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PubMed1976

The role of group practice in the distribution of physicians in nonmetropolitan areas.

The geographic maldistribution of physicians persists as a major obstacle to improving the availability of health services in rural areas. This study looks at group practice as a potential factor in the location of physicians in nonmetropolitan areas. The basic assumptions are 1) the expected conditions of practice are critical to a physician's decision about where to locate, and 2) a group practice form of organization alleviates many of the deterrents to rural practice. The sample for the study is 287 nonmetropolitan trade areas in eight geographic regions of the U.S. Stepwise multiple regression is used to evaluate the relationship of demographic and health system variables, including group practice, to the physician/population ratio. Analyses are done for 1960 and 1970 and then for the change over the ten-year time period. The regression outcomes show that income, population over age 64, and urbanization are most helpful in explaining physician distribution in 1960. In 1970, hospital facilities also contribute. However, the percentage change in the physician/population ratio between 1960 and 1970 is explained by the 1960 physician/population ratio and the per cent of physicians in group practice in 1960. The findings suggest that attractive practice arrangements may be one way to alter the geographic maldistribution of physicians.

Aged↗
PubMed2005

The global distribution of risk factors by poverty level.

OBJECTIVE: To estimate the individual-level association of income poverty with being underweight, using tobacco, drinking alcohol, having access only to unsafe water and sanitation, being exposed to indoor air pollution and being obese. METHODS: Using survey data for as many countries as possible, we estimated the relative risk association between income or assets and risk factors at the individual level within 11 medium- and low-income subregions of WHO. WHO and The World Bank data on the prevalence of risk factors and income poverty (defined as living on < US$ 1.00 per day, US$ 1-2.00 per day and > US$ 2.00 per day) were analysed to impute the association between poverty and risk factors for each subregion. The possible effect of poverty reduction on the prevalence of risk factors was estimated using population-attributable risk percentages. FINDINGS: There were strong associations between poverty and malnutrition among children, having access only to unsafe water and sanitation, and being exposed to indoor air pollution within each subregion (relative risks were twofold to threefold greater for those living on < US$ 1.00 per day compared with those living on > US$ 2.00 per day). Associations between poverty and obesity, tobacco use and alcohol use varied across subregions. If everyone living on < US$ 2.00 per day had the risk factor profile of those living on > US$ 2.00 per day, 51% of exposures to unimproved water and sanitation could be avoided as could 37% of malnutrition among children and 38% of exposure to indoor air pollution. The more realistic, but still challenging, Millennium Development Goal of halving the number of people living on < US$ 1.00 per day would achieve much smaller reductions. CONCLUSION: To achieve large gains in global health requires both poverty eradication and public health action. The methods used in this study may be useful for monitoring pro-equity progress towards Millennium Development Goals.

Health Services Accessibility↗
PubMedDate not supplied

[Distribution of educational and health services].

This paper presents some ideas on the relation between personal income and the quantity and quality of education and health. It is suggested that the high degree of inequality in income in Mexico could be attributed to ancestral differences in educative and health care opportunities. In the short run, the desirable decrease in educative and health inequities will not modify the income concentration rates. However it is a powerful tool in the struggle against poverty and a necessary condition for the gradual reduction of inequities in the long run.

Education↗
PubMed2005

[A nationwide wealth score based on the 2000 Brazilian demographic census].

OBJECTIVE: To propose an asset based indicator of wealth for Brazil using variables present in the demographic census. METHODS: The indicator, named IEN (Indicador Econômico Nacional/ National Wealth Score), was developed using 12 assets and the schooling of the household head, through principal component analysis. Data from the 2000 Brazilian Demographic sample was used for deriving the score and for the calculation of decile cut-off points. RESULTS: The indicator, first component obtained from the analysis with the 13 variables, retained 38% of the total variability, and presented a Spearman correlation of 0,74 with total family income and of 0,67 with per capita income. The necessary scores to calculate the indicator are presented, as well as reference distributions for the 27 states and their capitals, the five major regions as for the whole country. An example of use of indicator is presented. CONCLUSIONS: Differently from other economic indicators, the Indicador Econômico Nacional has local reference distributions available, along with the national distribution. It is therefore possible to compare a study sample to the municipal, state or country distribution. The small number of variables allow investigators to calculate the Indicador Econômico Nacional in research studies where economic classification is of interest.

Brazil↗
PubMed2004

Maternal socio-economic factors and the risk of low birth weight in Lithuania.

