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In this study, we examined the mortality and fertility effects of the early health-insurance programs sponsored by several European governments in the course of the demographic transition. Three sets of effects were hypothesized, and tested with data for five countries, covering the 1875-1913 period. First, although initially small, the growing health-insurance coverage of national populations accelerated longer-term downtrends in mortality. It not only expanded access to health care, but also helped in disseminating health information and awareness. Second, widening coverage also had an opposite effect on fertility; by lowering the costs of bearing and rearing children, it acted to slow the ongoing downtrend in marital fertility. Third, there was a diverse set of interactions between the mortality and fertility effects. Improved prospects for the survival of infants and children weakened parents' motivation to produce "extra" offspring to offset losses to mortality and to insure against future losses. Child survival was further enhanced by longer intervals between births and fewer children per family. However, the reduced cost of children tended to dilute these antenatal effects. Our regression results supported the expected pattern of partial effects, but simulations were needed to gauge the total impacts of health-insurance. Two sets of simulations were conducted: first, historical simulations, which closely tracked the actual experience of each sample country; second, counterfactuals, in which health-insurance coverage was set at zero for the entire time period. Comparisons of the historical and counterfactual simulations clearly indicated that health-insurance accelerated the downtrend in mortality, but slightly retarded the secular decline in marital fertility. These effects varied in magnitude, but not in direction, among the sample countries.
This study reports the effects which the introduction of a national health insurance plan had upon established patterns of seeking health advice from pharmacists. Data were obtained from a household survey conducted in Montreal, Canada before and after the introduction of the government sponsored compulsory health insurance program. The report documents the extent to which the citizens of Montreal sought advice about health matters from pharmacists and describes the dramatic alteration in the pattern of advice seeking which occurred when the economic barriers to medical care were removed.
For critically ill patients and their loved ones, high-quality health care includes the provision of excellent palliative care. To achieve this goal, the healthcare system needs to identify, measure, and report specific targets for quality palliative care for critically ill or injured patients. Our objective was to use a consensus process to develop a preliminary set of quality measures to assess palliative care in the critically ill. We built on earlier and ongoing efforts of the Robert Wood Johnson Foundation Critical Care End-of-Life Peer Workgroup to propose specific measures of the structure and process of palliative care. We used an informal iterative consensus process to identify and refine a set of candidate quality measures. These candidate measures were developed by reviewing previous literature reviews, supplementing the evidence base with recently published systematic reviews and consensus statements, identifying existing indicators and measures, and adapting indicators from related fields for our objective. Among our primary sources, we identified existing measures from the Voluntary Hospital Association's Transformation of the ICU program and a government-sponsored systematic review performed by RAND Health to identify palliative care quality measures for cancer care. Our consensus group proposes 18 quality measures to assess the quality of palliative care for the critically ill and injured. A total of 14 of the proposed measures assess processes of care at the patient level, and four measures explore structural aspects of critical care delivery. Future research is needed to assess the relationship of these measures to desired health outcomes. Subsequent measure sets should also attempt to include outcome measures, such as patient or surrogate satisfaction, as the field develops the means to rigorously measure such outcomes. The proposed measures are intended to stimulate further discussion, testing, and refinement for quality of care measurement and enhancement.
Since 1975, Rhode Island has operated a government-sponsored catastrophic health insurance program that is consistent in spirit with several of the national health insurance proposals. An important but often overlooked effect of such a program is its effect on the distribution of income. Actual claims data for the years 1975-79 are available for the Rhode Island program permitting direct estimation of an average benefit per family and an average tax burden per family in each of 12 income classes. This permits an assessment of the program's redistributional effects.
Training in gerontology in American institutes of higher education is conceptualized and realized in response to present societal demands. Although plurality of approaches prevails, gerontology has become an institutionalized discipline which in its research, training and application is formally sponsored by the national government. Programs are offered in many colleges and universities and assessed in terms of scientific excellence, of efficiency in teaching knowledge from multiple disciplines, and in terms of practicality. But still, problems of poor research and "quasi-professional" teaching, as well as of insufficiently founded practical work concern gerontologists. In a time of expansion, "instant gerontologists" have become a threat to the field. A brief "instant gerontologists" have become a threat to the field. A brief overview on questions presently discussed among teachers in gerontology is given, and a model-institution for gerontological training is briefly described, the Andrus Gerontology Center at the University of Southern California.
