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PubMed1994

Oral health and nutrition.

The relationships between oral health conditions, dietary practices and nutritional status, and general health status in the older American are complex, with many interrelating factors. Just as inadequate nutrition can affect oral health, poor oral health status affects food choices and, thus, nutritional status. It is clearly essential that the primary care practitioner and/or screening health professionals always include an evaluation of oral status in assessment of an elderly person. Effective care for the elderly dental patient requires knowledge about the disease of aging and the impact of those diseases on oral health and nutrition, pharmacology and drug interactions and their impact on oral health status, the biology of aging including sensory changes, the relationship of general medicine and systemic diseases, and psychology and sociology. The attitudes of empathy and understanding, caring and compassion, respect and a positive attitude toward the older patient, and flexibility in treatment planning are also critical elements. The interdisciplinary team of physicians, nurses, nutrition professionals, dentists, and social service professionals must all work together to ensure that good oral health status and adequate nutrition are maintained in older Americans. Recognizing and treating oral health and nutrition problems are important in improving the health and quality of life for the elderly population. Research that can provide more answers to health care problems in this growing group; educating professionals with respect to the relationships between oral health and nutrition; and public policy changes with regard to provision and funding of nutrition services, especially when provided by registered and/or licensed nutrition professionals, contribute to improving the health and quality of life for elders.

Aged↗

PubMedDate not supplied

The Medicaid eligibility expansions for pregnant women: evaluating the strength of state implementation efforts.

Surveys of state Medicaid agencies and maternal and child health programs were conducted in late 1991 and in 1992 to evaluate the extent to which states carried out a series of federal policy changes intended to improve low-income women's access to prenatal care. The results show a great deal of variability in the aggressiveness with which states implemented these Medicaid eligibility expansions. Overall, North Carolina, Maryland, Massachusetts, New York and Arkansas moved most aggressively to carry out the expansions; Kansas, Nebraska, South Dakota, North Dakota and Wyoming were ranked least aggressive. States with relatively high levels of poor birth outcomes or low-birth-weight deliveries prior to the Medicaid expansions were generally more likely than other states to have undertaken reforms intended to increase the number of women eligible for assistance and ease their enrollment. In addition, expansion efforts were greater in states where the federal government paid more of the cost of caring for Medicaid recipients.

Eligibility Determination↗

PubMed1993

The status of women in dermatology.

In the near future, almost one-third of all American physicians will be women. Many of these women will be pressured by the needs to balance parental/family and professional responsibilities during the formative stages of their careers. Recommendations for medical school policy changes that recognize these pressures are made.

Adult↗

PubMedDate not supplied

Public attitudes about cigarette smoking: results from the 1990 Smoking Activity Volunteer Executed Survey.

The 1990 Smoking Activity Volunteer Executed Survey collected information on a wide range of policy-relevant issues concerning public attitudes about cigarette smoking. These issues include cigarette taxes, advertising restrictions, minors' access to tobacco products, school-based prevention, and exposure to environmental tobacco smoke in workplaces and public areas. Survey data were collected during the spring and summer months of 1990 from random samples of adults from Arizona, Michigan, Pennsylvania, and Texas. Telephone interviews were conducted by trained American Cancer Society volunteers using standardized questionnaires. Cluster sampling techniques, interviewer training and supervision, and data collection procedures were designed in conformity with the methodology of the Behavioral Risk Factor Surveillance System of the Centers for Disease Control and Prevention. Smoking prevalence ranged from a low of approximately 20 percent in Texas to a high of 31 percent in Michigan. Between 60 and 69 percent of the respondents in the four States, including between 44 and 71 percent of current smokers, believe tobacco should be classified as a drug. Around 65 percent of the respondents would support an extra tax on tobacco to finance public campaigns against smoking, and between 61 percent and 69 percent favor banning cigarette advertising in the print media and on billboards. More than 82 percent of the respondents believe that stronger laws should be enacted to prevent the sale of tobacco products to minors, and more than 86 percent believe that existing laws should be better enforced. Current smokers were only slightly less likely than were former and never smokers to indicate support of policy changes to prevent minors'access to tobacco products; the two groups had somewhat more disagreement in the amount of support for the other smoking control policies.Finally, although between 62 and 88 percent of working respondents reported the presence of smoking restrictions at their workplace, between 26 and 48 percent still reported being bothered by smoking at work.These study findings suggest that existing smoking control policies are not restrictive enough or are inadequately enforced. The study documents strong public concern in the four States about the in adequacy of current policies and support for the enactment of stronger legislation to control smoking behavior.