AIM: To evaluate the importance of maternal socio-economic factors on the risk of low birth weight in Lithuania. MATERIAL AND METHODS: The case-control study involved 851 newborns with low birth weight (<2500 g) (cases) and 851 newborns with normal weight (controls). Study was accomplished from 1st February, 2001 until 31st October, 2002 in six main maternity hospitals in Lithuania. Mothers of infants were interviewed on the first day after delivery using the structured questionnaire. The database was processed by the application of statistical package "SPSS for Windows v.10.0". RESULTS: Young (<20 years) and older (35 years and older) maternal age, primary or basic education, being single, divorced or widowed, low income, living in rural area and unemployment before pregnancy and during pregnancy increased the risk to deliver low birth weight baby in univariate analysis. In logistic multivariable regression analysis, low education, low income and unemployment during pregnancy significantly increased risk of low birth weight--OR - 2.0, 1.7 and 1.6 respectively. Interaction between several unfavorable risk factors increased risk of low birth weight by 3.4-7.8 times, being the highest among mothers with low education, unstable marital status and low income. CONCLUSION: Maternal unfavorable socio-economic factors increased the risk to deliver low birth weight baby.

Adult↗
PubMed2001

Disparities in cholesterol screening: falling short of a national health objective.

BACKGROUND: The objective of this study was to determine whether the Year 2000 national health objective for cholesterol screening was attained and to identify disparities in cholesterol screening across racial or ethnic and socioeconomic groups. METHODS: Using data from 149,692 persons interviewed by the 1999 Behavioral Risk Factor Surveillance System, we estimated the proportion of adults age > or =20 years who were screened for high blood cholesterol within the preceding 5 years. RESULTS: Overall, an estimated 70.8% of the U.S. population was screened for cholesterol, falling short of the Year 2000 objective of 75%. Screening prevalence was lowest at ages 20-44 years (58.2%), in contrast to ages 45-64 years (81.9%) and > or =65 years (87.1%). Screening prevalence was also low among Asian or Pacific Islanders (62.7%) and Hispanics (60.7%), particularly Hispanic men (55.3%). After multivariate adjustment, Asian Pacific Islanders were significantly less likely to be screened compared with white non-Hispanics (OR = 0.76, 95% CI 0.65, 0.89). The likelihood of screening decreased with decreasing income level (P < 0.05) and persons with health insurance were 1.6 times more likely to have been screened during the past 5 years than adults with no insurance (P < 0.05). CONCLUSIONS: Significant disparities in cholesterol screening exist across age, gender, racial or ethnic, and socioeconomic groups in the United States. As we look to attain the objectives of Healthy People 2010, state and local health officials and policy makers should be aware of these disparities in order to design and target effective cholesterol screening programs and cardiovascular disease prevention programs to those most in need.

Adult↗
PubMed2003

Consumer attitudes and use of antibiotics.

Recent antibiotic use is a risk factor for infection or colonization with resistant bacterial pathogens. Demand for antibiotics can be affected by consumers' knowledge, attitudes, and practices. In 1998-1999, the Foodborne Diseases Active Surveillance Network (FoodNet( conducted a population-based, random-digit dialing telephone survey, including questions regarding respondents' knowledge, attitudes, and practices of antibiotic use. Twelve percent had recently taken antibiotics; 27% believed that taking antibiotics when they had a cold made them better more quickly, 32% believed that taking antibiotics when they had a cold prevented more serious illness, and 48% expected a prescription for antibiotics when they were ill enough from a cold to seek medical attention. These misguided beliefs and expectations were associated with a lack of awareness of the dangers of antibiotic use; 58% of patients were not aware of the possible health dangers. National educational efforts are needed to address these issues if patient demand for antibiotics is to be reduced.

Adult↗
PubMed2001

Private pharmacy practice and regulation. A randomized trial in Lao P.D.R.

OBJECTIVES: The objective of this study was to assess the effectiveness of government regulation of private pharmacy practice in a low-income country. METHODS: The intervention comprised inspections of the pharmacies, information, and distribution of documents to drug sellers and sanctions. It was implemented at two different intensity levels, active and regular intervention. The methods used to assess the effect of the interventions were interviews with the district drug inspectors, drug sellers and customers, inspection of drug purchases, and indicator surveys of pharmacies. Indicators for pharmacy-specific quality as well as for dispensing quality were developed. RESULTS: The main finding was one of strong overall improvements from initially low levels. The improvements were particularly marked by increases in the availability of essential materials for dispensing by 34% and in order in the pharmacy by 19%. Information given to customers increased from 35% to 51% and the mixing of different drugs in the same package went down from 17% to 9%. The pharmacies in the active intervention districts showed greater improvements for four of the six indicators, although statistically significant compared with the regular intervention districts only for the essential materials indicator. CONCLUSIONS: It was concluded that the regulatory activities have probably been an important factor behind the service quality improvements. It appeared feasible as well as effective to regulate private pharmacy practice in this particular low-income setting.

Developing Countries↗
PubMedDate not supplied

Prevalence and demographic correlates of tooth loss among the elderly in the United States.

