterly fatal traffic crashes. The dependent variable was modelled as the number of crashes and three variants of the crash rate (crashes per 10,000 km travelled, crashes per 1,000 vehicles, and crashes per 1000 population). Independent variables included in the models were unemployment rate (UER), real gross domestic product per capita, the proportion of motorcycles, the proportion of young males in the population, alcohol consumption per capita, the open road speed limit, and dummy variables for the 1973 and 1979 oil crises and seat belt wearing laws. UERs, real GDP per capita, and alcohol consumption were all significant and important factors in explaining the short-run dynamics of the models. In the long-run, real GDP per capita was directly related to the number of crashes but after controlling for distance travelled was not significant. This suggests increases in income are associated with a short-run reduction in risk but increases in exposure to a crash (i.e. distance travelled) in the long-run. A 1% increase in the open road speed limit was associated with a long-run 0.5% increase in fatal crashes. Substantial reductions in fatal crashes were associated with the 1979 oil crisis and seat belt wearing laws. The 1984 universal seat belt wearing law was associated with a sustained 15.6% reduction in fatal crashes. These road policy factors appeared to have a greater influence on crashes than the role of demographic and economic factors.

Accidents, Traffic↗
PubMed1992

Public expenditures and health care in Africa.

Unfavorable economic conditions in most of Africa (in this paper Africa refers to Sub-Saharan Africa only) have meant public austerity and a deceleration in government health spending. Given the dominant role of government in providing health services in Africa there is a need to investigate the links between public spending and the provision of health care. Analyzing information from five Sub-Saharan African countries, namely Botswana, Burkina Faso, Cameroon, Ethiopia and Senegal, we investigate the impacts of shifting expenditure patterns and levels on the process of providing health services as well as on delivery of health care. The country analyses indicate that in addition to the level of public spending, the expenditure mix (i.e. salaries, drugs, supplies etc.), the composition of the health infrastructure (hospitals, clinics, health posts etc.), community efforts, and the availability of private health care all influence health care delivery. Consequently, per capita public expenditure (the most important indicator in a number of related studies) alone as a measure of the availability of health care and especially for cross-country comparisons is inadequate. Reductions in government resources for health care often result in less efficient mixing of resources and hence less health care delivery, in quality and quantity terms. With the recent trends in health care spending in Africa there should be greater effort to increase the efficient use of these increasingly scarce resources, yet the trend in resource mix has been in the opposite direction. Given the input to public health care of local communities, as well as the provision of private health care, it would seem that government spending on health care should be counter-cyclical, i.e. government health spending should accelerate during periods of economic down turns. Such counter-cyclical spending would tend to offset the difficulties facing local communities and the declining ability of individuals to pay for private health care. Recommending counter-cyclical health spending may seem wishful, but it points up the necessity of understanding what is likely to happen to health care in African countries in the face of economic difficulties, and particularly in the face of fiscal austerity.

Botswana↗
PubMed1997

Risk factors for Kaposi's sarcoma in HIV-positive subjects in Uganda.

BACKGROUND: Kaposi's sarcoma (KS) is associated epidemiologically with HIV infection and with human herpesvirus 8 (HHV-8 or KSHV). Both KS and HIV infection are common in Uganda. We conducted a case-control study of 458 HIV-seropositive. Ugandan adults with KS and 568 HIV-seropositive subjects without KS to examine risk factors for HIV-associated KS. METHODS: We recruited newly diagnosed adult KS cases from five hospitals in Kampala, Uganda and controls from a large referral clinic for HIV infection at Mulago Hospital. All cases and controls were counselled and tested for HIV and answered an interviewer-administered questionnaire about their home, socio-economic conditions, lifestyle and sexual behaviour before they became ill. Only HIV-seropositive subjects were included in the analysis. RESULTS: There were 295 males and 163 females with KS and 227 male and 341 female controls. Age distribution was similar but there was a higher proportion of cases (45%) than controls (29%) residing in rural regions of Uganda. KS cases were more likely than controls to have a higher level of education (X2 for trend, 4.8; P = 0.03), to have occupations associated with affluence [chi 2 for heterogeneity, 17.3 on 5 degrees of freedom (df); P = 0.004] and to come from larger settlements [adjusted odds ratio (OR) for settlements of > 1000 versus 10-99 houses, 1.8; 95% confidence interval (CI), 1.1-3.0]. Cases were more likely than controls to have high household income (chi 2 for trend, 32.6; P < 0.001) and other markers of urban or rural wealth such as owning several cows (chi 2 for trend, 9.5; P = 0.002). Cases were more likely to travel away from home (adjusted OR, 1.6; 95% CI, 1.1-2.3) and more likely to have spent increasing time in contact with water (chi 2 for trend, 12.3; P < 0.001). Few indices of sexual behaviour were related to risk of KS, including reported number of sexual partners. Cases were more likely than controls to be married to one rather than several spouses (adjusted OR, 1.6; 95% CI, 1.2-2.2) and to have reported a history of sexually transmitted diseases (STD) (adjusted OR, 1.6; 95% CI, 1.2-2.3). CONCLUSIONS: Among HIV-infected subjects, KS cases are characterized by better education and greater affluence, compared with controls. Urban address, travel away from home, exposure to water, monogamous marriage and self-reported STD were also more frequent among KS cases than controls. The higher socio-economic status of persons with HIV and KS may be a marker for enhanced exposure to a possibly sexually transmitted agent, or for a delayed exposure to a childhood infection. The risk posed by exposure to water among KS cases requires further study.

