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PubMed2006

Differences in practice income between solo and group practice physicians.

An examination of the distribution of physician incomes between different types of practices could help policymakers and researchers alike to gain an understanding of the effects of different organizational characteristics of practices on the practice of medicine as a whole. This study uses a national database to explore the relationships that exist between practice incomes and practice types vis-à-vis the overall size of practices. The primary data source for this study, which includes 7757 office-based physicians, was provided by the Taiwan Department of Health (DOH), with the dependent variable of interest to this study being the annual gross income of physician practices, while the independent variables are physician practice types and the number of physicians within a clinic. Multiple regression analyses were used to model the logarithm of annual physician practice incomes as a linear function of a set of independent variables. Kruskal-Wallis test results revealed the existence of significant relationships between practice incomes and practice types (p<0.001) and the number of physicians within a clinic (p<0.001). Multiple regression analysis also showed that after adjusting for socio-demographic and professional characteristics, the annual incomes of physicians in both single-specialty or multi-specialty group practices (p<0.001) were higher than those of their solo practice counterparts. This study concludes that after adjusting for other factors, higher practice incomes are enjoyed by physicians in single-specialty or multi-specialty group practices as compared to their solo practice counterparts. The finding of higher incomes for those physicians organized into groups supports the policy call from the DOH in Taiwan for the widespread formation of group practices.

Adult↗

PubMedDate not supplied

The influence of income on morbidity, mortality and dependency in elderly Hong Kong Chinese.

The association between income and mortality, morbidity and dependency is examined in a 3-year prospective follow-up study of 2032 subjects aged 70 years and above in the Hong Kong Special Administrative Region, China. Subjects were recruited using stratified disproportional random sampling of the Old Age and Disability Allowance Schemes, covering over 90% of the population. Subjects were interviewed at baseline and after 36 months. Presence or absence of disease was based on self-report of doctor diagnosis together with a check of medication taken. Functional status was measured using the Barthel Index. For the disease analysis, subjects with the disease being analyzed at baseline were excluded; similarly for the dependency analysis, subjects who were dependent at baseline were excluded. Chi-square test, univariate and multiple logistic regression were used to examine the association between income and mortality, development of new disease, and dependency. There was no association between income and mortality, or with development of new disease. Development of dependency was associated with lower income at baseline. An income of less than 1000 HK dollars per month increased the risk of dependency by 1.8-fold (95%CI 1.1-2.9). However, this association disappeared after adjustment for age and sex. Absolute income is not an important factor contributing to mortality, morbidity and dependency in elderly Chinese aged 70 years and above. A freely accessible health and social service at low or no cost, the survivor effect, or other factors may account for the lack of association with income, contrary to findings from studies of whole populations worldwide. Therefore manipulating income alone is unlikely to affect these outcomes in the elderly.

Journal Article↗

PubMed2004

Narrowing the income gaps in preventive care for young children: families in healthy steps.

Persistent unmet preventive and developmental health care needs of children in low-income families are a national concern. Recently, there have been efforts to promote developmental services as part of primary care for all young children. However, there is limited research to determine whether the neediest families are well in universal interventions. In our study, we assessed if disparities persist in utilization of developmental services, well child care, and satisfaction with care among low-, middle-, and high-income families participating in Healthy Steps for Young Children. Healthy Steps is a national experiment that incorporated developmental services into primary care for children from birth to 3 years of age. In the United States, 15 pediatric practices participated in this prospective study. At birth, 2,963 children were enrolled between September 1996 and November 1998 and followed through 33 months of age. The utilization of developmental services, satisfaction with care, and receipt of age-appropriate well child visits were measured at 30-33 months and adjusted for demographic and economic covariates. We found that the adjusted odds of low-income families did not differ from high-income families in receipt of four or more Healthy Steps services, a home visit, or discussing five or more child rearing topics. Low- and middle-income families had reduced adjusted odds of receiving a developmental assessment and books to read. The adjusted odds of low- and middle-income families did not differ from high-income families in being very satisfied with care provided or receiving age-appropriate well child visits. A universal practice-based intervention such as Healthy Steps has the potential to reduce income disparities in the utilization of preventive services, timely well child care, and satisfaction with care.

Child Development↗

PubMed1990

Repair of UV-damaged incoming plasmid DNA in Saccharomyces cerevisiae.

