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PubMed1997

What should be the elements of any settlement with the tobacco industry?

Litigation and regulatory assaults on the tobacco companies may create a willingness among tobacco manufacturers to bargain resources and acceptance of public policy changes for limitations of liability, as has been seen by the recent settlement with the Liggett Group. Two elements absolutely critical to any plan are the elimination of tobacco advertising and promotion and the removal of addiction as a reason for tobacco use. Minimal components of any settlement should include: (a) acceptance by the tobacco manufacturers of the causal relationship between tobacco use and disease, and the addictive nature of nicotine; (b) a total ban on tobacco advertising and promotion; (c) FDA jurisdiction over tobacco products and their nicotine content, with the intent of removing nicotine as soon as acceptable nicotine substitution products are available; (d) reimbursement to the states for Medicaid and other state expenditures attributable to smoking, to the maximum extent feasible; (e) funding for local, state, and federal programmes and research in tobacco control; (f) acceptance of legislation and regulations protecting the right of non-smokers to breathe air free of tobacco smoke; (g) funding for a large, national, media-led, anti-tobacco campaign; and (h) cessation assistance for addicted smokers. If negotiations toward a settlement proceed, it is essential that the public health community participate in defining the elements of any agreement to ensure that whatever agreement develops is focused on reducing tobacco-related disease rather than continuing the profitability of American tobacco companies. That participation requires articulation of the core elements essential to an acceptable agreement. If resolution of the public health issues surrounding continued sale of tobacco products can be reached in the United States, it may provide a model for similar resolution in other countries.

Adolescent↗
PubMed1997

Community prevention and alcohol retail access.

This paper describes the design, rationale and implementation of the Alcohol Access Component within the Community Trials Project of the Prevention Research Center. The Alcohol Access Component was to reduce the concentration or density of alcohol outlets in each experimental community by a combination of local zoning and land-use planning approaches which was an effect to occur over several years. During the time of this trial, local regulations of alcohol outlets and public sites for drinking were changed in all three experimental communities. The amount of such alcohol policy change exceeded the goals for this component.

Alcohol Drinking↗
PubMedDate not supplied

Effect of Medicaid expansions on preterm birth.

OBJECTIVES: Inadequate prenatal care is thought to be a major modifiable risk factor for preterm birth, the leading cause of neonatal mortality. To improve high-risk women's financial access to prenatal care, the U.S. Medicaid program underwent major expansions during the 1980s. We evaluated these expansions over the nine-year period 1983 to 1991 in Tennessee to determine their effects on Medicaid enrollment, use of prenatal care, and preterm birth. METHODS: We used linked birth certificates, Medicaid data, and U.S. Census files to identify 610,056 singleton births to African-American or Caucasian women in Tennessee whose last menstrual period was between 1983 and 1991. These were classified by maternal characteristics to identify groups with the greatest postexpansion increases in Medicaid enrollment, which should have benefited most from the policy changes. Study outcomes were Medicaid enrollment by delivery, enrollment in the first trimester, inadequate prenatal care (modified Kessner index), and preterm (< 37 weeks) birth. We calculated the changes (delta expressed as births per 100) between 1983 and 1991 in percentages of births with each of these outcomes. RESULTS: The expansions led to pronounced increases in maternal Medicaid enrollment by delivery (21% of births in 1983 to 51% by 1991) and in the first trimester (from 10% to 37%). Married women with < 12 years of education, < 25 years of age, and < $12,500 mean neighborhood incomes (group 1) had the greatest increase, where enrollment and first-trimester enrollment increased from 24% to 86% and 7% to 68%, respectively. In group 1, the percentages of births with inadequate maternal use of prenatal care decreased substantially, from 12.8% in 1983 to 6.4% in 1991, a reduction of 6.4 births per 100 (95% confidence intervals [CI] = -7.6, -5.3). However, the preterm birth rate did not decrease (9.1% in 1983, 9.4% in 1991, change of 0.3[-0.7 to 1.2] births per 100). For other births, there were lesser increases in Medicaid enrollment, correspondingly lesser decreases in inadequate use of prenatal care, but no reductions in preterm birth rates. CONCLUSIONS: In Tennessee, the Medicaid expansions materially increased enrollment and use of prenatal care among high-risk women, but did not reduce the likelihood of preterm birth.