Adolescent↗

PubMed1993

HIV, breast-feeding and under-5 mortality: modelling the impact of policy decisions for or against breast-feeding.

A computer model was developed to assess the impact on under-5 child mortality of breast-feeding practices in developing countries in the context of HIV infection. The model was used to estimate the effect on mortality of cessation of breast-feeding among mothers HIV-positive and mothers HIV-negative at birth, for both urban and rural settings. Using parameter values for a hypothetical East African country, cessation of breast-feeding in urban areas was predicted to result in increases in under-5 mortality of 108% for children of mothers HIV-negative at birth, and 27% for those HIV-positive at birth, with slightly larger increases in rural areas, suggesting that breast-feeding should continue to be promoted. A sensitivity analysis was conducted to identify critical values of key variables for which a review of policies encouraging breast-feeding is indicated. This showed that, even under extreme assumptions, cessation of breast-feeding among mothers HIV-negative at birth (but at risk of acquiring HIV during the lactation period) would increase under-5 mortality. For mothers HIV-positive at birth, the key variables are the additional risk of vertical transmission attributable to breast-feeding, the under-5 mortality rate (U5MR) in breast-fed children, and the relative risk of mortality in non-breast-fed compared to breast-fed children. Depending on the values of these key variables, there may be some urban populations with low U5MR in which the positive and negative effects on under-5 mortality of a policy change are finely balanced. However, no change in policy should be made in these areas until more precise information is available on the key variables, and the many adverse consequences of such a change have been fully explored.

Breast Feeding↗

PubMed1993

[Smoking habits among pregnant women in Norway--suggestions for intervention].

Multiple surveys have shown that approximately 35 percent of women in Norway are daily cigarette consumers during their pregnancies. Smoking is the single most important risk factor in pregnancy leading to excessive rates of low birth weight, prenatal neonatal and infant mortality, sudden infant death syndrome and learning problems in school. Norway provides a decent prenatal care program free of charge to all pregnant women. But efforts to reduce smoking have been inadequate. A multilevel strategy including a media campaign, the policy changes recommended in the Action Plan "Smokefree Norway by the year 2000" and a standardized intervention program using generally available resources is suggested as a possible way to reduce the problem throughout the country.

Female↗

PubMed1993

Impact of the Catastrophic Coverage Act and new coverage guidelines on Medicare skilled nursing facility use.

The promulgation of new coverage guidelines and provisions of the 1988 Medicare Catastrophic Coverage Act indicated that Medicare's role in financing nursing home care could expand greatly. This paper presents a facility-level analysis addressing how the policy changes affected the payer mix of subgroups of Medicare-certified skilled nursing facilities (SNFs). Our analysis found that the new policies increased participation of nursing homes in the Medicare SNF program and suggested that the policies expanded both access to the Medicare SNF benefit and the role of public financing for nursing home care. Greater responsiveness to the policies was observed among proprietary SNFs and among those with more beds.

Catastrophic Illness↗

PubMedDate not supplied

Regulation of biotechnology products in the global pharmaceutical market: the case of the European community and the United States.

