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Biomedical subjects

D McIntyre

Publications and source records attributed to D McIntyre.

At least 19 recordsLinked to original sources
PubMed2002

Geographic patterns of deprivation in South Africa: informing health equity analyses and public resource allocation strategies.

There is a growing interest in the use of small area analyses in investigating the relationship between socioeconomic status and health, and in informing resource allocation decision-making. However, few such studies have been undertaken in low- and middle-income countries (LMICs). This paper reports on such a study undertaken in South Africa. It both looked at the feasibility of developing a broad-based area deprivation index in a data scarce context and considered the implications of such an index for geographic resource allocations. Despite certain data problems, it was possible to construct and compare three different indices: a general index of deprivation (GID), compiled from census data using principal component analysis; a policy-perspective index of deprivation (PID), based on groups identified as priorities within policy documents; and a single indicator of deprivation (SID), selected for relevance and feasibility of use. The findings demonstrate clearly that in South Africa deprivation is multi-faceted, is concentrated in specific areas within the country and is correlated with ill-health. However, the formula currently used by the National Treasury to allocate resources between geographic areas, biases these allocations towards less deprived areas within the country. The inclusion of the GID within this formula would dramatically alter allocations towards those areas suffering from human development deficits. The area in which analysis was undertaken was not, however, sufficiently small to identify pockets of deprivation within the less deprived metropolitan areas. These findings suggest that it is feasible to conduct small area analyses in LMICs but that specific attention needs to be given to the size of the geographic unit used in analysis. In addition, they highlight the importance of considering deprivation in resource allocation mechanisms if vertical equity goals are to be promoted through resource allocation, particularly within decentralized health systems.

Censuses↗
PubMed2001

Differential impact of predator or immobilization stressors on central corticotropin-releasing hormone and bombesin-like peptides in Fast and Slow seizing rat.

Lines of rats selectively bred for amygdala excitability, as reflected by kindling rates in response to electrical stimulation, also exhibit differences in tests of anxiety. Inasmuch as corticotropin-releasing hormone (CRH) and bombesin (BN) have been associated with anxiety, regional levels and release of these peptides, as well as plasma adrenocorticotropic hormone (ACTH) and corticosterone, were assessed in 'Slow' and 'Fast' seizing rats following predator exposure (ferret) or immobilization. Ferret exposure elicited a greater increase of plasma ACTH and corticosterone concentrations in the Slow than in the Fast rats. In contrast, immobilization provoked a greater rise of plasma ACTH levels in the Fast rats, paralleling the vigorous struggling observed in this line. In Slow rats, stressor exposure elicited increased levels of ir-BN at the anterior hypothalamus, and increased ir-CRH at the median eminence/arcuate nucleus (Me/Arc), paraventricular hypothalamic nucleus (PVN) and pituitary (Pit), whereas decreased levels of ir-BN were found at the nucleus tractus solitarius (NTS). Fast rats likewise showed decreased ir-BN at the NTS, but unlike the Slow rats, ir-CRH was reduced in the Me/Arc, PVN and Pit in response to both stressors. In vivo microdialysis experiments revealed that in response to ferret exposure, the Slow rats showed a greater CRH release at the central nucleus of the amygdala (CeA) as compared to Fast rats. However, immobilization elicited a more pronounced release of CRH in Fast than in Slow rats. Taken together, the results demonstrate that these two lines of rats show differential endocrinological and neurochemical response patterns to these stressors.

Adrenocorticotropic Hormone↗
PubMed2001

Modulation of the human nociceptive flexion reflex across the cardiac cycle.

Carotid baroreceptor stimulation has been shown to dampen pain. This study tested, in 40 normotensive adults, the hypothesis that pain is lower during systole when arterial baroreceptor stimulation is maximal than diastole when stimulation is minimal. The sural nerve was stimulated electrocutaneously to obtain a nociceptive flexion reflex (NFR) threshold, and then stimulation was delivered for 28 trials at 100% NFR threshold at seven intervals after the R-wave. Nociceptive responding was indexed by electromyographic (EMG) activity elicited in the biceps femoris. Significant variations in EMG activity occurred across the cardiac cycle, with less activity midcycle, indicating that the NFR response was attenuated during systole compared to diastole. Stimulation of baroreceptors by natural changes in blood pressure during the cardiac cycle dampened nociception, and accordingly, the data support the arterial baroreflex mechanism of hypertensive hypoalgesia.