The aging of the United States population and the contribution of tooth loss to oral health make it important to describe tooth loss among the elderly in this country. Data from the National Survey of Oral Health in US Employed Adults and Seniors: 1985-1986, conducted by the National Institute of Dental Research, were analyzed to examine the prevalence and demographic correlates of tooth loss among the elderly. Results show that there were important differences in tooth loss among subgroups of the elderly sample (overall n = 5,649 persons aged 65+ years attending senior centers). The oldest seniors and those with the least education or income were the most likely to be edentulous. The oldest dentulous seniors, blacks, those with the least education or income, and those who lived in New England or the Northeast had the fewest number of teeth present. These findings suggest that efforts to reduce tooth loss among the elderly should target those with the least education and income.

Age Distribution↗
PubMedDate not supplied

Prescription drug use among elderly and nonelderly families.

OBJECTIVE: This study augments existing literature by examining characteristics associated with prescription drug utilization and makes an in-depth assessment of family prescription drug economic burden within the United States. The objective of this study was to examine differences in prescription drug use and prescription drug characteristics among elderly and nonelderly families. METHODS: A measure of out-of-pocket prescription drug burden associated with family prescription drug utilization was constructed using data from the 1996 Medical Expenditure Panel Survey (MEPS). Families were designated as the unit of analysis and further divided by age (<65 and e 65 years) of the reference person. The 1996 MEPS database provides medical expenditure data on a national sample of 8,917 families (22,601 individuals) and 147,308 drug episodes, i.e., prescription procurement. The ratio of family prescription out-of-pocket expenditures to family income was used to assign families to economic burden rank-ordered quintiles, each representing 20% of U.S. families in 1996. RESULTS: Prescription size, price, and drug use were higher among elderly families. Their proportion of generic use was higher compared to nonelderly families. Additionally, out-of-pocket prescription expenditures represented 23.7% and 45.6% of the total out-of-pocket medical care burden for nonelderly and elderly families, respectively. The average prescription drug burden (total prescription out-of-pocket costs/family income) was 0.4% for nonelderly and 1.9% for elderly households. CONCLUSION: The study results demonstrate an ability to identify populations with high economic burden for prescription medications. The presumption is that persons age 65 or older, lacking purchasing leverage, are more likely to pay full retail price and, consequently, higher prices. Our findings suggest that high prescription drug burden was a function of prescription size and cost per prescription, with prescription size showing more drastic differences between the high and low prescription drug burden subgroups. Future studies should continue to assess factors influencing families. prescription drug economic burden, and the information derived from these studies should be used by benefit planners in designing drug benefits within health insurance plans.

Age Distribution↗
PubMed2006

Workload and reward in the Quality and Outcomes Framework of the 2004 general practice contract.

BACKGROUND: The Quality and Outcomes Framework (QOF) of the 2004 UK General Medical Services (GMS) contract links up to 20% of practice income to performance measured against 146 quality indicators. AIM: To examine the distribution of workload and payment in the clinical domains of the QOF, and to compare payment based on true prevalence to the implemented system applying an adjusted prevalence factor. We aimed also to assess the performance of the implemented payment system against its three stated objectives: to reduce variation in payment compared to a system based on true prevalence, to fairly link reward to workload, and finally, to help tackle health inequalities. DESIGN OF STUDY: Retrospective analysis of publicly available QOF data. SETTING: Nine hundred and three GMS general practices in Scotland. METHOD: Comparison of payment under the implemented Adjusted Disease Prevalence Factor, and under an alternative True Disease Prevalence Factor. RESULTS: Variation in total clinical QOF payment per 1000 patients registered is significantly reduced compared to a payment system based on true prevalence. Payment is poorly related to workload in terms of the number of patients on the disease register, with up to 44 fold variation in payment per patient on the disease register for practices delivering the same quality of care. Practices serving deprived populations are systematically penalized under the implemented payment system, compared to one based on true prevalence. CONCLUSIONS: The implemented adjustment for prevalence succeeds in its aim of reducing variation in practice income, but at the cost of making the relationship between workload and reward highly inequitable and perpetuating the inverse care law.

Family Practice↗
PubMed2004

Ecological measures of socioeconomic status and hospital readmissions for asthma among Canadian adults.

BACKGROUND: Lack of an association between area-based socioeconomic status (SES) and readmission for asthma was investigated in a country with a universal health care system. METHODS: Data linkage analysis was conducted based on hospitalization data from Statistics Canada's Person-oriented Information Database and area-based SES data from the 1996 Census. Hospital records for 8333 asthma patients aged 20-64 years in all Canadian provinces except Quebec who were admitted in 1995/1996 were linked to determine the number of patients who were rehospitalized within the same fiscal year. The area-based SES of the patients was defined according to the average personal income and proportion of residents with a university degree in an enumeration area (EA). Incidence rates of readmission for asthma were calculated based on the total years at risk. Cox's proportional hazard model was used to adjust for age, sex, province, and length of stay for first admission. RESULTS: The incidence rate of asthma rehospitalization was 31.6 per 100 person-years for men and 37.2 per 100 person-years for women. Neither average EA income or education level was significantly associated with rehospitalization for asthma. Women living in poor areas tended to have an increased incidence of asthma rehospitalization, but the difference was not significant after adjustment for covariates using the Cox regression model. CONCLUSION: Socioeconomic status measured at the neighborhood level has no significant impact on rehospitalization for asthma among Canadian adults.