AIDS-Related Opportunistic Infections↗
PubMed2004

Coca-colonization of diets in the Yucatan.

Over the past three decades, tourism-based economic development has transformed social and economic conditions in the Yucatan Peninsula, Mexico. Mayan communities have become directly involved in the changing economy as the main source of inexpensive labor for construction and service jobs at tourism centers, and as sites of ecotourism and archeotourism. In this paper, we address how these macro-processes of change intersect locally with the commoditization of food systems, diets and nutrition in four Yucatec Mayan communities with differing relationships to the tourist economy. Yucatec Mayan diets have become increasingly dependent on purchased foods, and reflect a greater consumption of commercialized processed foods. Coca-Cola, an international icon of US culture, along with other local and internationally owned calorie-dense but nutrient-poor snack foods, is now a common element of Mayan diets, leading to what we call "coca-colonization." The consequences of this diet, likely exacerbated by the increased consumption of snack foods, include an apparent increase in overweight and obese adults as well as signs of growth stunting in children. The Maya we talked with recognize both the potential disruption that tourism brings to all aspects of their lives and the necessity of jobs that tourism creates to meet their families' basic needs.

Body Mass Index↗
PubMed1991

Drug supply in Nigeria.

The health situation in Nigeria is typical of tropical Africa. It is characterised by high childhood and maternal mortality and a relatively short life expectancy. Mortality in childhood in due mainly to diseases like malaria, measles, poliomyelitis, tetanus, diarrhoea and acute respiratory tract infections. Diseases like filariasis, schistosomiasis and leprosy which are now readily controlled by drugs cause considerable morbidity in later life. Although the technology and tools (particularly vaccines and drugs) for the control of most of these diseases are now available, it has not been possible to make optimal use of them in Nigeria and other tropical African countries because of unfavourable social and economic conditions. The non-availability of drugs most needed for healthcare and disease control has been found to be due not only to insufficient funds but also to the use of the limited funds on expensive drugs that have little bearing on the disease pattern. The Essential Drug Programme initiated by the World Health Organisation, now adopted by Nigeria and about 100 other countries mostly in the Third World, aims to correct this unsatisfactory drug supply situation by ensuring that the available funds are used to provide those drugs needed by the large majority of the people and are made available at all times at prices that most people can afford. The Bamako Initiative in the African Region of the World Health Organization is also designed to ensure regular availability of drugs particularly to primary healthcare facilities. Seed drugs are provided to the health institutions either by the National Government or through external aid. These are sold to patients at a small profit margin. The proceeds are then used to replenish stocks and the small profit used to improve services in the health centre. The introduction of these programmes in Nigeria has improved drug availability considerably in the past couple of years and should soon start yielding further dividend in the form of measurable improvement in the health situation.

Developing Countries↗
PubMed2006

Impact of biological and economic variables on optimal parity for replacement in swine breed-to-wean herds.

