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Non-government organisations to combine for work on chronic disease in Aboriginal peoples, Torres Strait Islanders and rural and remote populations.

As a result of the National Health Priority Area Report on Cardiovascular Health and in particular, its remote and indigenous section, a consortium of five organisations ran a national workshop in Townsville in October 1999 on heart disease in Aboriginal peoples, Torres Strait Islanders and rural and remote populations. One of the priority areas identified at this workshop was the need for a more coordinated approach to chronic diseases and for the formation of an alliance of non-government organisations (NGOs) to work towards this and to undertake a lobbying and advocacy role. A meeting of a wide range of NGOs working in chronic disease, led by the National Heart Foundation of Australia, was held in Sydney in May 2000. At the Sydney meeting it was agreed that an alliance of NGOs could be formed for the development of a chronic disease strategy for Aboriginal peoples, Torres Strait Islanders and rural and remote populations. The NGOs drafted a 'Statement of Intent', which would inform their work on both heart disease and on broader work to address chronic preventable disease in the target populations. There is a considerable amount of procedural work to be done before the proposed alliance becomes a reality but the prospect of closer collaboration between the NGOs working in chronic disease has much to offer, especially for the population groups that were the focus of the Townsville workshop. This 'alliance' initiative comes at a time when there are national and State/Territory moves on broader aspects of what could become a 'national chronic disease prevention and management strategy'.

Australia↗

Surveys using general practice registers: who are the non-responders?

BACKGROUND: General practice population registers are important sampling frames for surveys of disease prevalence, lifestyles and health needs. In any survey there is a problem of non-response in the target population which can reduce precision and may bias any estimates derived from the study. Bias related to those who choose not to respond has been studied, but the problems posed by those who no longer live at the address on the register have received less attention. The specific objectives of this study were to estimate the number of non-responders in a registered general practice population who had not received a questionnaire ('ghosts') as distinct from those who chose not to respond to it ('refusers') and to determine whether ghosts and refusers were different from non-responders in ways which might affect the purpose of the survey. METHODS: A total of 500 people aged 18-75 years were selected from a general practice register in Stockport for a postal survey of shoulder pain in the adult population. Forty-one were identified as "ghosts' during the survey. After three mailings of a baseline screening questionnaire for shoulder pain and a further mailing of a final reminder, there were 120 further non-responders. They were classified as ghosts or refusers on the basis of a comparison of their current address on the practice register with that on the electoral roll. A matched sample of 120 survey responders was identified and was used to check the accuracy of the electoral roll in classifying non-responders. Ghosts and refusers were compared with the sample of responders using consultation information obtained from medical records at the practice, if the latter were available. RESULTS: In total, 108 of the 500 people in the sample (22 per cent) were classified as "ghosts'-41 on the basis of information obtained during the survey and 67 on the basis of a comparison with electoral roll details. In addition, 48 were classified as refusers on the basis of the electoral roll comparison. This compared with 8 (7 per cent) of the matched sample of responders who would have been classified as "ghosts' using the electoral roll. People who had addresses outside the electoral district were excluded from classification. Medical records were available for 105 (90 per cent) of the responders, 31 (46 per cent) of the ghosts and 40 (83 per cent) of the refusers. Of those who had consulted at least once for any reason in the previous two years, a similar proportion of responders and refusers (48 per cent and 46 per cent) had attended because of musculoskeletal problems, but responders were more likely to have consulted specifically about shoulder pain (10 per cent compared with 3 per cent, but based on small numbers). Ghosts by contrast had a lower proportion of consultations for both all musculoskeletal (33 per cent) and shoulder-specific problems (none), but were more likely to have consulted with a psychological problem than responders. CONCLUSIONS: We have estimated the number of non-responders to a survey of shoulder pain who were likely not to have received the baseline questionnaire (ghosts) to have been 22 per cent of a sample drawn from a practice-based Family Health Services Authority register. The error of using the electoral roll to make such a classification was found to be small, with only 8 (7 per cent) of the samples of responders being misclassified as ghosts. Those ghosts who still had records at the practice appeared to differ from refusers with respect to musculoskeletal and psychological morbidity. It may be inappropriate to exclude ghosts from the denominator in population surveys.

Adolescent↗

Evaluation of a Tay-Sachs screening program on a college campus.

