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PubMed2004

Recent trends and geographic variation in the safety net.

BACKGROUND: Policymakers and researchers are concerned that changes in the healthcare market have stressed and weakened the safety net nationwide. OBJECTIVES: The objectives of this study were to investigate variations in the safety net across communities and over time and to explore the effect of market changes on the safety net. MATERIALS AND METHODS: We examined the safety net in all large urban communities from 1993 to 1998. Data from a variety of sources measure uncompensated hospital care, local government spending for health, admissions to safety net hospitals, visits to outpatient departments of safety net hospitals, visits to community health centers, and demographic and market characteristics of the communities. Descriptive analyses examine trends and community variations. Multivariate methods are used to estimate the effect of market structure and of economic factors on the safety net. RESULTS: The safety net did not erode in urban areas over the study period. There was substantial variation across communities, but the disparity did not increase over time. HMO penetration and hospital competition are not significantly related to variations in the safety net, although demographic and economic factors are. CONCLUSIONS: Local financing capacity is a factor in variations across communities in the safety net. The economic downturn and pressures on state budgets could lead to future problems.

Community Health Planning↗

PubMed1995

Review of international criteria and mixture rules for health hazard classification.

The presentation of consistent hazard information in the face of conflicting inter- and intranational regulations and standards is a formidable task. The principal challenge arises from the varying definitions of what is and is not a hazardous chemical and the differing rules that regulate the disclosure of components on material safety data sheets (MSDS) and labels. Some of the effects on hazard communication of nine health hazard classification systems of the United States, Canada, and the European Union are analyzed. The additional complication of differing rules that govern the hazard classification of mixtures is also discussed. The combination of inconsistent hazard classification of individual chemicals and dissimilar mixture rules can result in different conclusions about the hazard classification of commercial products. Faced with this situation, hazard communicators must focus on developing clear statements of the health effects that may arise from overexposure to a chemical, which is the essential purpose of developing MSDS and labels. These statements may be distinct from the terminology derived from the various classification systems. All national MSDS systems make provisions for including statements of hazard and also for providing the toxicology information that is the basis for translation into the locally governing classification terminology. Requirements for labels are often more restrictive, and the complete resolution of conflicting communication must await international harmonization of hazard classification systems including mixture rules.

Air Pollutants, Occupational↗

PubMedDate not supplied

An assessment of national need for community physician manpower in Nigeria.

This is a study of the government policy situation in all the 19 states of Nigeria in relation to the practice of community medicine in the context of primary health care and the movement for health-for-all by the year 2000, as well as the existing mechanisms for the achievement of those policies. The result of the study, which was carried out by means of mail questionnaires to all the 19 Ministries of Health (MOH) and each of the State Health Management Boards (SHMB) or Health Councils (SHC), show that only 8 of the states have actual or assumed policy for the provision of community medical officers ("Medical Officers of Health") for each of their local government areas. Only 3 states have a mechanism for operating the said policy. Details of the study methods and the responses, as well as other aspects of community medical practice in the states are discussed and suggestions made towards their improvement for the attainment of the health-for-all objectives in Nigeria in the foreseeable future.

Community Medicine↗

PubMed2002

Supporting community-based prevention and health promotion initiatives: developing effective technical assistance systems.

As research evidence for the effectiveness of community-based prevention has mounted, so has recognition of the gap between research and community practice. As a result, state and local governments are taking a more active role in building the capacity of community-based organizations to deliver evidence-based prevention interventions. Innovations are taking place in the establishment of technical assistance or support systems to influence the prevention and health education activities of community-based organizations. Several challenges for technical assistance systems are described: (1) setting prevention priorities and allocating limited technical assistance resources, (2) balancing capacity-building versus program dissemination efforts, (3) collaborating across categorical problem areas, (4) designing technical assistance initiatives with enough "dose strength" to have an effect, (5) balancing fidelity versus adaptation in program implementation, (6) building organizational cultures that support innovation, and (7) building local evaluative capacity versus generalizable evaluation findings.

Community Health Services↗

PubMed2001

Urban catchment management in a developing country: the Lotus River project, Cape Town, South Africa.

