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PURPOSE: Nearly 46 million Americans did not have health insurance in 2004. Recent studies have documented physicians' support for various remedies, including universal health care. The authors undertook this study to assess medical students' views on these topics. METHOD: In 2002, the authors surveyed a national random sample of first-year and fourth-year medical students (from the American Medical Association Masterfile) to determine their views about health care reform options, including universal health care. Response data were weighted and compared using chi-squared tests; statistical significance was set at p < or = .05. RESULTS: Of 1,363 medical students, 770 completed the questionnaire (response rate = 56.5%). In rating the importance of several health care issues, more than 80% of both first-year and fourth-year students rated the expansion of health care coverage as important. Nearly all first-year (90%) and fourth-year (88%) students agreed with the statement, "Everyone is entitled to adequate medical care regardless of ability to pay." Most students favored health care reform that would achieve universal health care, with first-year students (70%) somewhat more likely than fourth-year students (61%) to support universal health care (p = .012). Students were less likely to believe that physicians support universal health care, and more likely to believe that the public does. CONCLUSIONS: Both groups of students generally support the expansion of health coverage to the uninsured and some form of universal health care. This may be relevant both to policymakers in their considerations of health care reform and to medical educators concerned with teaching students about health policy issues.
Health promotion concept and practices have brought many significant changes even in disease management and care settings. In the Ottawa charter, health promotion is defined as "the process of enabling people to increase control over, and to improve, their health". However, care settings are in contradiction with this process on several levels (focus on disease and not enough on health, concern more on cure than on care, etc.). The emergence of health promotion practices has been deeply questioning these features. Care institutions start to reconsider their role and missions. However, changes are slow and there has been much resistance. What is the current situation of health promotion in French speaking Belgian care institutions in 1998? The WHO EUROPE HEALTH PROMOTING HOSPITALS' (HPH) project, which officially started in 1991, aims at "promoting positive health and well-being in hospitals and beyond that, in the community". For each participating hospital, the implications of membership have an important influence on the institution and care project, because it implies adherence to the principles of the Ottawa charter on health promotion, and to the philosophy and objectives of HPH. Belgium joined the WHO project and the HPH network in 1996. It was necessary to review the situation of health care institutions in the French speaking community of Belgium in order to understand the evolution over the last years, to assess health professionals expectations and the feasibility of some actions, and to provide political decision makers with information likely to influence future decisions and choices in a positive way. This article presents the descriptive results of a survey carried out on nursing and patient education departments in health care institutions. Half of 105 hospitals answered the questionnaires sent. Out of these answers, 150 projects and actions were identified and briefly described by the institutions, which had the possibility to present a maximum of five actions. The main topics addressed were chronic diseases, psychology (conflict management, aggressiveness, ill-treatment), maternity, screening, prevention and vaccination. Regarding perspectives, 78% of actions concern disease and/or risks of disease (therapeutic or preventive perspectives) and 22% concern the maintenance or improvement of health. 90% of listed and described actions are permanent, and only 10% are selective (limited), which suggests an evolution of projects and their integration in practices. Concerning the number of projects, two aspects were analysed: the number by institution and the evolution over the last twenty years. On average, there are 3.2 actions per institution. As for the evolution, 7% of hospitals said they had at least one education action/project in 1980, 60% in 1990 and 98% in 1998. This amazing and remarkable evolution occurred simultaneously to the development of education committees, of patient education co-ordinators and/or resource persons. In this field, there was also a remarkable evolution since the creation of the first committees in 1983. Amongst the elements encouraging the development of information and health education initiatives and actions mentioned by hospital managers, the first one is a demand from the public (and patients). It is the first time, since the existence of such surveys that this factor is mentioned as the most important.