A screening program for Tay-Sachs disease was done on a predominantly unmarried, university student population and later evaluated. Ten carriers were detected among a population of 390 screened. Voluntarily screened individuals were given a questionnaire at the time of screening and after their carrier status was revealed. In addition, individuals in a target population were queried as to why they did not attend the screening. Results of evaluation indicate that both the screened and unscreened students were able to answer approximately two thirds of a set of questions on Tay-Sachs correctly, but there was widespread lack of knowledge regarding the implications of carrier status and inheritance of the disease. In general, respondents to the questionnaires were not opposed to abortion. However, when asked about the family planning alternatives that they would consider if they were carriers, more subjects preferred adoption, artificial insemination, or avoidance of pregnancy to abortion.

Abortion, Eugenic↗

Provision of care to the underserved populations by National Health Service Corps alumni dentists.

OBJECTIVE: This study examined factors associated with dentists continuing to provide care to the underserved populations beyond their National Health Service Corps (NHSC) obligation period. METHODS: Self-administered questionnaires were mailed in 1998 to 404 dentists who had completed their service obligation between 1980 and 1997. The outcome variable was dentist self-report of continuing to work with the underserved population past NHSC obligation. RESULTS: Among 249 respondents (62% response rate), 46 percent of alumni dentists continued to work with an underserved population. Multivariate analyses found that being an African American (odds ratio [OR] = 3.2), higher final salary during the NHSC assignment (OR = 1.2), and higher altruistic motivation to work with the underserved populations prior to entering NHSC (OR = 1.1) were significantly associated with continued service to the underserved populations. CONCLUSIONS: A small number of factors were associated with alumni NHSC dentists' decisions to continue to provide care for the underserved populations. Targeting African-American students and students interested in caring for the underserved may improve the long-term commitment of dentists to provide care for the underserved populations. Attention will also need to be given to increased salary as a potential intervention to increase the numbers of dentists who continue to serve the underserved populations.

Adult↗

An optimal cutoff point of expired-air carbon monoxide levels for detecting current smoking: in the case of a Japanese male population whose smoking prevalence was sixty percent.

An optimal cutoff point of expired-air carbon monoxide (Ex-CO) for detecting smokers should be determined in terms of its sensitivity and specificity and the prevalence of smoking in the target population. The purpose of this study is to determine the optimal cutoff point of Ex-CO for detecting smoking males in a Japanese community whose smoking prevalence was over 50%. Among free-living residents in a rural population, "true smokers" determined by presence of cotinine in serum were 61% (n = 94). When Ex-CO at 7 ppm or over differentiated "smokers" from "non-smokers", sensitivity and specificity for detecting smokers was 0.93 and 0.95, respectively, which comprised the best Youden's index. This setting also produced the minimum percentage of misclassified cases. In conclusion, 7 ppm of Ex-CO, which is exceptionally low value relative to the western standard, appears to be the most optimal cutoff point for a survey in a population with such high smoking prevalence.

Breath Tests↗

CHIPS: a health care system for the future.

The Comprehensive Health/Integrated Provider System (CHIPS) is a vertically integrated care delivery model that enables hospitals to maintain or increase market share by sponsoring the widest possible range of health-related services. These include long-term care, dental care, fitness promotion, sleep disturbance therapy--virtually any service that can be incorporated in a system of providers. The CHIPS model can be modified to focus on a specific segment of the population rather than attempting to serve as many people as possible. This focus could be based on geographic considerations or on some demographic or health characteristic of the targeted population segment. Three basic strategies are available for choosing CHIPS locations. Providers can be consolidated in a single campus, or a loose network of services can be scattered throughout the area. Midway between these two strategies is the satellite approach, whereby CHIPS providers offer their services shopping center-style in one or more locations; this approach could be used either in addition to or instead of the campus strategy. A CHIPS may establish financial links with its patients through such insurance models as prepaid group practices or health maintenance organizations based on independent practice associations. Such links can provide significant price advantages on insured items sold to patients without exposing the hospital to antitrust liability. Other advantages of a CHIPS are that it can build patient loyalty (its chief purpose) and strengthen ties with the medical staff.

Catchment Area, Health↗

Community analysis for health planning: strategies for primary care practitioners.