Adult↗
PubMed1997

Health policy and the nursing profession: a deafening silence.

The Australian healthcare system, and those of many other Western countries are experiencing significant shifts in the development of health policy. Many of these shifts are directly related to economic factors that have contributed to the spiralling costs of health care. The trends in health policy appear to be embracing a 'market driven' approach to the distribution of resources and health services. Technology and medical developments have contributed to these current economic trends. Over the past 20 years nurses have been faced with significant shifts in the direction of health policy to the extent that many policies have significantly impacted upon their practice without their apparent contribution. Several theoretical positions exist about nurses' lack of policy participation. This paper examines some of the current health policy changes in Australia that are perceived to have had the greatest impact on the nursing practice, and identifies some of the barriers to the nursing profession's participation in the formulation of health policy.

Australia↗
PubMed1997

Defining 'competency' in nursing (Part I): A policy review.

How the nursing profession in England defines the basic competency of the registered general nurse is crucial for the safety of the patient and the protection of the nurse. It is also essential for determining advanced practice, extended practice and specialist practice in nursing. An historical overview of documentation from the United Kingdom Central Council for Midwifery and Health Visiting, the English National Board for Nursing, Midwifery and Health Visiting and the Royal College of Nursing shows a profound change in educational policy during the 1980s regarding the interpretation of nursing competency. The effects of this policy change on the current methods developed to define, teach and test nursing competency are examined. Preliminary conclusions show shortcomings and uncertainty in the present preparation and evaluation of nursing competency.

Clinical Competence↗
PubMed1997

Impact of banning alcohol on outpatient visits in Barrow, Alaska.

CONTEXT: Community availability of alcohol affects alcohol consumption patterns and alcohol-related health and social problems. In Barrow, Alaska, an isolated community at the northernmost reaches of the United States, during a 33-month period, possession and importation of alcohol were legal, completely banned, made legal again, and then banned again. OBJECTIVE: To determine the impact of these public policy changes on alcohol-related outpatient visits at the area hospital. DESIGN: Retrospective review of outpatient records; time-series analysis of alcohol-related visits with respect to community alcohol policy. MAIN OUTCOME MEASURES: Total monthly outpatient visits for alcohol-related problems. RESULTS: There was a substantial decrease in the number of alcohol-related outpatient visits when the ban on possession and importation was imposed compared with baseline. When the ban was lifted, outpatient visits increased; when the ban was reimposed, the number of outpatient visits again decreased. Interrupted time-series analyses confirm that the alcohol ban, its lifting, and its reimposition had a statistically significant and negative effect on the number of alcohol-related outpatient visits (P<.05). CONCLUSION: In a geographically isolated community, the prohibition of alcohol can be an effective public health intervention, reducing the health problems associated with alcohol use.

Alaska↗
PubMedDate not supplied

The changing requirements for health manpower and the University of Oklahoma College of Medicine.

Sweeping national changes in health care financing and delivery are forcing major modifications in the numbers, types, and distribution of physician manpower thought to be appropriate for the new paradigms. Not surprisingly, these changes are exerting great pressure on medical education institutions to also adapt to the changing requirements. In Oklahoma, these financial and policy changes are accompanied by demands upon the colleges of medicine to increase the numbers of physicians who locate their practices in rural locations. The maintenance of a comprehensive and well balanced basic and advanced medical education effort within these complex and shifting requirements continues to tax the abilities of all faculties, including the Oklahoma University College of Medicine (OUCOM).

Education, Medical↗
PubMed1998

[Changes in homes for the aged and nursing homes: functional impairments and behavioral disorders of residents are increasing].

Residents in homes for the elderly and in nursing homes suffer from physical and mental disorders that are prevalent far above average. In the course of the changes that are presently taking place in the German health care system there is now an increase in the number of mentally ill and severely impaired persons residing in old-age homes. Earlier epidemiological studies do not yield any conclusive predictions of changes in residential structures and hence in nursing care requirements. Two cross-sectional studies are presented on the prevalence of physical and mental diseases, daily and behaviour problems among residents of old-age and nursing homes in Mannheim. There was a distinct increase in average age, functional impairment, depression and disoriented behaviour among residents in 12 homes for the elderly in Mannheim conducted in 1988 (n = 542) and 1992 (n = 497). During the period it was noted that disoriented behaviour significantly increased the mortality risk. In another study the by far larger group of nursing home residents was investigated. So far we have data for 1995 and 1996 on results obtained from 1178 residents of Mannheim homes for the elderly and nursing homes. Among the residents of nursing homes there was a much higher prevalence of functional impairment and behaviour problems than among those of homes for the elderly. Despite a very high prevalence of depression or disorientation, only every third resident was diagnosed as suffering from organic brain disease and only every tenth resident had a depressive disorder. Since a growing proportion of residents will be mentally ill or severely impaired, these institutions will be facing increasing medical and nursing demands. Due to limited resources, the homes cannot meet these demands adequately. Hence, health policy changes are mandatory to improve nursing care and to avoid placing an increasing burden on the nursing staff.