A whole-cell transformation assay was used for the repair of UV-damaged plasmid DNA in highly transformable haploid strains of Saccharomyces cerevisiae having different repair capabilities. Six rad alleles were selected from the three epistasis groups: rad 1-1 and rad2-1 from the RAD3 group, rad6-1 and rad18-2 from the RAD6 group, and rad52-1 and rad54-1 from the RAD52 group. Cells carrying single, double and triple rad alleles were transformed to uracil prototrophy by centromeric plasmid DNA (YCp19) modified in vitro with UV (254 nm). Surviving fractions were calculated as the number of transformants at each fluence relative to the number of transformants with unirradiated plasmid DNA. The sensitivity of incoming DNA in single rad mutants shows that most repair is carried out by excision repair and a RAD18-dependent process. In the rad52-1 host, the sensitivity of incoming DNA was intermediate between those found in RAD+ and rad2-1 hosts, suggesting the involvement of a recombinational repair process. Non-epistatic interactions were observed between rad alleles belonging to different epistasis groups. This provides validation for the classification of the three epistasis groups concerning the repair of chromosomal DNA for UV-incoming DNA. In both rad1-1 rad6-1 and rad1-1 rad18-2 rad54-1 hosts, the mean fluence for one lethal event corresponds approximately to one pyrimidine dimer per plasmid molecule, indicating that they are absolute repairless hosts for incoming DNA. A comparison between cell and plasmid survival reveals that there are differences in the repairability of both chromosomal and incoming DNA. The large effect of rad6-1 mutation on cell survival and the small effect on incoming DNA suggest that, in the RAD+ strain, the RAD6 product may be essential for the repair processes which act on chromosomal DNA, but not for those which act on incoming DNA. It is proposed that in yeasts postreplication repair of incoming DNA is limited to supercoiled molecules with 1-2 pyrimidine dimers that can initiate replication.

Alleles↗

PubMed2004

Primary source of income is associated with differences in HIV risk behaviors in street-recruited samples.

BACKGROUND: The relationship between primary source of income and HIV risk behaviors and the racial/ethnic differences in risk behavior profiles among disadvantaged populations have not been fully explored. This is unusual given that the phenomenon of higher risk in more disadvantaged populations is well-known but the mechanisms remain unclear. We examined the relationship between primary source of income and differences in HIV risk behaviors among four racial/ethnic groups in the southern United States. METHODS: Self-reported data on primary source of income and HIV risk behaviors were collected from 1494 African American, Hispanic, Asian, and White men and women in places of public congregation in Houston, Texas. Data were analyzed using calculation of percentages and by chi-square tests with Yates correction for discontinuity where appropriate. RESULTS: Data revealed that a higher proportion of whites were involved in sex for money exchanges compared to the other racial groups in this sample. The data suggest that similar street sampling approaches are likely to recruit different proportions of people by primary income source and by ethnicity. It may be that the study locations sampled are likely to preferentially attract those involved in illegal activities, specifically the white population involved in sex for drug or money exchanges. Research evidence has shown that people construct highly evolved sexual marketplaces that are localized and most unlikely to cross racial, ethnic, and socioeconomic or geographical boundaries. Thus, the areas that we sampled may have straddled a white sexual marketplace more than that of the other groups, leading to an over-representation of sex exchange in this group. Drug use was highest among those with illegal primary sources of income (sex exchange and drug dealing and theft), and they were also those most likely to have injected drugs rather than administered them by any other route (p < 0.001). In addition, bisexual or homosexual identification was reported by more respondents in the sex exchange as primary source of income category. The number of sexual partners in the last three months followed a similar pattern, with those whose primary source of income was drug dealing or theft reporting relatively high partner numbers. CONCLUSIONS: These data suggest that social disadvantage is associated with HIV risk in part by its association with drug and sex work for survival, and offers one variable that may be associated with the concentration of disease among those at greatest disadvantage by having an illegal and unstable primary income source.

Journal Article↗

PubMed2004

Physician asthma education program improves outcomes for children of low-income families.