Primary care practitioners have an important role in planning for the health of individuals and selected target populations. Community analysis and needs assessment are the first steps in health planning. Community analysis involves identifying health issues within a community; gathering data about the community, the target group, and the health concern; analyzing data; and assessing community needs. Community needs assessment involves identifying both existing and potential health problems as well as health promotion needs. By using appropriate skills in carrying out needs assessments, primary care practitioners become active contributors in planning for the health of individuals, groups, and the nation as a whole. This article provides strategies for identifying, analyzing, and evaluating the health needs of a community.

Community Health Planning↗

[Interaction of primary and specialized care and the patient in a program for early detection of cancer of the breast].

OBJECTIVE: To describe a method of carrying out an early detection programme (EDP) for breast cancer in a health area, as a coordinated activity between the primary care teams (PCTs) and specialist care. DESIGN: A descriptive, longitudinal study. SETTING: Area II of the Principality of Asturias. This is a predominantly rural and geographically very large area, although it has a high proportion of its population concentrated in several urban nuclei. PARTICIPANTS: The women between 50 and 65 registered as living in the area were chosen: a total of 3548. MEASUREMENTS: The participation, detection and biopsy rates, and the length of delays between different steps in the process were measured. These steps were: performing the mammography, further tests, receipt of the report, referral for treatment if appropriate. MAIN RESULTS: 2562 mammographies were carried out. There was 72.21% reply rate. 14 malign tumours were detected (detection rate 5.46 per 1000). The biopsy rate was 1.25%. The mean delay times were three days from the mammography to the primary care doctor's receiving the report; five days until the results were given to the patient; and 14 days before surgical treatment in case of breast cancer. CONCLUSIONS: The coordination between PCTs and specialist care considerably speeded up the development of the EDP for breast cancer in a large health area with a scattered population. Technically satisfactory results were achieved. The participation of the PC doctor enabled directed anamnesis and physical examination to be available and contributed to greater awareness among the target population.

Aged↗

A program to improve access to health care among Mexican immigrants in rural Colorado.

CONTEXT: Migration to the United States from Mexico is increasing every year. Mexican immigrants tend to be poor, uninsured, monolingual Spanish speakers without adequate access to appropriate medical care. As a further barrier, many are also undocumented. PURPOSE: This article describes a program developed to improve access to health care among Mexican immigrants in northern Colorado. METHODS: The program was implemented by a migrant/community health center in rural northern Colorado based on findings from an in-depth health needs survey of the target population. The program consists of community outreach services vertically integrated into the main medical clinics, which comprise Salud Family Health Centers. A mobile unit went to nontraditional areas identified by community workers as gathering places for Mexican immigrants. Services provided included preventive health care (screening for diabetes, hypertension, mental health problems, dental problems, and HIV); education; and primary care for acute problems. Patients were referred to a health care home for ongoing care. RESULTS: In the first 6 months, 1,553 Mexican immigrants were seen on the mobile unit. Hypertension and psychosocial problems were the most common problems in this population. Thirty-five percent of patients who received consultation in the mobile unit have visited any of the clinics for follow-up within the following year. CONCLUSIONS: A community-based mobile outreach program targeted toward Mexican immigrants can be effective in uncovering medical and mental illness and in directing patients to a health care home. This is an important first step in eliminating health disparities among this population.

Adolescent↗

Inverse relationship between tobacco smoking and both psychotechnic and education levels.

The relationship between psychotechnic and education levels and smoking habits was evaluated in a population of 2,430 Belgian male army conscripts who were 18-29 y of age. Smoking habits were quantified by a questionnaire and by urinary cotinine-to-creatinine concentration ratio. The results were analyzed relative to education level (graded 1-4) and to results of psychotechnic tests (scored 1-9). The urinary cotinine-to-creatinine concentration ratio was correlated strongly with the number of cigarettes smoked/d (r = .76, p < .00005). The concentrations averaged 27 +/- 153 ng/mg (mean +/- standard deviation) creatinine in nonsmokers, 69 +/- 186 ng/mg creatinine in exsmokers, and 388 +/- 392 and 867 +/- 833 ng/mg creatinine in subjects who smoked fewer than or more than 10 cigarettes/d, respectively. Significant inverse relationships were observed between the urinary cotinine-to-creatinine concentration ratio and both education (p < .0001) and psychotechnic levels (p < .0001). The inverse relationship between smoking and both the education and psychotechnic levels underlined the importance of adapting smoking prevention programs to the intellectual capacities of the populations targeted.