Adult↗
PubMed2000

Redressing dis-advantage: promoting vertical equity within South Africa.

This paper represents the first attempt to apply vertical equity principles to the South African health sector. A vertical equity approach, which recognises that different groups have different starting points and therefore require differential treatment, appears to offer an appropriate basis for considering how best to redress the vast inequities which exist in post-Apartheid South Africa. Vertical equity principles are applied in critically analysing two areas of recent policy action which are particularly relevant to health sector equity in South Africa, namely public-private sector cross-subsidies and the allocation of government resources between provinces. Despite a strong political commitment to redressing historical inequities, recent government policy actions in these two areas appear to fall short of desirable goals when viewed through a vertical equity lens. In particular, policies since the first democratic elections in 1994 have done little to reduce the extent of government subsidies to the private health sector, which serves a minority of the population. In addition, recent proposals for a Social Health Insurance will allow minimal cross-subsidies between high- and low-income earners and would not adequately redress the currently inequitable public-private cross-subsidies. With respect to the allocation of government resources between provinces, a vertical equity approach would suggest that the most historically dis-advantaged provinces have an even greater claim on government resources than reflected in the current formula, as developed by the Department of Finance. This paper also considers the potential benefits of engaging with societal views in determining what constitutes dis-advantage in the South African context, in order to identify those who should receive priority in resource allocation decisions. It concludes with a review of a number of practical steps that can be taken to draw vertical equity principles into policy action.

Black or African American↗
PubMed2000

A pilot study to establish a randomized trial methodology to test the efficacy of a behavioural intervention.

How can pregnant women be helped to stop smoking? This was a pilot study of midwife home-based motivational interviewing. Clients were 100 consecutive self-reported smokers booking at clinics in Glasgow from March to May 1997. Smoking guidance is routinely given at booking. In addition, intervention clients received a median of four home-based motivational interviewing sessions from one specially trained midwife. All sessions (n = 171) were audio-taped and interviews (n = 49) from 13 randomly selected clients were transcribed for content analysis. Three 'experts' assessed intervention quality using a recognized rating scale. Cotinine measurement on routine blood samples confirmed self-reported smoking change from late pregnancy telephone interview. Postnatal telephone questionnaire measured client satisfaction. Focus groups of routine midwives explored acceptability, problems and disruption of normal care. Fisher exact, chi 2 and Mann-Whitney tests compared enrolment characteristics. Two-sample t-tests assessed outcome between groups. Motivational interviewing was satisfactory in more than 75% of transcribed interviews. In this pilot study, self-reported smoking at booking (100 of 100 available) corroborated by cotinine (93 of 100) compared with late pregnancy self-reports (intervention 47 of 48; control 49 of 49) and cotinine (intervention 46 of 48; control 47 of 49) showed no significant difference between groups. Tools have been developed to answer the question: 'Can proactive opportunistic home-based motivational interviewing help pregnant smokers reduce their habit?'.

Adult↗
PubMed2000

Inequalities in health care use and expenditures: empirical data from eight developing countries and countries in transition.

This paper summarizes eight country studies of inequality in the health sector. The analyses use household data to examine the distribution of service use and health expenditures. Each study divides the population into "income" quintiles, estimated using consumption expenditures. The studies measure inequality in the use of and spending on health services. Richer groups are found to have a higher probability of obtaining care when sick, to be more likely to be seen by a doctor, and to have a higher probability of receiving medicines when they are ill, than the poorer groups. The richer also spend more in absolute terms on care. In several instances there are unexpected findings. There is no consistent pattern in the use of private providers. Richer households do not devote a consistently higher percentage of their consumption expenditures to health care. The analyses indicate that intuition concerning inequalities could result in misguided decisions. It would thus be worthwhile to measure inequality to inform policy-making. Additional research could be performed using a common methodology for the collection of data and applying more sophisticated analytical techniques. These analyses could be used to measure the impact of health policy changes on inequality.

Data Collection↗
PubMed1999

Health expenditure and finance: who gets what?

The methods used in South Africa's first comprehensive review of health finance and expenditure are outlined. Special measures were adopted to make the process acceptable to all concerned during a period of profound political transition. The estimation of indicators of access to public sector resources for districts sorted by per capita income allowed the health care problems of disadvantaged communities to be highlighted.