STUDY OBJECTIVES: To determine whether an interactive physician seminar that has been shown to improve patient/parent satisfaction and to decrease emergency department visits for children with asthma was also effective for those children from low-income families. DESIGN: Seventy-four pediatricians and 637 of their patients were randomized to receive two asthma seminars or no educational programs and were observed for 2 years. SETTING: Physicians in the New York, NY, and Ann Arbor, MI, areas were enrolled, and, on average, 10 patients with asthma per provider were surveyed and observed for 2 years. PATIENTS OR PARTICIPANTS: A total of 637 subjects were enrolled, and 369 subjects remained in the study after 2 years. Of these, 279 had complete medical and survey information. INTERVENTIONS: Physicians were randomized, and then a random sample of their patients was enrolled and surveyed regarding the physician's communication style, the child's asthma symptoms, medical needs, and asthma care. Low income was defined as annual income of < 20,000 dollars. MEASUREMENTS AND RESULTS: The families of 36 children (13%) had an income of < 20,000 dollars, and they were treated by 23 physicians. Low-income children in the treatment group tended to have higher levels of use of controller medications, to receive a written asthma action plan, and to miss fewer days of school, although these differences were not statistically significant compared to low-income children in the control group. However, low-income treatment group children were significantly less likely to be admitted to an emergency department (annual rate, 0.208 vs 1.441, respectively) or to a hospital (annual rate, 0 vs 0.029, respectively) for asthma care compared to children in the control group. CONCLUSIONS: The educational program for physicians improved asthma outcomes for their low-income patients. Provider interventions targeted to these high-risk patients may diminish hospital and emergency department asthma care.

Asthma↗

PubMed1992

Prevalence of migraine headache in the United States. Relation to age, income, race, and other sociodemographic factors.

OBJECTIVE: To describe the magnitude and distribution of the public health problem posed by migraine in the United States by examining migraine prevalence, attack frequency, and attack-related disability by gender, age, race, household income, geographic region, and urban vs rural residence. DESIGN: In 1989, a self-administered questionnaire was sent to a sample of 15,000 households. A designated member of each household initially responded to the questionnaire. Each household member with severe headache was asked to respond to detailed questions about symptoms, frequency, and severity of headaches. SETTING: A sample of households selected from a panel to be representative of the US population in terms of age, gender, household size, and geographic area. PARTICIPANTS: After a single mailing, 20,468 subjects (63.4% response rate) between 12 and 80 years of age responded to the survey. Respondents and non-respondents did not differ by gender, household income, region of the country, or urban vs rural status. Whites and the elderly were more likely to respond. Migraine headache cases were identified on the basis of reported symptoms using established diagnostic criteria. RESULTS: 17.6% of females and 5.7% of males were found to have one or more migraine headaches per year. The prevalence of migraine varied considerably by age and was highest in both men and women between the ages of 35 to 45 years. Migraine prevalence was strongly associated with household income; prevalence in the lowest income group (less than $10,000) was more than 60% higher than in the two highest income groups (greater than or equal to $30,000). The proportion of migraine sufferers who experienced moderate to severe disability was not related to gender, age, income, urban vs rural residence, or region of the country. In contrast, the frequency of headaches was lower in higher-income groups. Attack frequency was inversely related to disability. CONCLUSIONS: A projection to the US population suggests that 8.7 million females and 2.6 million males suffer from migraine headache with moderate to severe disability. Of these, 3.4 million females and 1.1 million males experience one or more attacks per month. Females between ages 30 to 49 years from lower-income households are at especially high risk of having migraines and are more likely than other groups to use emergency care services for their acute condition.

Adolescent↗

PubMed1988

Postwar changes in the income position of the aged.

Since the war the relative number of aged persons with income from employment has declined, while the proportion with income from social insurance benefits has increased. Despite the fact that social insurance benefits yield a lower average income than do earnings, the averaged aged person's income in 1952 was higher in both current dollars and dollars of stable purchasing power than it was in 1945. The improvement is the result of several factors, including larger earnings by aged workers, increased benefits paid retired workers and their aged survivors under social insurance and related programs higher old-age assistance payments and the rise in the relative number of persons with money income. The growth in the average aged person's income, however, has been at a rate lower than that of the average income of the population as a whole. As a result the average person has had a smaller share in total consumer income in each of the years since 1945 that he had in that year.

Aged↗

PubMedDate not supplied

Depressive symptoms, unemployment, and loss of income: The CARDIA Study.