OBJECTIVE: The purpose of this article is to report the findings of the 2001 National Survey of Children With Special Health Care Needs regarding the extent to which children with special health care needs (CSHCN) have access to public or private health insurance that meets their needs. METHODOLOGY: As part of its effort to develop systems of care for CSHCN, the US Maternal and Child Health Bureau established a health insurance core outcome. Successful attainment was measured on the basis of whether the child met 3 distinct components at the time of the interview: presence of public or private coverage; continuity of coverage over the previous 12 months; and adequacy of coverage. Adequacy of coverage was measured from the family's perspective of whether their insurance covered needed services, covered a reasonable share of costs, and allowed families to see the providers they felt were best for their child. Bivariate and multivariate statistical methods were used to assess independent predictors of respondents meeting the health insurance core outcome. RESULTS: Results of the survey indicated that 59.6% of CSHCN nationally met the health insurance core outcome using the 3 components of presence of insurance coverage, continuity of coverage, and adequacy of coverage. Poverty status, race/ethnicity, and functional ability were significant factors in whether a child met the health insurance core outcome as well as each of the 3 components. Of Hispanic and non-Hispanic black CSHCN, 45.2% and 57.6%, respectively, met the health insurance core outcome, compared with 62.5% of their white counterparts. Children with the most limited functional ability were 50% less likely to meet the health insurance core outcome than CSHCN without limitations. More than 10% of Hispanic CSHCN were uninsured at the time of the interview, and 20% of Hispanic CSHCN experienced gaps in coverage. Although insurance met the needs of most families, more than one fourth of families reported that uncovered costs were not reasonable. Children who did not meet the health insurance core outcome were also more likely to have unmet needs. CONCLUSIONS: Results of the survey demonstrated that although the majority of CSHCN have adequate health insurance, additional work is needed to improve the adequacy of insurance, particularly for children below the poverty line, Hispanic children, and children with the most limited functional ability. The survey results also demonstrated the importance of continuous and adequate health insurance, because children who met the health insurance core outcome had fewer unmet needs.
Mental health is an intrinsic part of health. Its prevailing position as secondary to physical health and its consequent neglect are based on inaccurate assumptions about mental health. Nowhere in the world, in either the developed or the developing countries, has mental health work been given priority as part of social policy, health policy or public policy. Yet all countries readily admit the major impact of mental health disturbances on the national economy and public health. The mentally sick are at the bottom of the list in service systems the world over, and the common attitude towards them tends to be highly negative. Meanwhile there is convincing evidence of the global and growing need for mental health services. The international debate on mental health policy has its origins in two arenas: in human rights issues and in service reform issues. The debate on human rights concerns legislation on mental health, compulsory treatment and coercive measures. As to the service reform process, the universal focus has been on the financing of health care, on cuts and downsizing, where no priority has been given to the quality of care. The social consequences of mental illnesses may be far more seriously marginalising for the patient than is the illness itself. They are caused by the inexperience and the exclusion mechanisms of the social community. They are evident also in non-institutional services, causing isolation and rejection. The state of mental health patients will not improve without the strong involvement of health policy planners, quality assurance developers and the medical and scientific community. We need far more studies and research in the field. We need also the empowerment of the patients themselves and their relatives.
OBJECTIVES: It is important that health measures are both reliable and responsive to clinical change. The aim of this study was to assess the reliability and responsiveness of the physical, mental, and social health scales of the Duke Health Profile (DUKE). METHODS: Impotent males self-administered the Duke Health Profile before and during treatment with alprostadil for erectile dysfunction during a 19-month period. Subjects were 490 patients in the United States and 583 patients in 12 other countries. Each of the three basic Duke Health Profile scales has only five items, and each is heterogeneous because each measures more than one health concept. RESULTS: Cronbach's alpha reliability estimates were: physical health, 0.68 for United States and 0.64 for other countries; mental health, 0.62 and 0.52, respectively; and social health, 0.53 and 0.47, respectively. Alprostadil was expected to improve mental health primarily, and results of the study were consistent with this hypothesis. For example, at approximately 14 months from therapy onset, mental health improved for patients both in the United States (standardized response mean, SRM, = 0.17) and other countries (mean SRM = 0.30), whereas physical health worsened in the United States and was unchanged in other countries, and social health was unchanged in the United States and improved in other countries. Maximum responsiveness was shown for mental health in the other countries, where the mean standardized response means at four follow-ups during a 19-month period were 0.11, 0.21, 0.30, and 0.36. CONCLUSIONS: This study provides support for the responsiveness of the Duke Health Profile mental health scale.
OBJECTIVE: To examine, among middle-aged individuals, if subjective socioeconomic status (SES) predicts health status and change in health status over time better than objective SES. METHODS: Data are from the Whitehall II study, a prospective study of British civil servants. SES data are drawn from Phase 5 (1997-1999) of the study and health data from Phases 5 and 6 (2000-2001). Physical and mental component scores from the Short Form 36, the General Health Questionnaire, and self-rated health were used to assess health status. Multiple linear regressions were used to examine the relationship between SES and health and change in health status. RESULTS: Complete data were available on 5486 people. Results show both measures of SES to be global measures of SES. Both measures of SES were significantly associated with health outcomes and with decline in health status over time. However, when both objective and subjective measures of SES are entered simultaneously in the model to predict change in health status, it was only the latter that continues to be significantly associated with health and changes in health. CONCLUSIONS: Subjective SES is a better predictor of health status and decline in health status over time in middle-aged adults. These results are discussed in terms of three possible explanations: subjective SES is a more precise measure of social position, the results provide support for the hierarchy-health hypothesis, and the results could be an artifact of common method variance.