Voluntary and involuntary culling practices determine the average parity when sows are replaced in a herd. Underlying these practices is the economic effect of replacing a sow at different parities. A dynamic programming model was used to find the optimal parity and net present value in breed-to-wean swine herds. The model included income and costs per parity weighted by the discount rate and sow removal rate. Three scenarios that reflect a wide range of cases were considered: low removal rates per parity with no salvage value (LRNS), high removal rates per parity with no salvage value (HRNS), and high removal rates per parity with a percentage of the sows having a salvage value (HRYS). The optimal parity of replacement for the base biological and economic conditions was 4 and 5 parities in the high and low removal scenarios, respectively. Sensitivity analyses identified the variables influencing the optimal replacement parity. Optimal parity of replacement ranged from 3 to 7 parities in the low replacement scenario, compared with 1 to 5 parities in the high replacement scenarios. Sow replacement cost and salvage value had the greatest impact on optimal parity of replacement followed by revenues per piglet weaned. The discount rate and number of parities per year generally had little influence on optimal parity. For situations with high sow costs, low salvage values, and low revenues per piglet, the optimal parity at removal was as high as 6 to 10 parities, and for situations with low sow cost, high salvage values, and high revenues per piglet, the optimal parity at removal was as low as 1 to 2 parities depending on removal rates. The modified internal rate of return suggested that, for most LRNS and HRYS scenarios considered, investment in a swine breed-to-wean enterprise was favored over other investments involving a similar risk profile. Our results indicate that in US breeding herds, sows are culled on average near the optimal parity of 4. However, the optimization process should be a dynamic one that adapts to changes in replacement rates, salvage value, replacement cost, and revenues per piglet.

Agriculture↗
PubMed1986

Ophthalmology in Chile.

The practice of ophthalmology in Chile does not differ much from that in the United States. Basic ophthalmologic knowledge is the same, and common clinical problems are solved in the same way. The difference becomes evident in the more complex clinical problems. We have the knowledge and ability to perform the treatment but come up against the problem of high cost of technical instruments. Vitreous surgery, intraocular lens surgery, and laser treatments are performed, but we have to overcome the obstacles of obtaining the expensive and limited number of instruments. Perhaps, a US ophthalmologist will not understand this problem because, as I became aware during my stay as a fellow at The Wilmer Institute, Baltimore, and at other times when I have visited the United States, these difficulties do not arise. Lasers are bought, instruments are ordered by telephone, and manufacturers swamp the doctors with propaganda and offers of "call toll free for 30 days on trial." On the other hand, we know that, due to our efforts and using the means at our disposal, we have managed to keep the specialty at a high level, solving health problems and making the practice of ophthalmology pleasant in this beautiful country. Chilean ophthalmology has great prestige in South America. It has been the forerunner in the instruction of ophthalmologists, creating a method of teaching and of systematic specialization that has been unique in Latin America. It is an example to other branches of medicine in Chile. Although ophthalmologists are badly distributed in the country, considering our particular geographic and economic conditions, they fulfill their objectives in providing adequate visual health care for the population. This has come about through the combined effort of all Chilean ophthalmologists based on the example of their predecessors. Also, there has been a sense of solidarity among us, with responsibility and enthusiasm shown in practicing and in communicating ophthalmic precepts altruistically to the coming generations.

Chile↗
PubMed1989

A market analysis comparing the practices of psychiatrists and psychologists.

Data are analyzed that describe the clinical work of representative samples of psychiatrists and clinical psychologists who practiced in one of 62 markets for mental health services in the United States during 1982 and 1983. For psychiatrists, intensity of treatment (ie, mean face-to-face treatment minutes per patient per month) varied from 107 to 368 minutes vs 124 to 283 minutes for psychologists. Multiple regression models explain these variations somewhat differently for each provider group. Whereas the patient's severity or stage of illness is explanatory for both psychiatrists and psychologists, only psychologists appear to alter intensity of treatment in response to local economic conditions. Psychiatrists have large diversified practices, whereas psychologists tend to treat fewer persons and the bulk of these have less severe mental and emotional conditions. Neither practitioner group appeared to provide services in excess of their perceptions of patient need. These and other important similarities and differences are explored, and the advantages of local market focus for examining relevant public policy issues are discussed.

Female↗
PubMed1998

International retirement migration in Europe.

"This paper presents a review and prospectus of international retirement migration (IRM), dealing mainly with European evidence but also referring to some analogous trends in North America. The paper is in three main parts. It first makes the case for regarding IRM as a significant aspect of population geography and of migration studies; in certain areas of Mediterranean Europe, IRM also has effects on regional economic geography. The second section of the paper discusses some of the early findings from a comparative study of British elderly residents in Tuscany, Malta, the Costa del Sol and the Algarve.... The final part of the article offers further reflections on why IRM is important--for the individual migrants themselves, for the host communities, and for public policy."

Adult↗
PubMedDate not supplied

Why the poor pay more: household curative expenditures in rural Sierra Leone.