Biotechnology represents an opportunity for innovative products, new markets, or capital investments, depending on one's perspective. A primary consideration in regulating this industry is to ensure that innovation is not stifled yet the public is protected from potentially unsafe or ineffective products. We compared the regulatory requirements and procedures for obtaining marketing approval for biotechnology products in the European Community (EC) and the United States and identified key concerns of the biotechnology industry regarding the regulatory aspects of these products. The methodology consisted of a secondary literature review and mail survey. Biotechnology products are approved faster in the EC than the US. Both the EC and the US use advisory or expert committees in their respective approval procedures, although the EC does so more regularly. Market exclusivity provisions for biotechnology products range from 6 to 10 years in the EC compared with 7 years for "orphan" biotechnology products in the US. Regulatory affairs managers of the biotechnology industry were most concerned about application review time periods, communication with regulatory agencies, consistency in implementing regulations, and public policy changes. These concerns provide insight into the deficiencies that exist in regulatory processes and are valuable in identifying problems and implementing improvements.

Biotechnology↗

PubMed1995

Assessing the outcome of making it easier for patients to change general practitioner: practice characteristics associated with patient movements.

BACKGROUND: The government white paper, Promoting better health, suggested that primary health care services should be made more responsive to patient needs and that competition, brought about by the freer movement of patients between practices, could act as a mechanism for improving the quality of the services provided. Policy changes reflecting these aims were introduced with the 1990 contract for general practitioners. AIM: A study was carried out to estimate the volume of patient movement between practices not attributable to a patient's change of address or to a major change in the practice they had left, and to investigate which practice characteristics patients moved towards and which they moved away from when changing general practitioner. METHOD: Data on 2617 patient movements during June 1991 were collected from five family health services authorities. These patient movements were analysed in relation to data on practice characteristics obtained from family health services authority records. RESULTS: The estimated volume of movement of patients between practices was small (1.6% of the registered population per year). The majority of movements were between group practices; a quarter of the movements recorded were to single-handed general practitioners. However, the ratio of the number of movements from group practices to single-handed general practitioners compared with those from single-handed general practitioners to group practices was 1.37 (95% confidence interval 1.19 to 1.57). In choosing single-handed general practitioners these patients were willing to forgo access to a woman general practitioner, extended services and greater hours of general practitioner availability. Among the subset of movements between group practices, patients were more likely to gain access to a practice nurse, longer surgery hours and a woman general practitioner as a consequence of their move. CONCLUSION: The scale of patient movement observed did not indicate any substantial mechanism by which the new policy of encouraging consumerist behaviour on the part of primary care users could effect desired changes in primary care practice. Among the patient movements observed, the evidence suggests that when choosing a practice potential patients were not deterred by the fact that a practice was single-handed. The public's perception of the factors contributing to a high quality of service may conflict with the official characterization of good practice and high quality services in primary health care.

Adolescent↗

PubMed1996

Research ethics and the medical profession. Report of the Advisory Committee on Human Radiation Experiments.

The Advisory Committee on Human Radiation Experiments was convened by President Clinton in January 1994 in response to allegations of unethical practices in radiation experiments involving human subjects that were sponsored by the US government between 1944 and 1974. The committee's Final Report was released in October 1995. In addition to analyzing the history of the ethics of medical research involving human subjects, the committee reviewed current federal policies and procedures for protection of human subjects. In this article, the committee's findings are discussed as they relate to the patient-physician relationship, the issue of trust, and the specific role of the physician-investigator in all types of human experimentation. The committee found evidence of discussion of the conduct of human research at the highest levels of the government and within the medical profession, particularly with regard to risk, during the 1940s and 1950s. However, in both federal policy and professional practice, requirements for consent were more likely to apply to "healthy volunteers" than to patient-subjects (ie, those with disease or illness). Today, consensus exists that duties to obtain informed consent apply to all human subjects, whether healthy or sick, regardless of the risk or potential for medical benefit from participation in the research and regardless of the nature of sponsorship or funding (eg, federal, military, or private). Based on a finding of serious deficiencies in the current system of protections for human subjects, the committee offers a number of recommendations, including changes in institutional review boards; in the interpretation of ethics rules and policies; in oversight, accountability, and sanctions for ethics violations; and in compensation for research injuries. More than public policy changes, however, the committee recommends that the medical profession intensify its commitment to the ethics of research involving human subjects.