Costs and Cost Analysis↗
PubMed1999

General practitioners and national health insurance--results of a national survey.

OBJECTIVE: To determine the attitudes of South African general practitioners (GPs) to national health insurance (NHI), social health insurance (SHI) and other related health system reforms. DESIGN: A national survey using postal questionnaires and telephonic follow-up of non-responders. SETTING: GPs throughout South Africa. PARTICIPANTS: Four hundred and forty-three GPs were randomly selected from a national sampling frame of 6,781 GPs. MAIN OUTCOME MEASURES: Acceptance of NHI and GP preferences with regard to financing, provision, benefits, coverage and the role of GPs. MAIN RESULTS: A response rate of 82.1% was achieved. Sixty-two per cent of GPs approved of the introduction of some form of social or NHI in South Africa, while 24.1% disapproved. Approval rose to 81.6% if GPs were to maintain their independent status, e.g. own premises and working hours, to 75% if additional private top-up insurance was allowed, and to 79.9% if payment was by fee-for-service. Seventy per cent of GPs in the study stated that they had the capacity to treat more patients. The most important reason given for approving of NHI was to make health care more equitable and accessible to the majority of South Africans. A high proportion of GPs approved of increasing the level of interaction between GPs and district health authorities. CONCLUSIONS: Most GPs approved of some form of social or NHI system, provided that the system did not significantly threaten their professional autonomy or economic and financial situation.

Adult↗
PubMed1998

Towards equity in health in an unequal society.

South Africa is one of the world's most unequal societies and its health sector mirrors these inequalities. Since the first democratic elections in 1994 the government has been under enormous pressure to diminish disparities between population groups in access to health services. This paper documents the structural inequalities in the health sector and discusses the strategic options that are being considered for reducing them. The overall level of health expenditure is high, amounting to 8.5% of GDP. However, less than 40% of expenditure is on public health services and three quarters of that is on acute care hospitals. A more detailed analysis of public health expenditure reveals large differences between census districts. The districts where household incomes are low tend to have fewer public health services. Public health expenditure per capita was lower than the estimated cost of providing basic primary health care in a fifth of districts. The most urgent need is to improve the services likely to reduce excess mortality and morbidity. This will involve additional funding of primary health service services, particularly in underserved localities. Government cannot increase public health rapidly and it will have to re-allocate funding from hospitals. The paper discusses options for achieving this, including the introduction of social health insurance. It argues that restructuring the health sector is complex and there is a risk of failure. Governments should base their strategies on a good understanding of the health sector and of the likely impact of different reform options.

Health Care Rationing↗
PubMed1998

P67L: a cystic fibrosis allele with mild effects found at high frequency in the Scottish population.

Only three mutant cystic fibrosis (CF) alleles have to date been established as conferring a dominant mild effect on affected subjects who are compound heterozygotes. We now add a fourth, P67L, which occurs on about 1.4% of Scottish CF chromosomes. Among 13 patients (12 unrelated) with this allele, the average age at diagnosis was 22.5 +/- 11.3 years. None of the cases had consistently raised sweat chloride concentrations, the average value being 57 +/- 9 mmol/l; 77% of the patients were pancreatic sufficient. When compared to three other established mild CF alleles, R117H, A455E, and 3849 + 10kb C-T, a compound heterozygote for P67L has minimal disease and clinical suspicions are unlikely to be confirmed other than by DNA typing.

Adolescent↗
PubMed1997

A model for phosphocreatine resynthesis.

A model for phosphocreatine (PCr) resynthesis is proposed based on a simple electric circuit, where the PCr store in muscle is likened to the stored charge on the capacitor. The solution to the second-order differential equation that describes the potential around the circuit suggests the model for PCr resynthesis is given by PCr(t) = R - [d1.exp(-k1.t) +/- d2.exp(-k2.t)], where R is PCr concentration at rest, d1, d2, k1, and k2 are constants, and t is time. By using nonlinear least squares regression, this double-exponential model was shown to fit the PCr recovery data taken from two studies involving maximal exercise accurately. In study 1, when the muscle was electrically stimulated while occluded, PCr concentrations rose during the recovery phase to a level above that observed at rest. In study 2, after intensive dynamic exercise, PCr recovered monotonically to resting concentrations. The second exponential term in the double-exponential model was found to make a significant additional contribution to the quality of fit in both study 1(P < 0.05) and study 2(P < 0.01).

