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PubMedDate not supplied

Regulation and its role in the prevention of building-associated illness.

Many groups have as their common goal the maintenance of acceptable indoor air quality, which protects occupants from adverse health effects and discomfort, but no one group possesses the interest or expertise to deal with all of the IAQ issues. Nonetheless, conclusions can be made regarding available alternatives to mitigate indoor air quality problems, including building-associated illness. It has been suggested that congressional action is needed in three areas related to BAI and IAQ: Recognition that controlling outdoor air only--even if "health based"--will not result in substantial improvement of public health; Definition of responsibilities for achieving healthful indoor environments; and Resolution of jurisdictional disputes between various federal agencies. Through their studies of buildings whose occupants complained of building-associated illness, NIOSH and others have concluded that inadequate supply and distribution of outdoor air to indoor spaces are the most common causes of SBS. Nonetheless, there are no reports of follow-up studies which confirm that the recommended ventilation upgrades actually solved the IAQ problems. Other reports indicate that maintenance, energy management, and air distribution are as important as ventilation rate. Corrective action, therefore, should include these issues. Systematic research directed toward providing cost-effective and innovative solutions should be the driving force. Rather than regulation, governments should assist in funding the necessary research, providing educational, technical and legal assistance, and developing policy options directed at reducing indoor air pollutants. In those cases where the specific causes of IAQ problems can be identified, remedial actions should be immediately implemented utilizing available technology. It has been suggested that "sick buildings" resulted from too much emphasis on efficency and safety and not enough on occupant health and well-being. Because health has been defined as "a state of complete physical, mental and social well-being not merely the absence of disease or infirmity," greater emphasis should be given to the concept of control and maintenance of healthy indoor environments (i.e., "healthy buildings") through utilization of quality assurance measures. Also, human response, system performance, and service factors should be utilized to assure an acceptable building performance. Finally, building designers, contractors, owners, managers, and operators must be knowledgeable regarding indoor air quality problems and their consequences and work together to build and maintain healthy buildings. This includes developing training, education, monitoring, and preventive maintenance programs to assure accountability for the proper management of the building systems. The certification (or licensing) of those responsible for providing indoor air quality has been suggested.

Air Pollutants, Occupational↗
PubMedDate not supplied

The need for epidemic intelligence.

The past decade has witnessed an unprecedented upturn in tuberculosis morbidity and outbreaks of difficult- to-treat and highly lethal multidrug-resistant tuberculosis. In the early 1990s, a national consensus developed among public health officials to define more comprehensively the problem, and in January 1993, expanded tuberculosis surveillance was implemented nationwide. Carefully selected epidemiologic and case management variables were added to the Report of Verified Case of Tuberculosis form. Information is collected on the health status and treatment of patients, including human immunodeficiency virus status, drug susceptibility test results, and the initial drug regimen. Completion of therapy and use of directly observed therapy are also monitored. The new surveillance system allows a comparison of the quality of care of patients in the public and private sectors. Additional epidemiologic variables include membership in high-risk groups (the homeless, residents of correctional or long-term care facilities, migrant workers, health care workers, and correctional employees) and substance abuse (injecting drug use, non-injecting drug use, and excess alcohol use). The additional information derived from expanded tuberculosis surveillance is crucial to optimal patient management, policy development, resource allocation, as well as program planning, implementation, and evaluation at Federal, State, and local levels.

AIDS-Related Opportunistic Infections↗
PubMed1998

[Impact of a multidisciplinary approach for monitoring prescribing of antibiotics in a hospital].

OBJECTIVE: The aim of this study was to examine the impact of a rationalized antibiotic prescription program in a 600-bed hospital. PATIENTS AND METHODS: The program was based on a local consensus policy, developed with the prescribers themselves, together with individual nominative dispensing (IDN) of the most costly antibiotics, and training/information programs aimed at institutional prescribers. The impact of the program was assessed in terms of the relevance of prescriptions (6-monthly audits), changes in the overall cost of anti-infectives, the average daily cost per hospital patient, and changes in the pattern of antimicrobial resistance among pathogens isolated in the institution. RESULTS: Reference recommendations were established for most clinical settings encountered in the hospital (104 for adults, 78 for children). The four audits conducted since June 1996 show that the rate of unjustified prescriptions has remained below 6%. The cost of antimicrobials has fallen regularly, both in absolute terms and as a proportion of total drug costs. Finally, resistance rates among the different pathogens studied have fallen or remained stable. CONCLUSION: Rationalization of antimicrobial chemotherapy in a short-stay hospital necessitates an institution-based policy with long-term objectives, a large initial investment and, above all, a participative approach among all prescribers.