This paper describes a 2-year pilot project undertaken in an urban catchment in Cape Town, South Africa. The impermeable area of the Lotus River catchment has doubled over 15 years, from 17% in 1983 to 34% in 1997. Following the abolition of urban influx control in 1990, informal settlements in the catchment grew rapidly and now house about 90,000 out of the catchment's total population of 380,000 people. The informal areas are still largely unserviced, despite a commitment from local government to speed up service delivery to the poorest areas of the city. Within the Lotus River project, hydrological and ecological assessments of the urban watercourses were undertaken, through physico-chemical and microbiological sampling programmes, macro-invertebrate counts, and vegetation sampling. All available information regarding the catchment was integrated within a GIS platform, including demographic and socio-economic data on the various communities, and hydrogeological information on the underlying aquifer obtained from earlier studies. The integrated nature of the project allows a number of conclusions and recommendations to be drawn, regarding the management of this particular catchment. However, important general lessons have also been learned which can be applied by local authorities responsible for urban catchments in developing countries. The necessity of providing the required institutional structures cannot be overemphasised.

Animals↗

PubMed1994

Correlations of crystal structures of DNA oligonucleotides with enantioselective recognition by Rh(phen)2phi3+: probes of DNA propeller twisting in solution.

Rh(phen)2phi3+ (phen = 1,10-phenanthroline; phi = 9,10-phenanthrenequinone diimine) avidly binds to DNA via intercalation from the major groove and upon photoactivation produces strand scission with single base 5' asymmetry. Enantiomers of Rh(phen)2phi3+, which lack hydrogen-bonding substituents in ancillary positions, distinguish a DNA site through shape-selection; site recognition depends upon the local variations in structure at a binding site. Here, we examine the application of delta-Rh(phen)2phi3+ as a sequence-dependent structural probe and, in particular, as a probe of DNA propeller twisting in solution, by comparing directly cleavage results using delta- and lambda-Rh(phen)2phi3+ on crystallographically characterized oligonucleotides with several sequence-dependent crystallographic parameters. The three oligonucleotides examined in this study are the Dickerson-Drew dodecamer, 5'-CGCGAATTCGCG-3', the NarI dodecamer, 5'-ACCGGCGCCACA-3', and the CG decamer, 5'-CCAACGTTGG-3', all of which have been crystallized in the B-form. Enantioselective cleavage and reaction favored by the delta-isomer is found to be governed locally by the opening of the site in the major groove. A correlation is demonstrated between cleavage by delta-Rh(phen)2phi3+ and the opening in the major groove that results from the change in propeller twist (differential propeller twist) at a base step. When the major groove is closed as a result of a change in propeller twist, there is little cleavage evident by either enantiomer; at sites which are indicated crystallographically to be open in the major groove, a direct correlation is observed between enantioselective cleavage and the degree of opening. A trend of higher enantioselectivity at sites possessing higher twist angles is also observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Base Sequence↗

PubMed1993

Subsidized elderly housing: public-private partnerships on the brink.

Starting in the early 1960s, the federal government joined with the private-sector housing developers in a partnership: in return for subsidized mortgages and tax benefits, developers would rent to low- and moderate-income tenants. Today, many elderly people live in these "publicly subsidized" units. The initial agreement, however, held out an escape clause: after 15 to 20 years, for-profit developers that wanted to end the partnership could prepay their mortgages, leaving tenants in those buildings "at risk" of rent increases and/or evictions. This article discusses that partnership, its options for dissolution, and the current solutions to the problem of the expiring agreements, including a moratorium, vouchers, and incentives. The compromise legislation responds to all interested parties--owners, current and would-be tenants, local governments, tax-payers--through a multi-stage sequence of dissolution, yet such a finely tuned, acutely sensitive legislative solution may not work easily or efficiently.

Aged↗

PubMed2002

Toward a national health risk management approach in Australia.

There has been increasing international consensus about the importance of competition for achieving national growth and community well-being. The Australian government accordingly has introduced policies to promote such competition. Major legislative review and many public inquiries have assisted implementation of national competition policy and the development of national goals and standards related to international agreements to promote health and sustainable development. Since the 1980s, Australia has had legislation that requires the identification and control of health risks arising at work. The management structures necessary for coordinated delivery of national programs designed for effective identification and control of health risks arising in communities to achieve national health and development goals are still being developed, however. Major difficulties related to this development are discussed. National health development programs should be approached primarily through establishment of regional partnerships between bodies responsible for managing community health, local government, and employment placement, in consultation with other relevant organizations and the community. Related research and evaluation programs are required.