Humans↗
PubMed1996

Noninvasive capnometry in a pediatric population with respiratory emergencies.

OBJECTIVE: This study was designed to investigate the reliability, safety, and efficacy of measuring end tidal CO2 (ETCO2) in nonintubated pediatric patients presenting to an emergency department (ED) with respiratory emergencies. DESIGN/SETTING/PATIENTS: Eighty-five children were enrolled in a clinical, prospective, observational study at a university-affiliated children's hospital. Children age four weeks to 15.3 years with upper and lower respiratory diseases were enrolled by convenience sampling over a five-month period. INTERVENTIONS: ETCO2 measurements were obtained on each patient by oral/nasal side-stream capnometry. When a consistent waveform was obtained, the value was compared with a capillary arterial partial pressure of CO2 (CapCO2), oxygen saturation (O2Sat), and clinical observations. RESULTS: Study patients had a mean ETCO2 reading of 33 mmHg with a standard deviation (SD) of 4.6 mmHg and CapCO2 reading of 36 mmHg with a SD of 4.5 mmHg. Pulmonary findings, final diagnosis, and age did not significantly alter the relationship between CapCO2 and ETCO2. The relationship between CapCO2 and ETCO2 was significant (t = 14.9, P < 0.0001, r = 0.87), with a 95% confidence interval for prediction of +/-5 mmHg. CONCLUSION: Dependable ETCO2 values can be obtained using an oral/nasal capnometry circuit, and they consistently correlate with CapCO2 in a pediatric population with upper and lower respiratory diseases. Noninvasive ETCO2 analysis is safe and reliable within the limitations of this study group. Further exploration is necessary to determine the value of this technology in assisting with clinical decisions in the patient with impending respiratory failure.

Adolescent↗
PubMed1996

Value for money in South African health care: findings of a review of health expenditure and finance.

This article highlights the most striking findings of a review of health expenditure and finance in South Africa in 1992/3. The level of national expenditure on health care, and the distribution of resources between the public and private sectors, are discussed first. Then the article highlights the maldistribution of financial, physical and human resources on a geographic basis, racially and between levels of care. The cost of redressing inequities, at least at the primary care level, is mentioned in the context of seeking options for additional sources of finance. The article concludes by examining the planning prerequisites for successful reform.

Financial Support↗
PubMed1995

The metabolic costs of different types of contractile activity of the human adductor pollicis muscle.

1. The metabolic costs and physiological consequences of shortening contractions of a human muscle working in situ have been compared with those of the muscle maintaining a continuous isometric contraction and when performing repeated brief isometric contractions. 2. After a total of 10 s stimulation, the shortening and intermittent brief isometric protocols had very similar effects, causing a 30% loss of force and a threefold increase in the half-time of relaxation. This was in contrast to the continuous isometric contraction protocol where there was less than 10% loss of force or slowing of relaxation. 3. The ATP cost over the first 5 s of the continuous isometric protocol was 27 mmol (l intracellular water)-1 while for the shortening and repeated brief isometric protocols the costs were 48 and 46 mmol (l intracellular water)-1, respectively. 4. The results show that shortening and repeated brief isometric contractions are considerably more energetically demanding, and hence more fatiguing, than sustained isometric contractions.

Adenosine Triphosphate↗
PubMed1995

Expenditure on health research in South Africa, 1991/1992.

OBJECTIVE: To determine expenditure on health research in South Africa in 1991/1992. DESIGN: Data from the financial statements of large statutory councils conducting research in South Africa, as well as other relevant reports, particularly the Department of National Education's (NATED) survey of research institutions, were analysed. RESULTS: A total of R198.7 million was spent on health research in 1991/1992, 56.1% by the tertiary education sector and 20.7% by the Medical Research Council. Only 1.1% of expenditure on health was spent on research. Less than 9% of health research expenditure by tertiary educational institutions is classified within the category of 'comprehensive medicine' (which includes community health, epidemiology and nutrition), whereas 82% of expenditure by autonomous government institutions is so classified. CONCLUSIONS: Given that expenditure on health research in South Africa is relatively low by international standards, an increase in expenditure by both the public and private sectors should be considered. Given the scarcity of research resources, there should be adequate planning, co-ordination, and particularly prioritisation of resource allocations, so that research can be directed towards addressing the country's health needs.

Health Expenditures↗