Adult↗
PubMed2003

The living anonymous kidney donor: lunatic or saint?

Studies indicate that 11% to 54% of individuals surveyed would consider donating a kidney, while alive, to a stranger. The idea of 'living anonymous donors' (LADs) as a donor source, however, has not been embraced by the medical community. Reservations focus on the belief that LADs might be psychologically unstable and thus unsuitable donors. Our goal was to inform policy development by exploring the psycho-social make up and motivations of the LAD. Ninety-three unsolicited individuals contacted our center expressing interest in living anonymous donation. Of these, 43 participated in our study, completing two extensive inventories of psychopathology and personality disorder and taking part in the Comprehensive Psycho-Social Interview (CPSI). From the Personality Assessment Inventory (PAI), the revised NEO Personality Inventory (NEO PI-R), and the CPSI, coders assessed psychological health, psycho-social suitability, commitment, and motivations. Twenty-one participants passed the stringent criteria to be considered potential LADs. Content analysis of motivations showed that potential LADs were more likely than non-LADs (those who did not pass the criteria) to have a spiritual belief system and to be altruistic. Non-LADs were more likely than potential LADs to use donation to make a statement against their families. The authors conclude with a preliminary outline of eight policy recommendations.

Altruism↗
PubMed1995

A review of selected blood-borne pathogen position statements and federal regulations.

One response to the AIDS epidemic has been the formation of blood-borne pathogen policy statements by medical associations, athletic governing bodies, and the federal government. The policy statements by medical associations and athletic governing bodies discuss a wide range of issues, including the eligibility of infected athletes and the right of infected health care workers to practice. In contrast, federal regulations are limited to employees in the work environment. Despite the apparent comprehensiveness of these documents, major deficiencies in the documents do exist. For example, employees exposed to body fluids are entitled to free, employer-provided HIV testing. Similarly, athletes exposed to body fluids also are entitled to voluntary HIV testing. However, it is unclear who should pay for this testing. Furthermore, AIDS testing of student athletic trainers is never discussed. Although there are deficiencies, these documents provide guidelines for resolving the deficiencies. For example, because student athletic trainers act as employees of their institution, it is reasonable to suggest that they receive the same protections that federal regulations provide to employees. Thus, the athletic trainer should find these documents useful for developing policies related to blood-borne pathogens.

Journal Article↗
PubMed1995

[Child vaccination and its representations in Iran today: from Teheran to Hassanabad].

The reception of child immunization in Iran today can be explained by the conjunction of several factors. Firstly, the Pasteur Institute of Teheran (established in 1921) initiated the vaccine transfer, while the successive public health policies developed and systematized it. Since the Islamic Revolution, the application of the Expanded Program of Immunization has allowed the Islamic Republic of Iran to reach the fourth world-wide rank for immunisation of child populations. The socio-cultural appropriation of the technique can also be explained by its integration into the popular preventive practices (such as magic and religious rituals) as well as a specific treatment of the collective/individual question. This paper describes some results of a qualitative anthropological research conducted in Teheran and the rural district of Hassanâbâd (near Isfahân) between 1991 and 1992.

Age Factors↗
PubMed2004

Health impact assessment as an agent of policy change: improving the health impacts of the mayor of London's draft transport strategy.

OBJECTIVE: To increase the positive and mitigate the negative health impacts of the mayor's draft transport strategy for London. DESIGN: A rapid prospective health impact assessment (HIA) of the penultimate draft of the strategy, using a review commissioned by the regional director of public health; an appraisal of congestion charging; and a participatory workshop. Two audits of changes were performed to assess the impact on policy of the HIA process. SETTING: Regional government policy development. INTERVENTION: Recommendations from the rapid HIA were fed back into the drafting process. MAIN OUTCOME MEASURE: Changes (a) between the penultimate draft and the draft for public consultation and (b) between that and the final mayoral strategy. RESULTS: The draft transport strategy published for consultation differed in a number of respects from the previous version. Almost all the recommendations from the HIA were incorporated into the final strategy. Significant changes included promoting sustainable travel plans for workplaces and schools; giving priority to infrastructure and services that benefit London's deprived communities; increased emphasis on promoting walking and cycling and reducing reliance on private cars; and a commitment to track the health impacts of the final strategy and its implementation. Specific additions included re-allocating road space. CONCLUSION: HIA was successful in influencing the transport strategy for London, resulting in several improvements from a health viewpoint. HIA is an effective method both for bringing about significant change in policy proposals and in increasing policy makers' understanding of determinants of health and hence in changing attitudes of policy makers.