Activities of Daily Living↗
PubMedDate not supplied

Child health, poverty and the environment: the Canadian context.

In Canada, there has been little research exploring the link between child poverty and exposure to environmental contaminants. However, children living in poverty are more likely to grow up in neighbourhoods adjacent to polluting industries and heavily used transportation corridors. They are also more likely to live in improperly designed or maintained buildings where levels of contaminants and toxic residuals may be high, and indoor air quality poor. Risk factors such as exposure to cigarette smoke and poor nutritional status, together with the above living conditions during growth and development, create conditions that make children living in poverty more vulnerable to the effects of environmental contaminants. In Toronto, the South Riverdale Community Health Centre is developing grassroots techniques to build awareness and protect citizens. Given the growing levels of child poverty in Canada and decreasing environmental protection, the author suggests increased community action and health research for use in advocating for appropriate policy changes.

Canada↗
PubMedDate not supplied

Is a routine radiological consultation cost-effective for pediatric orthopedic radiographs?

This investigation was undertaken to determine the value of a routine radiological consultation on all examinations taken during the course of evaluation and treatment of children with elective orthopedic problems. Shriners Hospital in Los Angeles treats children with chronic orthopedic problems. All radiographs are ordered by an orthopedic surgeon. Currently all plain examinations are also read and reported by a pediatric radiologist. The study was a retrospective chart review. Three hundred nineteen radiographic examinations (6.7% of the total performed in calendar year 1995) were reviewed. The orthopedic surgeons documented the results of their readings in 69% of the cases, while the radiology staff documented 92% of the studies. The data do not show evidence of significant misinterpretations in the readings by the orthopedic surgeons. Therefore routine radiological consultation for all examinations is unnecessary in that specific setting. If a policy change were instituted, it would represent a major saving in health-care costs.

Child↗
PubMed1998

Healthcare organizational change: implications for access to care and its measurement.

OBJECTIVES: To summarize evidence from peer-reviewed literature on access to care for vulnerable HMO enrollee populations; to discuss the potential effect of recent HMO and physician organization changes on access to care and its measurement. STUDY DESIGN: Review and summary of peer-reviewed literature for two HMO populations: those with chronic conditions and diseases, and those subject to discrimination due to income, color, or ethnic background. I also reviewed and summarized literature on three major changes in capitated organizations (HMOs and capitated physician organizations) that could affect access to care for vulnerable populations, and summarized findings from healthcare manager interviews conducted for several recent research projects on health system change. PRINCIPAL FINDINGS: Although mixed, there are enough negative results to raise some concerns about access to care for HMO enrollees with chronic conditions and diseases. Several emerging organizational changes have the potential to change access to care for the vulnerable HMO enrollees. The shift in cost-cutting from fragmented clinical management of specific services at a point in time toward more integrated clinical management of all services for specific types of patients across time may improve access to care, as may increased efforts to attract and retain HMO enrollees. The increased importance of capitated provider organizations within the health system may restrict access in some ways, and expand access in others. CONCLUSIONS: Organizational changes can affect both access to care and its measurement. More research is needed on the effects of these changes on access to care and quality of care. For researchers examining access to care for vulnerable HMO enrollee populations, these changes create challenges to determine the most appropriate measures of access to care, and the most appropriate organizations and organizational characteristics to measure. RELEVANCE TO CLINICAL PRACTICE, MANAGEMENT, AND/OR POLICY: Changes in market competition are leading to organizational changes that affect access to care for vulnerable HMO enrollee populations. Public and/or private policies that improve measurement and reporting can affect market competition and improve access to care.

Capitation Fee↗
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↗