Increasing emphasis in recent years has been placed on health promotion, prevention, and the self-management of health care. These strategies presume the public has sufficient levels of relevant health information, as well as necessary attitudes and skills for the effective use of this information in the management of their own health care. This study tests this assumption as it relates to the level of public knowledge of digestive health and disease, a major health concern affecting an estimated 1 in 10 Americans. This paper reports results of a telephone survey of a representative national sample administered to 1,250 Americans in May 1983 that was designed to assess their level of information about digestive health and disease, comfort in communicating about digestive problems, and preference for health information sources. The results indicate that the American public is largely uninformed and misinformed about digestive health and disease, and they underscore the need for disseminating relevant health information about digestive health and disease to the public to facilitate prevention of digestive health problems and self-management of digestive health care. Health information dissemination is severely complicated by the widespread stigma associated with digestive topics, manifested in the American public's general discomfort in communicating with others about digestive health. These factors necessitate development of sensitive and pervasive digestive health promotion and education programs in the United States.
It is widely understood that maternal health care relies on the entire health system. However, little empirical, country-specific, research has been done to trace out the ways in which health system elements can shape maternal health outcomes. This study seeks to redress this situation, by providing an example of how a health systems approach can benefit the understanding of maternal health services. A comparative analysis was conducted based on extensive case studies of maternal health and health systems in Bangladesh, Russia, South Africa, and Uganda. A number of cross-cutting health system characteristics affecting maternal health were identified by comparing these diverse settings. The most important common systems issues underlying maternal health care were found to be the human resource structures, the public-private mix of service provision, and the changes involved with health sector reforms. Specific country contexts can further determine many factors influencing maternal health outcomes and service performance. Systems issues were found to influence the access to and utilization of services, quality of care provided, and ultimately maternal health outcomes. This paper provides a first step in tracing out how such broad systems issues actually work to influence maternal health.
Focusing mainly on the United States and Latin America, we aimed to identify the constructions of social reality held by the major stakeholders participating in policy debates about global trade, public health, and health services. In a multi-method, qualitative design, we used three sources of data: research and archival literature, 1980-2004; interviews with key informants who represented major organizations participating in these debates, 2002-2004; and organizational reports, 1980-2004. We targeted several types of organizations: government agencies, international financial institutions (IFIs) and trade organizations, international health organizations, multinational corporations, and advocacy groups. Many governments in Latin America define health as a right and health services as a public good. Thus, the government bears responsibility for that right. In contrast, the US government's philosophy of free trade and promoting a market economy assumes that by expanding the private sector, improved economic conditions will improve overall health with a minimum government provision of health care. US government agencies also view promotion of global health as a means to serve US interests. IFIs have emphasized reforms that include reduction and privatization of public sector services. International health organizations have tended to adopt the policy perspectives of IFIs and trade organizations. Advocacy groups have emphasized the deleterious effects of international trade agreements on public health and health services. Organizational stakeholders hold widely divergent constructions of reality regarding trade, public health, and health services. Social constructions concerning trade and health reflect broad ideologies concerning the impacts of market processes. Such constructions manifest features of "creed," regarding the role of the market in advancing human purposes and meeting human needs. Differences in constructions of trade and health constrain policies to address the profound changes generated by global trade.
OBJECTIVE: To assess whether and how the rankings of the world's health systems based on disability adjusted life expectancy as done in the 2000 World Health Report change when using the narrower concept of mortality amenable to health care, an outcome more closely linked to health system performance. DESIGN: Analysis of mortality amenable to health care (including and excluding ischaemic heart disease). MAIN OUTCOME MEASURE: Age standardised mortality from causes amenable to health care SETTING: 19 countries belonging to the Organisation for Economic Cooperation and Development. RESULTS: Rankings based on mortality amenable to health care (excluding ischaemic heart disease) differed substantially from rankings of health attainment given in the 2000 World Health Report. No country retained the same position. Rankings for southern European countries and Japan, which had performed well in the report, fell sharply, whereas those of the Nordic countries improved. Some middle ranking countries (United Kingdom, Netherlands) also fell considerably; New Zealand improved its position. Rankings changed when ischaemic heart disease was included as amenable to health care. CONCLUSION: The 2000 World Health Report has been cited widely to support claims for the merits of otherwise different health systems. High levels of health attainment in well performing countries may be a consequence of good fortune in geography, and thus dietary habits, and success in the health effects of policies in other sectors. When assessed in terms of achievements that are more explicitly linked to health care, their performance may not be as good.