Environmental Health↗
PubMed1998

Core function-related local public health practice effectiveness.

This article assesses the extent to which the U.S. population in 1995 was being effectively served by public health's three core functions (assessment, policy development, and assurance). A random sample of local health departments (LHDs) stratified by population size and type of jurisdiction was asked to provide their opinion of, as well as indicate performance on 20 core function-related measures of local public health practice. The article concludes that, in 1995, the nation fell far short of its year 2000 national objective, which called for 90 percent of the population to be served by an LHD effectively carrying out public health's core functions. Considerable capacity building and performance improvement is needed within the public health system.

Humans↗
PubMedDate not supplied

[Health inequalities in Panama].

OBJECTIVES: To document socioeconomic inequalities in health and health services in Panama and thus create a baseline for the prospective monitoring of the impact of health policies on equity. METHODS: Analysis of data from the 1997 Living Standards Measurement Survey, the 1990 National Population Census and birth registration data for 1996. The relative index of inequality and concentration coefficient were calculated for a wide range of indicators of out-of-pocket health expenditure, access, utilization and quality of health services and of health outcomes. RESULTS: Large and statistically significant socioeconomic differences in many of the variables examined were detected, almost all of which favored the rich. The inequalities identified included qualitative factors such as the type of care received as well as quantitative factors such as travelling times and utilization rates. Some of the inequalities were concentrated among a small, very poor segment of the population whilst others were the result of gradually increasing advantage with increased levels of outcome. CONCLUSIONS: The results obtained provide a valuable starting point for the Panamanian government from which it can identify the most serious inequalities in health and health service provision and develop policies to eliminate or reduce them. They also offer a baseline to monitor changes in the magnitude of these inequalities over time.

Delivery of Health Care↗
PubMed1998

Determining the function of a hospital clinical ethics committee: making ethics work.

The objective of this study was to identify ethical issues of greatest concern to hospital staff, and to establish perceptions regarding the optimal function of a Clinical Ethics Committee (CEC). The design involved a descriptive, cross-sectional study using a self-report questionnaire, which was sent to a random sample of medical, nursing, allied health, technical and administrative staff working at the John Hunter Hospital (a 650-bed, urban, teaching hospital in New South Wales) in September 1995. The questionnaires were sent to 565 staff and completed by 287: an overall compliance rate of 51%. Although the majority of staff supported the existence of the CEC in principle, approximately two-thirds were actually aware of its existence and less than 10% were aware of policies/guidelines produced by the CEC. Ethical issues of greatest concern to respondents were informed consent and confidentiality. Most believed that the main function of the CEC should be education and policy development; fewer supported a role in case consultation or case review, and even less believed that the CEC should take any role in resource allocation decisions. While there is a strong degree of support for the existence of a CEC, there is considerable variation in opinion regarding what should be its function and how it should be organized. The results of this study provide some insight into the issues associated with the emergence of CECs in an Australian context.

Attitude of Health Personnel↗
PubMed2001

Changing roles and identities of midwives in rural Costa Rica.

The roles and social identities of rural midwives in Costa Rica reflect the changing history of local birth practices vis-à-vis pragmatic local needs as well as the changing relation of the nation-state to the production of birth. This article explores how midwifery practices changed over time in relation to Costa Rican state policy and why prenatal massage (an important element of prenatal care historically) retains its importance despite the massive hospitalization of birth. Home birth's history as a heterogeneous, flexible model for care, combined with the pragmatic needs of women, make midwives and prenatal massage central in the production of hospital birth. Costa Rican midwives survive in the interstices of the biomedical model of care, providing interventions demanded by women (although demeaned by biomedicine) and serving as a safety net for pregnancy crises in hinterland communities. While acknowledging the potential for maternal or child death during pregnancy crises in isolated regions, midwives generate acute critiques of the biomedical model of birth and clearly articulate the practical need for (and continuing importance of) their practices in rural areas. This case study illustrates the obstacles to international awareness faced by midwives in so-called Third World countries like Costa Rica-midwives who must overcome not only geographic and socioeconomic marginalization, but also overwhelming opposition from the state and multilateral "reproductive development" policies.

Attitude of Health Personnel↗
PubMedDate not supplied

Azoospermia and oligospermia among a large cohort of DBCP applicators in 12 countries.