BACKGROUND: Previous studies have suggested an association between depression and low socioeconomic status, but few have empirically examined the effect of depressive symptoms on income and employment over time. OBJECTIVE: To determine whether depressive symptoms are associated with subsequent unemployment or loss of family income. METHODS: We performed a prospective cohort study of 5115 adults aged 18 to 30 years. These participants included approximately equal numbers of African Americans and whites and men and women from 4 cities in the United States who completed the 1990-1991 examination of the Coronary Artery Risk Development in Young Adults (CARDIA) study. For this analysis, we included 2334 participants who were employed full or part time and who reported an annual family income of $25 000 or more. Participants completed the Center for Epidemiologic Studies Depression Scale and were considered to have depressive symptoms if they scored 16 or higher on the 60-point scale. We evaluated self-reported unemployment and annual family income during 5 years of follow-up. RESULTS: Thirty-three percent (118/354) of participants with depressive symptoms (Center for Epidemiologic Studies Depression Scale score >/=16) in 1990-1991 and 21% (335/1581) of participants without substantial depressive symptoms (Center for Epidemiologic Studies Depression Scale score <16) reported new unemployment during the subsequent 5 years (odds ratio, 1.9; 95% confidence interval, 1.4-2.4; P<.001). This association remained strong after adjusting for potential confounding variables, including marital status, education, history of unemployment, current part-time (vs full-time) employment, and cigarette smoking (odds ratio, 1.6; 95% confidence interval, 1.2-2.0; P =.001). Seventeen percent (62/371) of participants with depressive symptoms and 7% (113/1631) of participants without substantial depressive symptoms in 1990-1991 reported that their family income had decreased below $25 000 by 1995-1996 (odds ratio, 2.7; 95% confidence interval, 1.9-3.8; P<.001). This association also remained strong after adjusting for potential confounding variables (odds ratio, 1.9; 95% confidence interval, 1.3-2.7; P<.001). CONCLUSIONS: Depressive symptoms are associated with subsequent unemployment and loss of family income among working young adults. Socioeconomic indicators, such as income and employment, should be considered in evaluating the potential benefits of treatment for patients with depressive symptoms.

Adolescent↗

PubMed2003

Time and money: a retrospective evaluation of the inputs, outputs, efficiency, and incomes of physicians.

BACKGROUND: Physicians' concerns with the health care system focus on having less time with their patients and needing to work harder to maintain incomes. We sought to determine whether physicians are working longer hours and whether their incomes are declining. METHODS: Using survey data, we conducted a retrospective analysis of physician inputs, outputs, efficiency, and incomes for generalists, general internists, general surgeons, pediatricians, and obstetrician-gynecologists from 1987 to 1998. RESULTS: Physician inputs (as measured by the average hours worked in professional activities) showed little absolute change across specialties over time. Outputs (as measured by the total number of patient visits per week) decreased between 9% and 28%, depending on the specialty. Efficiency (the proportion of time spent in direct patient care and the amount of time spent during a typical office visit) remained stable over the time examined. Consumer price index inflation-adjusted annual incomes increased considerably over the time period examined (42% for general internists, 28% for pediatricians, 13% for generalists, and 8% for general surgeons); only obstetricians-gynecologists showed a net loss of annual income when adjusting for inflation (a 6% loss). CONCLUSIONS: Our findings do not confirm the prevailing concern that physicians are working harder or longer or that their incomes are declining, but they offer an explanation of how physicians are maintaining incomes without increasing work inputs. There is a great deal of dissatisfaction with the health care system among physicians; exploration of perceptual reasons for that dissatisfaction may outline a course of action needed to resolve it.

American Medical Association↗

PubMed2000

Hitting a moving target: income-related health insurance subsidies for the uninsured.

New government health insurance programs are likely to emphasize voluntary purchases in a market setting, with subsidies targeted at low-income populations and stress on managed care. Such programs are best structured with a guaranteed enrollment period that is as long as six months to a year. However, given that incomes change over time, errors will be made in awarding income-related subsidies for that long. These errors are assessed in simulations undertaken with longitudinal data from the Survey of Income and Program Participation. Two allocations of the subsidies, based on current income at the beginning of the enrollment period and on actual income assessed at the end, are compared for a variety of program designs. Prospective determination of subsidies is somewhat biased toward overpayment. Net overpayments amount to 5-10 percent of subsidy costs. However, prospective payment encourages participation in the subsidy program. The simulated participation rate for true eligibles is as high as 73 percent with prospective subsidies, compared to 69 percent with retrospective reconciliation. Net overpayments are slightly reduced by testing income less frequently and over longer periods.