Australia↗

PubMed2004

Psychosocial effects of river blindness in a rural community in Nigeria.

Onchocerciasis (river blindness) is a serious public health problem with important socioeconomic consequences. The presence of onchocercal skin lesions is unsightly and has a psychosocial effect on the affected. This cross-sectional study was undertaken to assess the perception and social implication of onchocerciasis in the village of Apana in Nigeria. Apana is a rural community, hyper-endemic for onchocerciasis and currently receiving ivermectin treatment. The village is one of the ten communities of Uzairue district of Etsako West Local Government Area (LGA), Edo State, Nigeria. There are many water streams in the community which serve the domestic needs of the inhabitants but also provide the breeding sites for the vector flies of onchocerciasis. Multi-stage sampling methods were used to select the 385 respondents that participated after informed consent was obtained. A structured researcher-administered questionnaire was the tool for data collection. Of the 385 respondents that participated in the survey, 240 (62.3%) were male while 145 (37.7%) were female. The awareness of the disease among the respondents was fair. They were aware of the nuisance value of blackflies ('Uja-ini') and associated the bite with itching. The signs and symptoms of onchocerciasis were recognised as specific diseases with specific local names. They called itching and rashes 'Erhue', nodules and leopard skin 'Evbiomu-Ogui', worm in the eye 'Okogho-Ikpalo' and blindness 'Orunalo'. The attitude of the non-affected towards the affected was partially discriminatory and suspicious. The affected were socially withdrawn, probably due to the frustration of their health condition. There is a need to improve people's attitude towards the disease and improve disease awareness through appropriate health education, which will encourage the acceptance of ivermectin as adequate treatment and compliance to the treatment regimen to reduce morbidity and promote self-esteem.

Adolescent↗

PubMed1995

[Not Available].

This paper condenses legal thought elaborated during the late Middle Ages by law doctors regarding rules to be observed during the plague. What they thought about this problem was scattered through wide commentaries on Roman and Canon law. Those hints were gathered by three Italian jurists working at the beginning of the XVI century, at the time of a strong, new epidemic wave (1522-1523). Italy showed again its primacy in the growth of the peculiar Continental common law. In the first part of this work we present the legal rules dealing with prevention, i.e. what lawyers could learn concerning good government of a city from old texts. This is interesting because this teaching gave a model referred to public powers all over Europe. In this way old teachings were transferred to modern governors, who had the opportunity to select the alternatives offered by ancient wisdom and its recent interpretations. The three 'tractatus' we refer to were written at the same time independently of each other. However, we shall see that they have many common conclusions, because they derive from the same cultural environment. The three authors worked in Bologna, Avignon and Pisa, but with the same legal sources which were at that time the same all over Continental Europe. From these works it is possible to understand how wise the different provisions issued by the local government were. In the second and final part of this work regulations during the plague for private business will be illustrated.

Europe↗

PubMed2003

Facing war, terrorism, and disaster: toward a child-oriented comprehensive emergency care system.

The combination of the overwhelming nature of disasters and the massive losses they engender gives rise to a complex clinical and social picture with longterm physical, psychological, and social effects on children, families, and communities. The authors suggest that to assess the damage properly, implement interventions on a large scale, keep tabs on rising needs, and restore societal function, mental health professionals must adopt an ecologic systems approach. This approach entails working within and together with related institutions (education, health, local government) and assisting other committed professionals within these institutions to mediate care. This is of utmost importance in the area of children's care because of their particular vulnerability and their special importance for families and society. For this reason, the authors suggest that emergency mental health systems be better designed and implemented while keeping children at the center of their focus. An essential component of the ecologic systems approach is improved education for mental health professionals, providing them the appropriate tools to cope with widespread disaster and the expertise to apply these tools. This approach, however, is not enough. A good outcome cannot be achieved without preparedness on the part of the other relevant institutions and the community as a whole. Greater awareness is needed among local and national authorities of the importance of metaadaptive systems and of local, national, and international networking. In the current global village that is threatened by pervasive terrorism, no community must face it alone. The challenge of a disaster to one community is a challenge to all. By working together we can lessen the devastating impact of these events, save countless lives, prevent untold suffering, and maintain hope for a better world for children.