This paper draws on data from Sierra Leone, and secondary data from elsewhere, to show that the rural poor can be disproportionately disadvantaged by user charges for health care, paying a higher percentage of their incomes for health care than wealthier households. Cost sharing systems at primary care level should include exemptions for the poor, but rarely succeed in consistently protecting them. The regressivity of health expenditures also results from lack of protection from the higher costs of less-frequently used, expensive providers. In Sierra Leone, the burden of curative treatment costs for all groups came mainly from private and NGO providers. Proximity to facilities appeared a more important factor in their use than average price levels. Even if a perfect exemption system existed at government primary care facilities, it would not have had much overall effect because of their relatively small contribution to household health expenditures. The financial burden on households could be relieved by making basic health facilities more accessible and at hospital level using additional resources generated through improved efficiency and cross-subsidization to provide exemptions. Also, pricing policy should take into account local economic conditions. Insurance/prepayment schemes covering the cost of hospitalization would come closer to an ideal solution, but have been implemented in very few of the poorer countries.

Cost Sharing↗
PubMedDate not supplied

Growth of Han migrants at high altitude in central Asia.

Han Chinese of low-altitude descent have been living in Qinghai Province of Western China for at least two millennia. For most of this time they have lived at elevations under 2,500 m. However, during the last four decades an increasing number of Han have moved into high-altitude towns at elevations over 3,000 m, and some above 4,000 m. There are now sufficient numbers of Han descendants who have been born and raised at high altitude to allow a comparison of their morphological and physiological growth patterns with low-altitude Han to detect the effect of hypoxia. The field study reported here was conducted by collaborating Chinese and American researchers over a 6-year period, and included 1,227 Han living at high altitude in Qinghai and at low altitude near Beijing. This study demonstrates that Han born and raised at high altitude are smaller and lighter than those at low altitude-particularly as children and adolescents. Slower growth at high altitude may be a consequence of hypoxia, but it also corresponds to poorer economic conditions in rural Qinghai Province, and thus may reflect nutritional inadequacies. Differences in altitude and/or nutrition do not seem to affect thorax dimensions, since, relative to stature, chest dimensions are similar at both high and low altitudes. Nevertheless, lung volumes are higher among Han at high altitude, possibly reflecting the influence of hypoxia on alveolar growth. The hematological values of Han growing up at 3,200 m are not different from those at low altitude-an unusual finding relative to other low-altitude groups that may reflect population differences in response to hypoxia. At 3,800 m and 4,300 m, however, Han show elevated hemoglobin relative to Han at low altitude.

Adolescent↗
PubMed1993

Sexual dimorphism in schoolchildren of the Villa IAPI neighborhood (Quilmes, Buenos Aires, Argentina).

Villa IAPI is a poor neighborhood of about 5,000 inhabitants in the overpopulated conurbano bonaerense at the outskirts of the city of Buenos Aires. Most of the adult male residents are construction workers; the rest are temporary workers, underemployed, or unemployed. The inhabitants of Villa IAPI suffer the effects of many adverse socio-economic conditions, including poor nutrition, deficient sanitation, and inadequate medical care. Seven anthropometric variables were measured on 765 children from 6 to 14 years old to test for the presence of an altered pattern of sexual dimorphism. It was found that there were practically no sex differences in standing height and upper-arm muscle circumference. In some age groups, there was a weak but significant sexual dimorphism in body weight and sitting height. The greatest and most persistent dimorphism was found in head circumference, and in triceps and subscapular skinfolds. In all except two age groups, head circumference in males was significantly greater than in females. The other dimorphic variables (body weight, sitting height, and triceps and subscapular skinfolds) showed the opposite relationship. Essentially, females showed increments in subcutaneous fat, while reduced growth in muscle and bone was evident in males. The hypothesis of "better female canalization" can explain the altered dimorphic pattern found in the malnourished Villa IAPI population.

Adolescent↗
PubMed1984

[The formation of eating behavior].

Food behaviour involves the totality of the actions of man which aim at satisfying his nutritional need. It is based on psychical reflection, decision and assessment processes. Food behaviour has social and historical determinants and forms accordingly to the dialectic relation of biological, social and economic conditions. Hunger, thirst and appetite are perceived as nutritional need which results from the requirements of energy, nutrients and liquid, and is satisfied by the food behaviour in conformity with the actual material potential, situational influences, subjective ideas, interests, attitudes and knowledge as well as other psychical properties. Consequently, food behaviour is rich in variations with dynamic and conservative features. Motives as well as will components are essential constituent conditions of food behaviour. For this reason, empirical studies arteo provide psychological cognition concerning the subjective reflection of the nutritional requirements, the requirement-standard integration, the sensation of stimulation and the decision-making in food behaviour, the ultimate goal being to deduce measures for food behaviour guidance.