Adolescent↗

Birth number base and its application.

"This paper attempts to present the concept of 'birth number base' as a reflection of the fecundity of women, explain the methods of determining the base, and its application." The birth number base is defined as the number of births in a given year when the total fertility rate is one. The concept is applied to Chinese data from the 1 per 1,000 population survey of 1982 to project the number of births that will have to be prevented in the future if China is to reach its population targets.

Asia↗

Sensitivity of four psychometric tests to measure cognitive changes in brain aging-population-based studies.

Choosing the measure of cognition in an epidemiologic study investigating cognitive changes over time is a challenging question. A powerful measure must be able to detect small cognitive changes in all the range of cognition observed in the target population. This work aims at comparing the sensitivity to detect cognitive changes in the observed range of cognition of four widely used psychometric tests in an aging-population-based study through a nonlinear latent process model, assuming that the psychometric tests are nonlinear noisy transformations of their common factor. With data from the French prospective cohort study PAQUID (1989-2001), the authors found that the Mini-Mental State Examination and the Benton Visual Retention Test exhibited a better sensitivity to cognitive changes in low levels of cognition, while the Digit Symbol Substitution Test was more sensitive to changes in high levels of cognition. In contrast, the Isaacs Set Test shortened at 15 seconds appeared to be sensitive to small changes in all the range of cognition and, thus, represents an appropriate measure of cognition in population-based studies including both highly normal and severely impaired subjects.

Aged↗

Granulocyte-macrophage colony-stimulating factor (GM-CSF) targets myeloid leukocytes in the uterus during the post-mating inflammatory response in mice.

Factors in seminal plasma elicit a surge of GM-CSF expression in uterine epithelial cells after mating in mice. This study investigates the nature of the endometrial cell populations targeted by epithelial GM-CSF. In quantitative RT-PCR studies, expression of the alpha-subunit of the GM-CSF receptor (GM-CSF-R) parallelled GM-CSF expression, being maximal during the 48 h period after mating and declining thereafter. Expression of mRNA encoding beta-common chain (AIC2B) also increased after mating and remained high until the time of embryo implantation on day 4 of pregnancy. Cells expressing GM-CSF receptors were identified in sections of uterus on the day after mating using 125I-GM-CSF, and were located predominantly in the endometrial stroma subjacent to the luminal epithelium, co-localising with abundant populations of myeloid leukocytes. Cells expressing GM-CSF receptor were identified as macrophages, granulocytes and putative dendritic cells by flow cytometric analysis using lineage and receptor subunit specific antibodies. Recombinant GM-CSF injected into the uterine lumen of ovariectomised mice was found to elicit a dose-dependant accumulation of macrophages and granulocytes in the endometrium, in a pattern of distribution comparable to that seen in uteri after natural mating. Together, these data indicate a role for epithelial cell-derived GM-CSF in mediating the recruitment and potentially in modifying the behaviour of uterine leukocytes during the post-mating inflammatory response in mice.

Animals↗

Theories used in patient/health education.

Patient and health education programs may need to use a multitheory approach to promote health behaviors such as cancer prevention and early detection practices and decrease negative responses such as anxiety, distress, pain, and use of damaging alternative treatments. Multiple intrapersonal, interpersonal, organizational, and community approaches are required. For example, a strategy for breast cancer education should be characterized by an understanding of the target population's attitudes and beliefs about breast cancer, communication of information, education regarding specific facts about breast health and breast cancer, social influence strategies to promote acceptance of the target behaviors, and organizational and community-based interventions to reach the widest audience. Nurses should design education programs that carefully integrate theories to obtain predicted result for the largest number of people for whom the results are desirable. Intervention strategies designed to alter the identified influential factors will have the most successful impact and optimal chance of attaining program goals.

Health Education↗

Screening for cervical cancer--should the routine be challenged?

Despite the extensiveness of cervical cancer screening programs, certain major issues are still at stake: (a) substantial false negative rates are common, mostly due to impaired test quality, (b) the optimal length of interval between screenings is uncertain, being a function of available resources and the physicians' attitude, (c) the postmenopausal population, in which incidence is highest, is inadequately tapped. Efforts must be made to optimise the process through more stringent control measures, and a more comprehensive cover of the target population.