In this article we describe the methodologic approaches of the Pew Environmental Health Commission at the Johns Hopkins Bloomberg School of Public Health used to identify priority environmental health conditions and develop recommendations to establish a national environmental public health tracking network. We present the results of a survey of public health and environmental practitioners to uncover state and local health tracking needs and priorities. We describe the steps that combined the findings from the state and local health tracking survey and a review of the state of the science on environmental impacts on health to identify priority health end points. Through an examination of national health and health care databases, we then describe trends and public health effects of those diseases that may be linked to the environment. Based on this analysis, respiratory diseases and neurologic diseases are recommended as priorities for tracking. Specific end points recommended for tracking include asthma and chronic respiratory diseases, and chronic neurodegenerative diseases such as multiple sclerosis. Based on trends in reported prevalence, consideration should also be given to developmental disabilities, reproductive disorders, and endocrine/metabolic disorders. Strengthening of current efforts to track cancer and birth defects should also be included as components of a nationwide health tracking network. Finally, we present the recommendations for environmental public health tracking. These recommendations provided the groundwork for the development of the Centers for Disease Control and Prevention's National Environmental Public Health Tracking Progam that now includes 21 states, three cities, and three academic centers throughout the nation.
This study describes the rates of health care access among Mexican Americans with different health insurance coverage. An interview questionnaire was used to collect information regarding sociodemographics, perceived health status, health insurance coverage, and sources of health care from a random sample of 501 Mexican Americans from San Antonio, Texas. Health care access was determined more by having health insurance coverage than by health care needs. Poor Mexican Americans with health insurance had higher health care access rates than did poor Mexican Americans without health insurance. Health care access may improve health care outcomes, but more comprehensive community-based campaigns to promote health and better use of health services in underprivileged populations should be developed.
OBJECTIVES: The relationship between health insurance and subjective health status was investigated. It was hypothesized that persons without health insurance would have lower levels of subjective health status than those with health insurance and that this relationship would hold for both poor and nonpoor persons. METHODS: Data from the 1987 National Medical Expenditure Survey were analyzed to examine the relationship between health insurance and self-reported health status. The analysis controlled for sociodemographic and attitudinal variables and medical conditions. RESULTS: Persons without health insurance had significantly lower levels of subjective health status than did persons with insurance. This adverse effect persisted after adjustments were made for the effects of age, sex, race, income, attitude toward the value of medical care and health insurance, and medical conditions. The detrimental effect of lacking health insurance on subjective health status was present for persons at all income levels and was greater than the effect on subjective health status found for 2 of the 11 reported medical conditions. CONCLUSIONS: Lacking health insurance is associated with clinically significant lower levels of subjective health status in both poor and non-poor persons.
The Study Model for Future Occupational Health (funded by a research grant from the Ministry of Health, Welfare and Labor) is a joint research project involving various organizations and agencies undertaken from 2002 to 2004. Society has undergone a dramatic transformation due to technological developments and internationalization. At the same time a low birth rate and an aging population have resulted in an increase in both the percentage of workers experiencing strong anxiety and stress in relation to their jobs and the working environment and the number of suicides. As a natural consequence, occupational health services are now expected to provide EAP, consulting and other functions that were formerly considered outside the realm of occupational health. In consideration of this background, the present study propose the following issues to provide a model for future occupational health services that meet the conditions presently confronted by each worker. 1. How to provide occupational health services and occupational physicians' services: 1) a basic time of 20 minutes of occupational health services per year should be allotted to each worker and to all workers; 2) the obligatory regulations should be revised to expand the obligation from businesses each with 50 or more employees under the present laws to businesses each with 30 or more employees. 2. Providers of occupational health services and occupational physicians' services: (1) reinforcement of outside occupational health agencies; (2) fostering occupational health consultant firms; (3) development of an institute of occupational safety and health; (4) support of activities by authorized occupational physicians in the field; (5) expanding of joint selection of occupational physicians including subsidy increase and the extension of a period of subsidy to five hears; (6) licensing of new entry into occupational health undertaking. 3. Introduction of new report system: (1) establishment of the obligation to submit reports on risk evaluation and improvement measures; (2) establishment of the obligation to prepare a report on results of medical examinations in all sizes of businesses. 4. Introduction of a merit system into businesses in establishment of a new system: the application of the special merit system of the workers' compensation insurance shall be revised to add occupational health activities, cover business with 20 or more to 100 or less employees and expand the period of application for three years under the present laws to five years. 5. Ensuring of international coordination: harmonization of standards of individual countries for occupational health and safety; thorough (1) ensuring of international agreement on high-level specialist qualifications; (2) mutual recognition of qualifications of occupational physician, nurse, occupational hygienist, ergonomist, and counselor; (3) preparation of guidelines for occupations relating to occupational health businesses.