Appetite↗
PubMed1993

The cost and efficiency of public and private health care facilities in Ogun State, Nigeria.

During the 1980s, Nigeria faced difficult economic conditions resulting in a severely constrained budget for public health services. To assess more carefully the costs and efficiency of the public and private health sectors, the Federal Ministry of Health in Nigeria undertook a comprehensive survey of health care facilities in Ogun State in 1987, the analysis of which is presented in this study. The findings suggest that there is potential to increase service delivery within existing budgets by more cost-effective allocation of inputs. Many public and private providers are not operating a full technical capacity. It also appears that public facilities are not using cost-minimizing combinations of high and low-level health workers, in particular, too many low-level staff are being used to support high-level workers. The cost analysis indicates that there are short-run increasing returns to scale for inpatient and nearly constant returns to scale for outpatient services. Economies of scope for joint production of inpatient and outpatient services are not being realized. A major implication of such analysis is that improved resource allocation decisions heavily depend on the existence of information systems at the health facility level which carefully integrate financial information with other appropriate and adequate measures of service inputs, health care quality, facility utilization and ultimately health status.

Budgets↗
PubMedDate not supplied

Consumer payment patterns for primary health care services in low-income communities of Rio de Janeiro: implications for designing service financing schemes.

Primary health care (PHC) services are now recognized as a mainstay of development in low-income regions of the world. Yet, in many of these areas, economic conditions that include a burgeoning international debt, precipitous drops in the prices of raw materials, expanding population bases, and faltering currency rates, make the effective financing of PHC services an issue requiring the most immediate attention. A potentially valuable source of assistance in such endeavors is data on consumers' payment patterns for PHC services, and on socioeconomic conditions within their communities. The Centro de Pesquisas de Assistência Integrada à Mulher e à Criança (CPAIMC), the principal private source of PHC in Rio de Janeiro, has collected these type of data for nine low-income communities (LICs) within the Greater Rio de Janeiro Metropolitan Region. The current paper interfaces these data with previously developed solutions to address the problem of financing PHC services within the nine LICs. The solutions were recommended by a methodology developed and implemented by two of the authors. Results indicate that the consumer payment pattern and socioeconomic data support the methodology's recommendations and, more importantly, may be used to improve the effectiveness of those recommendations. Examples are provided and implications discussed.

Brazil↗
PubMed1994

Tobacco, alcohol and the risk of gastric cancer. A population-based case-control study in Sweden.

Previous studies have provided conflicting information on the role of tobacco and alcohol in gastric carcinogenesis. A population-based case-control study with 338 histologically confirmed gastric-cancer cases and 679 control subjects was conducted. Information relating to life-time tobacco consumption, alcohol intake and diet during adolescence and 20 years before interview, and to socio-economic conditions was obtained through face-to-face interviews. Current cigarette smokers were found to have a greater risk than non-users of tobacco. The duration of cigarette or pipe smoking was positively associated with gastric-cancer risk. There was significant interaction between tobacco use and fruit consumption. High fruit intake was more protective among users of tobacco than among non-users, and the risk estimates associated with cigarette smoking were higher among those with low fruit consumption than among frequent fruit-eaters. Likewise, though to a lesser extent, vegetable intake interacted with tobacco use. Snuff dipping and alcohol intake was not associated with gastric-cancer risk. However, high alcohol intake tended to increase the risk associated with tobacco use. This study adds further support to the role of tobacco smoking in gastric carcinogenesis, and demonstrates that high intake of fruits and vegetables may be particularly beneficial in smokers.

Adult↗
PubMedDate not supplied

The importance of remittances for the level and distribution of economic well-being in Lesotho.

"Using the 1986/87 Household Budget Survey of Lesotho, we measure the extent of inequality, identify the determinants of economic well-being and decompose total inequality by population subgroups. The results show large inequality in economic well-being. Many households in Lesotho are heavily dependent on miners' remittances from the Republic of South Africa. In the study we quantify their effects on the level of well-being and the extent of inequality. It is concluded that remittances decrease inequality in Lesotho."

Africa↗