Advisory Committees↗

PubMed1996

Incidence of death and hospitalization from assault occurring in and around licensed premises: a comparative analysis.

The aim of the research was to: determine the incidence of serious assault in and around licensed premises in New Zealand, and to compare the circumstances of assault with those that occurred in other locations. For the period 1978-87, inclusive, 49 assault fatalities occurred in or around licensed premises representing 9.4% of all homicides and 12.9% where a place was specified. The comparable figures for assaults resulting in hospitalization in 1988 were: 251, 10.2% and 18.4%, respectively. Further analyses suggests that our estimate of the incidence rate is likely to be an underestimate due to changes over time in the large number of assault cases which have no specific place of occurrence identified. In comparison with homes homicides in licensed premises were more likely to involve: males; Maori, unarmed fights and brawls; unknown assailants; alcohol; occur during the evening and toward the end of the week; and result in head injury. For non-fatal events similar differences were found. In comparison with homes non-fatal assaults were more likely to involve: males; young adults, Maori, the unemployed, unarmed fights and brawls, and head injury. There have been a number of significant policy changes in New Zealand since 1988 which may have resulted in a change to the situation reported here.

Adolescent↗

PubMed1996

The effects of ownership and ownership change on nursing home industry costs.

OBJECTIVE: This study examines the effects of ownership type and ownership change on nursing home cost structures, differentiating patient care costs from plant costs. DATA SOURCES: Administrative data from the Michigan Department of Social Services, Medical Services Administration (Medicaid), and the Michigan Department of Public Health are used. Cost data are based on audited cost reports for 393 nursing care facilities in Michigan in 1989. Other facility characteristics are based on data from the 1989 annual licensing and certification survey conducted by the Michigan Department of Public Health. STUDY DESIGN: A series of ordinary least squares regressions is estimated, in which the dependent variable is either per diem patient costs or per diem plant costs. Ownership types are defined as chain, proprietary non-chain, freestanding non-profit, government-owned, and hospital-based facilities. Pooled estimation techniques, as well as separate regressions by ownership type, are presented to test for interaction effects. Key variables include whether a facility changed ownership in the preceding five years and whether chain facilities are in-state- or out-of-state-owned, in addition to size, payer mix, and case mix. PRINCIPAL FINDINGS: Behavioral differences among nursing home ownership types in respect to patient care costs tended to distinguish government-owned and hospital-based facilities from the freestanding homes rather than the usual distinction between for-profit and not-for-profit classes. Variables traditionally included in nursing home cost studies, such as size, occupancy, payer mix and case mix, were found to have similar effects on per diem patient care costs for freestanding non-profit homes as well as for chain proprietary facilities. With regard to the effects of ownership change on per diem plant and per diem patient costs, however, there are few differences among ownership types. Chain and non-chain for-profit facilities, non-profit homes, and hospital long-term care units that had changed ownership reported significantly higher per diem plant costs than facilities without a change of ownership, but did not spend more on patient-related costs. Michigan Medicaid plant reimbursement system policy changes instituted in 1985 to promote continued ownership of facilities were not entirely successful. CONCLUSIONS: Non-profit homes look increasingly like their for-profit counterparts with respect to spending on patient care costs. Increased competition for the more lucrative private-pay patients, coupled with declining state Medicaid reimbursement to nursing homes, may have blurred the historical distinctions between the non-profit and for-profit sectors in the nursing home industry. An exception to increasing homogeneity within the nursing home industry is the tendency of proprietary homes to experience more frequent changes of ownership, which results in higher capital costs passed on to state Medicaid programs. Findings from this study indicate that while facility sales increase per diem plant costs, they do not result in increased spending for direct patient care, suggesting that state Medicaid programs may be indirectly subsidizing facility sales with no accompanying increase in expenditures for patient care. To discourage frequent facility sales, state Medicaid programs may need to consider alternative methods of reimbursing nursing home owners for capital costs.