Adult↗
PubMed1990

Occupational distribution of inflammatory bowel disease among German employees.

Previous reports have shown that both Crohn's disease and ulcerative colitis affect people in white collar occupations associated with higher income and higher social class more frequently than other groups in the population. This study sought to carry these analyses one step further and investigate the distribution of inflammatory bowel disease by individual occupations. The German social security statistics for 'rehabilitation' were used to assess the occupational distribution of Crohn's disease and ulcerative colitis. From 1982 to 1988, a total of 12,014 people were granted rehabilitation as a result of inflammatory bowel disease. Low male prevalence of inflammatory bowel disease was found among bricklayers, road construction workers, unskilled workers in brick and stone, unskilled labourers, and security personnel. Low rates were found among women employed in cleaning and maintenance, and in those without occupation. In contrast, a high male prevalence was found among instrument makers, electricians, bakers, and technical assistants. Among female employees, inflammatory bowel disease was significantly associated with sales representatives, office workers, health occupations, and hairdressers. These associations were found in the complete data for 1982-8 as well as in the separate data for the two half periods 1982-5 and 1986-8. Highly significant correlations between the occupational distribution of Crohn's disease and ulcerative colitis were found among both male and female employees. It seems that occupations involving work in the open air and physical exercise are protective, while being exposed to air conditioned artificial working conditions or extended and irregular shift working confer a risk of contracting inflammatory bowel disease.

Colitis, Ulcerative↗
PubMed2004

Delay in diagnosis of slipped capital femoral epiphysis.

OBJECTIVE: Delay in diagnosis of slipped capital femoral epiphysis (SCFE) has important implications in terms of slip severity and long-term hip outcome. The purpose of this study was to identify predictors of delay in the diagnosis of SCFE. METHODS: A review of 196 patients with SCFE was performed. The primary outcome measure was delay from onset of symptoms to diagnosis. Covariates included age, gender, side, weight, pain location, insurance status, family income, slip severity, and slip stability. Delay in diagnosis was not normal in distribution; therefore, nonparametric univariate and multivariate analyses were performed. RESULTS: The median delay in diagnosis was 8.0 weeks. There was a significant relationship between delay in diagnosis and slip severity (<30 degrees : 10.0 weeks; 30 degrees to 50 degrees : 14.4 weeks; >50 degrees : 20.6 weeks). There were no significant associations between delay in diagnosis and covariates of age, gender, side, and weight. There were significant associations between longer delay in diagnosis and covariates of knee/distal-thigh pain versus hip/proximal-thigh pain (6.0 vs 15.0 weeks), Medicaid coverage versus private insurance (12.0 vs 7.5 weeks), lower family income, and stable slips versus unstable slips (8.0 vs 6.5 weeks). Controlling for the other covariates, knee/distal-thigh pain, Medicaid insurance, and stable slips remained significant independent multivariate predictors of delay in diagnosis. CONCLUSIONS: Patients who present with primarily knee or distal-thigh pain, patients with Medicaid coverage, and patients with stable slips have longer delays in diagnosis of SCFE. Focused intervention programs to reduce the delay in diagnosis of SCFE should emphasize patients with knee/thigh pain and patients with Medicaid coverage.

Child↗
PubMedDate not supplied

[Growth analysis of 566 children from the fourteen day care centers of Paulínia (São Paulo, Brazil), with ages ranging from 3 months to 3 years].

To study the growth of 566 children (273 males and 293 females) from fourteen day care centers of Paulínia (São Paulo, Brazil), with ages ranging from 3 months to 3 years, admitted from March 1st to May 31st, 1993, the authors analyzed the z-score distribution of height for age and weight for height in relation to age group, per capita family income, social class levels, mothers education level and child birth weight. The Kruskal-Wallis test and the Multiple Comparison test were used in the statistical analysis. The children with less than 24 months or with birth weight less than 3000 g as the children with mothers education level less than four years, presented left deviated distribution in the height for age z-score. The weight for height score was less satisfactory in the group with per capita income less than one salary, in the group with birth weight less than 3000 g, and in the group with ages superior to 18 months.Therefore, institutional actions concerning the children and their parents are recommended in order to attenuate these factors.

English Abstract↗