Child↗

PubMed2001

The role of permanent income and family structure in the determination of child health in Canada.

We use data from the Ontario Child Health Study (OCHS) to provide the first Canadian estimates of how the empirical association between child health and both low-income and family status (lone-mother versus two-parent) changes when we re-estimate the model with pooled data. Two waves of data provide a better indication of the family's long-run level of economic resources than does one wave. Our measures of health status include categorical indicators and the health utility score derived from the Health Utilities Index Mark 2 (HUI2) system. Consistent with findings from other countries, we find that most outcomes are more strongly related to low-average income (in 1982 and 1986) than to low-current income in either year. Unlike some previous research, we find the quantitative impact of low-income on child health to be modest to large. Lone-mother status is negatively associated with most outcomes, but the lone-mother coefficients did not change significantly when we switched from low-current income to low-average income. This implies that the lone-mother coefficient in single cross-sections is not just a proxy for low-permanent income.

Adolescent↗

PubMed1992

Black-white mortality differences by family income.

Death rates among US black men and women under 75 years of age are higher than for their white counterparts. The explanation for this excess risk, though attributed to socioeconomic factors, remains unclear. We calculated mortality rates by family income for blacks and whites in a representative sample of the US population (National Longitudinal Mortality Study). For persons aged less than 65 years of age, mortality rates are lower in those with higher family income for both blacks and whites, and both men and women. However, at each level of income, blacks have higher mortality than whites. Higher levels of family income are also associated with lower death rates from cardiovascular disease, cancer, and deaths from causes other than cardiovascular disease or cancer. After adjustment for income, blacks have higher death rates from each of these three general causes. For subjects below 65 years, the mortality gradient by income is larger than the gradient by race. The differences in mortality rates by race not accounted for by income may be due to other differences such as access to health care, type or quality of medical care, or behavioral risk factors that disadvantage black populations.

Adult↗

PubMed2004

Income inequality and pregnancy spacing.

We examined the relationship between county-level income inequality and pregnancy spacing in a welfare-recipient cohort in Washington State. We identified 20,028 welfare-recipient women who had at least one birth between July 1, 1992, and December 31, 1999, and followed this cohort from the date of that first in-study birth until the occurrence of a subsequent pregnancy or the end of the study period. Income inequality was measured as the proportion of total county income earned by the wealthiest 10% of households in that county compared to that earned by the poorest 10%. To measure the relationship between income inequality and the time-dependent risk (hazard) of a subsequent pregnancy, we used Cox proportional hazards methods and adjusted for individual- and county-level covariates. Among women aged 25 and younger at the time of the index birth, the hazard ratio (HR) of subsequent pregnancy associated with income inequality was 1.24 (95% CI: 0.85, 1.80), controlling for individual-level (age, marital status, education at index birth; race, parity) and community-level variables. Among women aged 26 or older at the time of the index birth, the adjusted HR was 2.14 (95% CI: 1.09, 4.18). While income inequality is not the only community-level feature that may affect health, among women aged 26 or older at the index birth it appears to be associated with hazard of a subsequent pregnancy, even after controlling for other factors. These results support previous findings that income inequality may impact health, perhaps by influencing health-related behaviors.

Adolescent↗

PubMed2006

Does village inequality in modern income harm the psyche? Anger, fear, sadness, and alcohol consumption in a pre-industrial society.

Researchers have found a positive association between income inequality and poor individual health. To explain the link, researchers have hypothesized that income inequality erodes community social capital, which unleashes negative emotions, stress, and stress behaviors that hurt health. Few studies have tested the hypothesized path. Here we estimate the association between (a) village income inequality and social capital, and (b) three distinct negative emotions (anger, fear, sadness) and one stress behavior (alcohol consumption). We use four quarters of panel data (2002-2003) from 655 adults in 13 villages of a foraging-farming society in the Bolivian Amazon (Tsimane'). We found that: (1) village income inequality was associated with more negative emotions but with less alcohol consumption, (2) social capital always bore a negative association with outcomes, and (3) results held up after introducing many changes to the main model. We conclude that village income inequality probably affects negative emotions and stress behaviors through other paths besides social capital because we conditioned for social capital. One such path is an innate dislike of inequality, which might have pre-human origins. Our prior research with the Tsimane' suggests that village income inequality bore an insignificant association with individual health. Therefore, village income inequality probably affects negative emotions and stress behaviors before undermining health.