Capital Expenditures↗

PubMedDate not supplied

The case for breaking through ageism in mental health care.

This paper critically examines the recent policy in mental health nursing of refocusing care on people with severe and enduring mental health problems. It is argued that older people with severe and enduring mental illnesses such as dementia are excluded from this policy and that this amounts to a clear case of ageism. Various ways of addressing the problem of ageism in recent policy changes are explored.

Aged↗

PubMed1993

Restructuring federalism: the impact of Reagan policies on the family planning program.

Through fiscal cutbacks and structural changes, Reagan's federalism assaulted the ethos of public health. In assessing the effects of Reagan policies on a basic public health program, family planning services, we find a substantial decrease in spending for this program, a reduction in the numbers of patients served, and increased variation among the states in the provision of services to low-income women. These effects are comparable with findings from other studies on the impact of Reagan's federalism upon social programs and have manifold implications for public health.

Capital Financing↗

PubMed1983

Public policy and female sterilization in Costa Rica.

For 20 years, female sterilization has been increasing in popularity as a contraceptive method in Costa Rica. However, contraceptive sterilization has never been allowed explicitly under Costa Rican law. In 1976 the Costa Rican National Assembly instituted more stringent guidelines regarding medical sterilizations in order to eliminate contraceptive sterilizations, which had been occurring under relatively loose interpretations of national policy. Data from the 1976 National Fertility Survey and the 1981 Contraceptive Prevalence Survey indicate that the change in policy had only a short-term effect. Period sterilization rates fell substantially after 1976 but rebounded considerably by 1980, and the estimate of the proportion of married women who will ultimately be sterilized was approximately .5 for the periods both before and after 1976.

Adolescent↗

PubMed1995

A comparison of the determinants of safe injecting and condom use among injecting drug users.

A sample of 582 injecting drug users were interviewed as part of an evaluation of an AIDS prevention programme for drug users. This paper examines the biographic and predispositional determinants of five HIV preventive behaviours--equipment sharing (not receiving and not giving) and and condom use (with regular partners, casual partners and sex clients). A two-stage sequential approach was adopted for a logistic regression analysis. Initially, to model each of the five preventive behaviours, biographical and drug use variables were entered. In a second set of models, behavioural predisposition factors were included. Age, drug use and prison experience correlate with variables in both models, although not consistently in the same direction. While a predisposition to reject sharing correlates with safer rejecting and condom use, the predisposition to safer sex only correlates with condom use. Needle exchange programmes that only target the individual would seem to be inadequate. To enhance targeted interventions changes in public and agency policy that create a social environment conductive to behaviour change are required.

Acquired Immunodeficiency Syndrome↗

PubMed1989

Perinatal mortality in rural Tanzania.

Prolonged labour was the most frequent cause of perinatal death in a rural hospital in the south western highlands of Tanzania. After the introduction of an obstetric policy aiming to prevent prolonged labour by making use of the guidelines of the partogram, perinatal mortality was reduced from 71 to 39 per 1000 births. Baird's clinico-pathological classification is still considered a useful instrument for the discovery of avoidable factors in perinatal deaths. The concept of the partogram should be an integral part of the training of medical auxiliaries in the field of maternal and child health (MCH).

Delivery, Obstetric↗

PubMedDate not supplied

Fertility intentions and subsequent behavior: a longitudinal study in rural India.

This report compares fertility and family planning intentions of rural Indian women in 1975 with actual outcomes in 1987. Ninety-four of 103 respondents who had fewer children than they wanted in 1975 and had stated definite intentions with respect to future fertility and contraceptive use were reinterviewed in 1987. Overall, women had fewer children than desired and stopped childbearing when they reached or closely approximated their ideal number of sons. Since sons were clearly the determinant of "reproductive success," it is argued that only a significant change in the status of rural women can bring about widespread compliance with the official family planning program's two-child norm.

Adolescent↗