Health targets.de is a co-operation between the German Federal Ministry of Health (BMG) and the Association for Social Security Policy and Research (GVG) and is funded by the Ministry. Health targets.de unites numerous players in the field of health care and establishes a round table to put the development and implementation of some exemplary health targets to the test by the players themselves. The players are required to reach consensus about health targets and strategies and propose them collectively to health policy makers. Herewith, health targets.de aims to establish this "health targets" tool in order to supplement existing instruments of German health policy. Furthermore, its aim is to strengthen the idea of target setting at all levels of the health care system. Health targets.de was started in December 2001 and will present results at the beginning of 2003. Interim results are made accessible on the Internet. Since December 2001 health targets.de has so far been developing five specific health targets concerning diabetes; breast cancer; reduction in tobacco consumption; nutrition, physical activities and stress reduction in children and adolescents; and the improvement of the patients' and citizens' competence in health-related issues. Further topics will be dealt with later. For additional information see www.health targets.de.
AIM: To explore differences in self-perceived health as an indicator of health status and mortality, in six isolated populations from Croatian islands and to compare the results with control from general Croatian population obtained through the National Health Survey. METHOD: Health-related quality of life was measured using the Short Form Health Status Questionnaire (SF-36). The questionnaire was administered to 600 participants, inhabitants of 6 villages: Rab, Barbat, Lopar, and Supetarska Draga on island Rab, and Komiza and Vis, on island Vis, and to control group of 600 participants from the general Croatian population matched by age and gender to islanders. RESULTS: The islanders scored higher than controls on 3 out of 8 health dimensions, physical functioning (80.1+/-22.4 vs 73.2+/-24.8, P<0.001), vitality (61.0+/-20.3 vs 55.7+/-19.9, P<0.001), and pain (70.1+/-28.0 vs 65.9+/-26.5, P=0.008). Social functioning of islanders was significantly lower than in control group (73.4+/-18.6 vs 77.6+/-23.4, P=0.001). There was also a significant variation in health status among the islanders according to the isolation level, with the largest differences in general health perception and mental health. High isolation group reported the lowest score of all groups on mental health (P=0.018), physical functioning (P=0.045), general health (P=0.001), and vitality dimension (P=0.027). CONCLUSION: Inhabitants of Croatian islands in general showed better health-related functioning on the most of the health dimensions than general population. Islanders scored lower than controls only on social functioning which can be explained by their geographical isolation and small population. Low mental health score of islanders in the highly isolated group should be taken in account in planning health services for islands.
PURPOSE: The purpose of the present study was to explore structural relationships among health behavior and health consciousness and to delineate latent factors underlying them. METHODS: Data used in this study were obtained from a mail survey conducted by Toshima City Government, Tokyo, in 2002. The subjects were 3,000 community residents, living in the city, ranging in age from 20 to 79 years. The response rate was 54.3%. The data for 1,301 respondents without missing observations were analyzed. A second-order factor model utilizing 23 items of health behavior and health consciousness as observed indicators was developed for the analysis. RESULTS: Covariance structure analysis showed that a model consisting of 23 observed indicators, 9 latent first-order factors, and one second-order factor fitted well and explained the structure of health behavior and health consciousness: the 23 items of health behavior and health consciousness were indicatives of the latent second-order factor named Health-oriented Attitude. The second-order factor score was significantly higher in respondents willing to participate in programs of public health agencies than in those not willing. CONCLUSION: The results imply that reinforcement of the health-oriented attitude may bring about improved health consciousness and practice of health behavior. They also suggest the necessity to reconsider traditional programs of public health agencies because persons with a weak health-oriented attitude are less likely to participate.