Adult↗

Impact of population age structure on Wolbachia transgene driver efficacy: ecologically complex factors and release of genetically modified mosquitoes.

Wolbachia symbionts hold theoretical promise as a way to drive transgenes into insect vector populations for disease prevention. For simplicity, current models of Wolbachia dynamics and spread ignore ecologically complex factors such as the age structure of vector populations and overlapping vector generations. We developed a model including these factors to assess their impact on the process of Wolbachia spread into populations of three mosquito species (Anopheles gambiae, Aedes aegypti and Culex pipiens). Depending on the mosquito species, Wolbachia parameters, released mosquito life stage and initial age structure of the target population, the number of Wolbachia-infected mosquitoes that we predict would need to be released ranged from less than the threshold calculated by the simple model to a 10-30-fold increase. Transgenic releases into age-structured populations, which is an expectation for wild mosquitoes, will be difficult and depending on the circumstances may not be economically or logistically feasible due to the large number of infected mosquitoes that must be released. Our results support the perspective that understanding ecological factors is critical for designing transgenic vector-borne disease control strategies.

Aedes↗

Cognitive-behavioral treatment for PTSD among people with severe mental illness: a proposed treatment model.

The lifetime prevalence of posttraumatic stress disorder (PTSD) is about 8%-14% in the general population, and trauma victimization (51%-98%) and PTSD (up to 42%) are even more prevalent among persons treated within public-sector mental health clinics. Despite this, individuals with PTSD and severe mental illness (SMI) who are treated within the public sector tend to receive inadequate mental health services. In addition, treatments for PTSD for this population remain undeveloped, with virtually no available empirical treatment outcome data to guide clinicians. We propose a model for a comprehensive, multicomponent cognitive-behavioral treatment program for this target population that includes elements of consumer education, anxiety management training, social skills training, exposure therapy, "homework" assignments, and long-term follow-up care. Special considerations for public-sector consumers with PTSD and SMI are addressed, as are directions for future research.

Cognitive Behavioral Therapy↗

Geographic variations in prevalence and underdiagnosis of COPD: results of the IBERPOC multicentre epidemiological study.

OBJECTIVES: To ascertain the prevalence, diagnostic level, and treatment of COPD in Spain through a multicenter study comprising seven different geographic areas. DESIGN AND PARTICIPANTS: This is an epidemiologic, multicenter, population-based study conducted in seven areas of Spain. A total of 4,035 men and women (age range, 40 to 69 years) who were randomly selected from a target population of 236,412 subjects participated in the study. INTERVENTIONS: Eligible subjects answered the European Commission for Steel and Coal questionnaire. Spirometry was performed, followed by a bronchodilator test when bronchial obstruction was present. RESULTS: The prevalence of COPD was 9.1% (95% confidence interval [CI], 8.1 to 10.2%), 15% in smokers (95% CI, 12.8 to 17.1%), 12.8% in ex-smokers (95% CI, 10.7 to 14.8%), and 4.1% in nonsmokers (95% CI, 3.3 to 5.1%). The prevalence in men was 14.3% (95% CI, 12.8 to 15. 9%) and 3.9% in women (95% CI, 3.1 to 4.8%). Marked differences were observed between sexes in smoking; the percentage of nonsmokers was 23% in men and 76.3% in women (p<0.0001). The prevalence of COPD varied among the areas, ranging from 4.9% (95% CI, 3.2 to 7.0%) in the area of the lowest prevalence to 18% (95% CI, 14.8 to 21.2%) in the area of the highest. There was no previous diagnosis of COPD in 78.2% of cases (284 of 363). Only 49.3% of patients with severe COPD, 11.8% of patients with moderate COPD, and 10% of patients with mild COPD were receiving some kind of treatment for COPD. Multivariate analysis showed that individuals had a higher probability of having received a previous diagnosis of COPD if they lived in urban areas, were of male gender, were > 60 years old, had higher educational levels, had > 15 pack-year smoking history, or had symptoms of chronic bronchitis. CONCLUSIONS: COPD is a very frequent disease in Spain, and presents significant geographic variations and a very low level of previous diagnosis and treatment, even in the most advanced cases.

Adult↗