Azoospermia and oligospermia have been well demonstrated among workers exposed to 1,2-dibromo-3-chloropropane (DBCP) in manufacturing and formulation of this pesticide. After DBCP was banned in the United States in the late 1970s, two American companies continued to export it to many less developed countries. In the early to mid-1990s, attorneys assembled a cohort of approximately 26,400 male plaintiffs who, as workers on banana and pineapple plantations in 12 of these countries, had been exposed to DBCP, primarily during its application. These attorneys, for the purpose of a lawsuit against the two American companies, developed from interrogatories a database on these men that included information about stated periods of occupational DBCP exposure. Seminal fluid analysis results were also entered into the database. Analyzing information in this database, the authors found that, after a median exposure to DBCP of three years, 64.3% of these men overall, and 90.1% of men studied from the Philippines, had azoospermia or oligospermia. The mean number of children reported by the men was 2.5 overall. The percentage of men with no children was 28.5% overall. This report represents the largest cohort of DBCP-exposed workers in which adverse reproductive health effects have been described, and the first report of the adverse effects on the reproductive health of workers exposed to DBCP primarily through its application in a cohort of this size. This serious and extensive occurrence of adverse reproductive health effects due to the export of a hazardous pesticide before and after its ban in the United States illustrates a number of needs for monitoring, research, education, and policy development.

Adolescent↗
PubMed1994

Public health core functions--Alabama, Maryland, Mississippi, New Jersey, South Carolina, and Wisconsin, 1993.

The three core functions of public health are assessment, policy development, and assurance. Within these core functions, CDC has identified 10 basic public health practices that are integral to the operation of state and local health agencies (Table 1). As a part of assessing the core functions of public health, public health officials at local health departments in six states (Alabama, Maryland, Mississippi, New Jersey, South Carolina, and Wisconsin) were surveyed in 1993 by the state local liaison affiliates of the Association of State and Territorial Local Health Liaison Officials, the School of Public Health at the University of North Carolina at Chapel Hill, and CDC. This report summarizes the findings from this survey.

Alabama↗
PubMed2006

Private practitioners' communications with patients around HIV testing in Pune, India.

Unlike any other disease so far, the 'exceptional' nature of HIV/AIDS has prompted debate about the necessity, but also the challenges, of regulating practitioner-patient communication around HIV testing. In India, the National AIDS Control Organization (NACO) has adopted the guidelines of the World Health Organization with regard to HIV testing and counselling, yet the extent to which these guidelines are fully understood or followed by the vast private medical sector is unknown. This paper examines the gaps between policy and practice in communications around HIV testing in the private sector and aims to inform a bottom-up approach to policy development that is grounded in actual processes of health care provision. Drawing on 27 in-depth interviews conducted with private medical practitioners managing HIV patients in the city of Pune, we looked specifically at practitioners' reported communications with patients prior to an HIV test, during and following disclosure of the test result. Among these practitioners, informed consent is rare and pre-test communication is prescriptive rather than shared. Confidentiality of the patient is often breached during disclosure, as family members are drawn into the process without consulting the patient. While non-adherence to guidelines is a matter of concern, practitioners' communication practices in this setting must be understood in the given social and legal context of the patient-practitioner relationship in India. Communication with their patients is strongly influenced by practitioners' perceptions of their own roles and relationships with patients, perceived characteristics of the patient population, limitations in knowledge and skills, moral values as well as perceptions of legal guidelines and patient rights. We suggest that policy guidelines around patient-practitioner communication need to take sufficient cognizance of existing practices, cultures and the realities of care provision in the private sector. Patients themselves need to be empowered in order to grasp the importance and implications of HIV testing and counselling.

Communication↗
PubMed2004

A national assessment of children with special health care needs: prevalence of special needs and use of health care services among children in the military health system.