Adult↗

PubMed2006

An examination of income-related disparities in the nutritional quality of food selections among Canadian households from 1986-2001.

Socio-economic disparities in nutrition have been documented in numerous countries, and have been linked to health inequalities. Social and economic policy changes occurring over the last several years have resulted in growing levels of income inequality in many countries. However, the extent to which these temporal changes have affected nutrition disparities is largely unknown. Our research examined income-related disparities in the nutritional quality of food selections among Canadian households from 1986 to 2001. Data from the 1986, 1992, 1996 and 2001 Family Food Expenditure surveys were pooled together (n=35048). The relationships between household income and the nutritional quality of food purchases (considering nutrients both as absolute amounts and adjusted for energy, and total energy density) were estimated using general linear models, including tests of significance for differences across the survey years. Results revealed significant positive relationships between income and most nutrients, which persisted over time, and for some nutrients grew stronger. One exception was folate, where the positive relationship between income and folate (independent of energy) was no longer apparent in 2001; this could be attributed to the mandatory fortification of some cereal grain products with folic acid, which came into effect in 1998, resulting in greater availability of folate from grain products. There was also a significant negative relationship between income and total energy density (ratio of food energy to food weight), which persisted across the survey years. At a time of growing income inequality and worsening problems of poverty, food policy makers need to pay attention to the potential for policy interventions to exacerbate or improve nutrition disparities.

Canada↗

PubMed2005

Inequalities in the prevalence of smoking in the European Union: comparing education and income.

BACKGROUND: The aim of the study was to determine whether education or income was more strongly related to smoking in the European Union at large, and within the individual countries of the EU, at the end of the 1990s. METHODS: We related smoking prevalence to education and income level by analyzing cross-sectional data on a total of 48,694 men and 52,618 women aged 16 and over from 11 countries of the European Union in 1998. RESULTS: Both education and income were related to smoking within the European Union at large. After adjustment of the other socioeconomic indicator, education remained related to smoking in the EU at large, but income only remained so among men. Educational inequalities were larger than income-related inequalities among younger and middle-aged men and women. Educational inequalities were larger than income-related inequalities among men in all individual countries, and among women in Northern Europe. For women from Southern European countries, the magnitude of education- and income-related inequalities was similar. CONCLUSIONS: Education is a strong predictor of smoking in Europe. Interventions should aim to prevent addiction to smoking among the lower educated, by price policies, school-based programs, and smoking cessation support for young adults.

Adolescent↗

PubMed2001

Income inequality, the psychosocial environment, and health: comparisons of wealthy nations.

BACKGROUND: The theory that income inequality and characteristics of the psychosocial environment (indexed by such things as social capital and sense of control over life's circumstances) are key determinants of health and could account for health differences between countries has become influential in health inequalities research and for population health policy. METHODS: We examined cross-sectional associations between income inequality and low birthweight, life expectancy, self-rated health, and age-specific and cause-specific mortality among countries providing data in wave III (around 1989-92) of the Luxembourg Income Study. We also used data from the 1990-91 wave of the World Values Survey (WVS). We obtained life expectancy, mortality, and low birthweight data from the WHO Statistical Information System. FINDINGS: Among the countries studied, higher income inequality was strongly associated with greater infant mortality (r=0.69, p=0.004 for women; r=0.74, p=0.002 for men). Associations between income inequality and mortality declined with age at death, and then reversed among those aged 65 years and older. Income inequality was inconsistently associated with specific causes of death and was not associated with coronary heart disease (CHD), breast or prostate cancer, cirrhosis, or diabetes mortality. Countries that had greater trade union membership and political representation by women had better child mortality profiles. Differences between countries in levels of social capital showed generally weak and somewhat inconsistent associations with cause-specific and age-specific mortality. INTERPRETATION: Income inequality and characteristics of the psychosocial environment like trust, control, and organisational membership do not seem to be key factors in understanding health differences between these wealthy countries. The associations that do exist are largely limited to child health outcomes and cirrhosis. Explanations for between-country differences in health will require an appreciation of the complex interactions of history, culture, politics, economics, and the status of women and ethnic minorities.

Birth Weight↗