The experience of the Central Massachusetts Health Systems Agency (CMHSA) and the Central Massachusetts Business Group on Health (CMBGH) demonstrates the feasibility of cooperation between HSAs and BGHs. Objectives and strategies of the two groups in carrying out community health planning and working for health systems change are compared. Nearly two decades of government-sponsored community health planning programs, first through comprehensive health planning agencies and then through HSAs, have had less impact than many had anticipated because neither the technical nor political basis for such planning was sufficiently established. The CMHSA experience is typical, although it is credited with developing a hospital systems plan that is based on sound planning methods and statistical data. It is in the implementation of plans that the CMHSA has made slow progress, reflecting its inadequate community power base. The CMBGH, 1 of more than 90 groups that have developed recently across the country to attack high health care costs, was formed in 1981 by business leaders to address these rising costs. The principal strategy adopted by the CMBGH involves fostering a competitive health care market by creating a critical number of competing health plans. The providers in each plan will then have incentives to provide effective care in an efficient manner to keep the premium competitive and attract enrollees. Cooperation between the CMBGH and CMHSA is based on each organization's emphasizing its strengths. The CMHSA's data base and analyses have been the primary resources used by the CMBGH to identify problems. Each organization has developed its own set of goals and objectives, while keeping in mind those of the other organization. The CMBGH adopted a subset of theCMHSA's goals-those that focus on hospital capacity and utilization. Although the CMHSA's regulatory strategies differ greatly from the CMBGH's competition strategies, they do not necessarily conflict.Actually, each organization is supporting the other's strategies without deemphasizing its own.The CMBGH currently has a decisive advantage over the CMHSA in implementing activities because the business leaders are an integral part of the community power structure. Also, their companies' willingness to offer additional health plans to their employees is the prime incentive to develop such plans.
Nurses are regularly advised to become involved in community development initiatives, but what exactly does this entail and what are the precautions that should be considered? A 10-week, government sponsored, community-development program for family caregivers allowed nurses to offer education and support to six under-serviced areas of B.C. They offer a critique of the program and recommendations for the future.
The primary objective of this study was to evaluate a joint state and local government-sponsored potassium iodide (KI) distribution program in New Jersey. This program is part of a radiological emergency response system for residents living within the Emergency Planning Zones (EPZs) of nuclear power facilities. KI pills and an informational fact sheet were distributed locally at six different public clinics in the summer of 2002. In this study, a mailed survey was developed, pilot tested, and sent to the general public to assess knowledge about KI use. The survey consisted of two groups of people, those who attended a KI distribution clinic and those that did not attend a clinic. There was a statistically significant difference in knowledge among the two groups of survey respondents regarding KI prophylaxis, with a mean of 46% of survey questions answered correctly by those who attended a clinic vs. 15% by those who did not attend. Certain questions were problematic for the public to answer correctly and included potential low compliance with government instructions for taking KI, confusion regarding where the public can obtain KI pills during an emergency, and the lack of awareness on the proper use of KI for children, pregnant women, and persons over the age of 40 y. Additional outreach in these specific areas is warranted. This study also found that there was a highly variable geographic pattern of homes that have a supply of KI pills, with some areas having 60% of the households supplied with pills from the clinic while other areas had as low as 1% of the homes supplied with KI pills.
At a time of renewed interest in universal health insurance, an examination of earlier periods when society grappled with the link between socioeconomic status and health is fruitful. Between 1935 and 1947, the federal government sponsored a comprehensive medical care program for low-income farmers, sharecroppers, and migrant workers under the auspices of the Farm Security Administration (FSA). Despite the strong opposition of the American Medical Association, humanitarian and economic concerns at the local level often promoted physicians' participation in the program's group prepayment plans. Many FSA leaders clearly saw the program as a model upon which national health insurance might advance. However, in the wake of World War II, the FSA program declined as physicians' income improved, the rural population declined, and traditional ideological objections to federal intervention in medical care resurfaced. The FSA experience illuminates the complex ideological, economic, and humanitarian motivations of American physicians in the face of health care reform.
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There is a remarkable convergence in the current efforts to develop and evaluate new tuberculosis (TB) vaccine candidates for use in humans, domestic animals, and wild animal reservoirs. It is quite likely that similar vaccination strategies will prove useful in these diverse host species. Many TB vaccine candidates are being screened for protective efficacy in conventional laboratory animals (e.g. mouse, guinea pig), in captive wild species under laboratory conditions (e.g. brushtail possum), and in the target hosts (e.g. cattle, deer). These systems share some important features, e.g. direct challenge infection of the lung by intratracheal or aerosol exposure, and the use of bacterial enumeration, and gross and microscopic histopathology, as the readouts. Some TB vaccine candidates have been tested in many models, yielding important insights into common mechanisms of resistance to Mycobacterium tuberculosis and M. bovis, and providing evidence of the vaccine's ability to induce protection under widely different circumstances. Coordination of this global search for better TB vaccines, irrespective of target species, would facilitate the rapid application of new technologies and maximize the sharing of materials and experiences between human and veterinary TB researchers. The creation of liaisons between TB vaccine research efforts of government-sponsored medical and agricultural research programs, international bodies such as the World Health Organization (WHO) and the European Community (EC), private foundations and the vaccine industry, will yield a high return.