OBJECTIVE: Children are frequently perceived to be healthy, low-risk individuals with a majority of clinical services devoted to health maintenance and preventive clinical services. However, a subset of children have unique needs that require specialized care to achieve optimal health outcomes. The purpose of this research was to use survey tools that have been developed to identify children with special health care needs (CSHCN) to measure prevalence and resource needs of these children in the military health system (MHS). METHODS: The US Department of Defense manages the MHS, which is one of the largest integrated health care systems in the world and provides care to almost 2,000000 children. We incorporated the CSHCN survey screener and assessment questions into the annual health care survey of beneficiaries who are eligible for benefits within the MHS. In addition, we used claims information available from inpatient and outpatient services. We used parent reports from the survey to estimate the prevalence of CSHCN. Incorporating claims data and restricting our analyses to those who were enrolled continuously in a military health maintenance organization (TRICARE Prime), we described utilization of different types of health care resources and compared CSHCN with their healthy counterparts. Finally, we examined alternative types of special needs and performed regression analyses to identify the major determinants of health needs and resource utilization to guide system management and policy development. RESULTS: CSHCN compose 23% of the TRICARE Prime enrollees who are younger than 18 years and whose parents responded to the survey. The needs of a majority of these children consist of prescription medications and services targeting medical, mental health, and educational needs. CSHCN experience 5 times as many admissions and 10 times as many days in hospitals compared with children without special needs. CSHCN are responsible for nearly half of outpatient visits for enrolled children and more than three quarters of inpatient days. Service utilization varies dramatically by type of special need and other demographic variables. CONCLUSION: CSHCN represent a major challenge to organized systems of care and our society. Because they represent a group of children who are particularly at risk with potential for improved health outcomes, efforts to improve quality, coordinate care, and optimize efficiency should focus on this target population.

Child↗
PubMed1992

HIV issues for rural hospitals in U.S. frontier areas.

A Survey of 108 hospital administrators in the eight states of the Mountain Census Region was conducted to identify frontier rural hospitals' experiences (fewer than 50 beds) in the provision of care and services to patients with HIV infection; to assess the availability of HIV care and services in these small, remote rural hospitals; and to assess the status of education and policy development related to HIV infection. Of the 62 hospitals that responded, 16 (26%) had provided care and services to HIV-infected patients. Acute inpatient and emergency room care were the services most commonly utilized. An additional 11 hospitals reported the presence of HIV-positive individuals in their medical service areas. Thus, nearly 44 percent of the hospitals were aware of the importance of addressing HIV infection as a local concern. Employees in the hospitals that had experienced caring for HIV-positive persons expressed more concern about acquiring HIV infection than those in hospitals that had not. Four nursing assistants, two registered nurses, and one dietary worker had refused to provide care. HIV education consisted primarily of video programs, presentations by in-house staff, and sending employees away to workshops. Despite this HIV education, most staff remain fearful of caring for HIV infected patients. Major concerns expressed by the hospital administrators were related to enforcing universal precautions, confidentiality, staff response, community acceptance, and cost of care. Only 30 hospitals (48%) had AIDS policies in effect, and these focused primarily on infection control and universal precautions.(ABSTRACT TRUNCATED AT 250 WORDS)

HIV Infections↗
PubMed2006

Utilization of health-care services at the end-of-life.

End-of-life care poses a growing clinical and policy concern since most people who are dying utilize health-care services during this period of life. Hence, end-of-life care is a common and integral part of the care provided by health-care systems. There is a growing call for the implementation of a palliative approach as an integral part of all end-of-life care. The purpose of this study was thus to provide policy-makers, health-care providers and professional caregivers with increased knowledge about mainstream patterns of health-care utilization during end-of-life. The patterns of use of health-care services in a Swedish population who accessed the health-care system during their last 3 months of life were in this study examined through a retrospective examinations of medical and nursing records (n=229). We found high prevalences of use of both hospital care, primary care and care provided in people's homes and nearly three quarters of the persons included in the study used between two and three health-care services. However, the probability of using different health-care services was found to be strongly depending on demographic, social, functional and disease related characteristics. The study reveals a considerable use of different health-care services during end-of-life. It is hence essential to, on one hand delineate how such health-care services best can support people at the end-of-life, and on the other hand develop policies which facilitate the process of dying, both in hospitals as well as in peoples' homes. Implications for policy are discussed.

Aged↗
PubMed1992

AIDS, sex and condoms: African healers and the reinvention of tradition in Zaire.

Condoms offer considerable protection against sexual transmission of AIDS. Yet many Africans who are at risk of infection reject condoms as "unnatural." Data from Zaire have been used to examine this culturally constructed category in relation to sexuality, procreation, gender roles, class formation and international health and development policy. Much more than a simple transfer of biomedical technology is involved. Condom use with regular partners raises issues of cultural politics at many levels. "Traditional" African healers represent important social networks with considerable authority in poor urban communities. They are able to reinterpret cultural categories and endow behavior with new meanings. Action-research in Kinshasa was used to explore roles that healers might play in promoting change to safer sex practices.

Acquired Immunodeficiency Syndrome↗