In this article, the author presents an overview of substance-abuse education in U.S. medical schools. In the early 1970s, two nationwide conferences prompted an awareness of the need for improved medical education in substance abuse. The Council on Mental Health and the Committee on Alcohol and Drug Dependency, both of the American Medical Association, presented general guidelines for a curriculum in substance abuse. During the same era, the federal government sponsored a career teacher training program in drug abuse and alcoholism, and private foundation funding supported educational endeavors that resulted in long-term materials for teaching in medical schools. Three current programs that are improving drug-abuse education are described. These developments are good examples of efforts that should be considered for any medical school curriculum. Goals for the future should include some attempt to modify the institutions, both medical schools and hospitals, where patterns leading to physician impairment may develop.
An experimental emergency first-responder system was introduced in 36 small rural Georgia communities as a means for addressing inadequate access to emergency medical services for these communities. A prospective evaluation was designed to address the most efficient and effective means to organize, implement, and administrate such a program on a regional basis. Key to the program were community-selected residents who served as Emergency Medical Coordinators (EMCs) and performed as first responders, information sources on emergency care, and system organizers. The evaluation examined the process of organizing the program through local government versus voluntary group sponsors in terms of response and participation by communities and their ability to select effective EMCs. It assessed the effectiveness of a set of criteria for selecting residents as EMCs against three sets of performance measures encompassing first-responder skills and activities which maintained public awareness and program visibility. Critical to program success was the degree of sponsor involvement in selecting EMCs.
The transition in religious-sponsored health care from a ministry of direct service to one of governance has generated serious and penetrating questions, analyses, and retrenchment. Emphasis on and demand for value-laden leadership development programs are growing at the same time that sponsoring groups are becoming more actively involved in the governance and oversight of their corporate ministries. Two recent Catholic Health Association (CHA) studies focused on the critical governance relationship between the sponsoring group and its incorporated ministries. The first study asked religious institutes and dioceses that were sponsors of CHA member health care freestanding facilities and systems to describe their current governance structure. The second study represented an initial attempt to identify qualitative components of effective governance or sponsorship and asked 19 major superiors and system chief executive officers (CEOs) to characterize an ideal relationship between sponsor and ministry. The studies' findings included the following: In freestanding facilities, lay-religious governing boards have all but replaced the all-sponsor and all-lay advisory boards of the past. Trustee orientation, development, and evaluation were not equally stressed in the three groups surveyed, with trustee evaluation programs lagging behind in all three. Major superiors and CEOs had remarkably similar expectations relating to accountability for mission, relationships between sponsor and corporation, communication, and leadership development. Both major superiors and CEOs looked for greater collaboration in defining roles, translating mission into "business plan", and developing formation programs for leadership. Major superiors' emphasized simplicity of life-style, whereas the CEOs stressed stable commitment to corporate ministry.
The Massachusetts Department of Environmental Management initiated a pilot project to improve compliance with hazardous waste regulations and management of hazardous wastes with auto body shops around the state. The program consisted of mass mailings, a series of workshops throughout the state, a coordinated inspection program by the state regulatory agency, and technology transfer. At the start of the program in January 1986, approximately 650 of the estimated 2,350 auto body shops in the state had notified EPA of their waste generating activities; by January 1987, approximately 1,200 shops had done so. Suggestions for improving program efforts include tailoring the outreach effort to the industry, government-sponsored research and development directed at the needs of small firms, mandatory participation in hazardous waste transportation programs, and better coordination by EPA of its information collection and distribution program.
Because of the increased interest in the diets of children and adolescents and the possible relation between those diets and adulthood diseases, we reviewed nutritional assessment methods used specifically in young people. The assessment of diets of individual children and adolescents has evolved from Hasse's study of Swiss and Russian girls in 1882 to Burke's development of the dietary history to the Ten State Nutrition Survey. Currently, various government-sponsored surveys and several other assessment programs are studying the nutritional status of children and adolescents. We discuss the methods used in these investigations, compare the available dietary assessment tools (the dietary record, 24-h dietary recall, and food-frequency questionnaire), describe the development of a new food-frequency questionnaire (the Youth-Adolescent Questionnaire), and review new approaches. The data emerging from reproducibility studies suggest that food-frequency questionnaires provide enough accuracy in studies of adolescents to permit individual diets to be related to subsequent health outcomes.
A retirement crisis looms in the United States due to a number of recent and emerging trends that affect government retirement programs, employer- and union-sponsored retirement benefits and personal savings arrangements. The crisis can be averted, but only with well-thought-out action on a number of issues, particularly Social Security and Medicare reform.