Adolescent↗

PubMed1999

Measuring community/environmental interventions: the Child Pedestrian Injury Prevention Project.

OBJECTIVES: To assess the effectiveness of community/environmental interventions undertaken as part of the Child Pedestrian Injury Prevention Project (CPIPP). SETTING: Three communities (local government areas) in the Perth metropolitan area, Western Australia. METHODS: A quasiexperimental community intervention trial was undertaken over three years (1995-97). Three communities were assigned to either: a community/environmental road safety intervention and a school based road/pedestrian safety education program (intervention group 1); a school based road/pedestrian safety education program only (intervention group 2); or to no road safety intervention (comparison group). Quantification of the various road safety community/environmental activities undertaken in each community during the trial was measured, and a cumulative community activity index developed. Estimates of the volume and speed of vehicular traffic were monitored over a two year period. RESULTS: Greater road safety activity was observed in intervention group 1 compared with the other groups. A significant reduction in the volume of traffic on local access roads was also observed over the period of the trial in intervention group 1, but not in the remaining groups. CONCLUSIONS: The findings indicate that the various community/environmental interventions initiated in collaboration with CPIPP in intervention group 1 contributed, in part, to the observed reduction in the volume of traffic. A combination of community/environmental interventions and education are likely to reduce the rate of childhood pedestrian injury.

Accidents, Traffic↗

PubMed1975

Sudden infant death syndrome (SIDS): a burgeoning medicolegal problem.

This Article presents a summary analysis of the administrative and statutory bases for the documented, prevalent mismanagement of Suddern Infant Death Syndrome (SIDS) cases by a majority of local death investigation agencies in the United States. Herein, Alan P. Cleveland, J.D. advances the theory that the unsatisfactory handling of cases of SIDS by the medicolegal community is the inevitable outgrowth of state laws that expressly require investigative agencies to approach a sudden, unexplained death from the direction of determining first whether or not a criminal act has occurred. In so doing, most statutorily mandated autopsy procedures are socially counterproductive since, in ignoring an acute medical need for supportive family counselling, they often constitute an insuperable obstacle to the effective management of SIDS as a public health problem. The author recommends that a requisite first step in implementing an SIDS management program at the state level is to insulate surviving family members form criminal investigative procedures by appropriate amendment of state laws governing local death investigation systems.

Autopsy↗

PubMedDate not supplied

Using the U.S. Behavior Risk Factor Surveillance System's health related quality of life survey tool in a Canadian city.

As responsibility for health funding shifts from central to local governments, providers find themselves in decision-making roles or asked to give guidance in allocation of resources. To develop a picture of a population's health, data are needed about the effects that illness and disability have on a person's ability to function and thus on quality of life. This study assessed the validity in a Canadian city, of a Health-related Quality of Life (HRQoL) instrument developed by the US Centers for Disease Control and used in the US Behavioral Risk Factor Surveillance System. The HRQoL was administered to a random sample of 1,042 adults. The patterns of association among the HRQoL questions, and the direction of the relationships among independent variables and HRQoL were consistent with those hypothesized. The accumulating evidence for validity of the HRQoL support its use in monitoring the performance of local health initiatives in Canada.

Activities of Daily Living↗

PubMed1998

The Polish experience of quality improvement in primary care.

THE POLISH HEALTH CARE SYSTEM: The health care system in Poland is based on a model typical of east-central European countries, with features such as state-owned health care organizations, centralized management and administration, and primacy of access to care over quality. Poorly planned and uncoordinated reforms have been undertaken to transfer some of the authority for health service management to local governments. PRIMARY HEALTH CARE IN POLAND: The reform of the health care system entails substitution of family physician-based for medical specialist-based primary care. Newly trained family physicians, as the first to start private surgery clinics financed from public sources, are the forerunners of the comprehensive reform and property structure transformation. MAKING THE TRANSITION FROM QUALITY ASSURANCE TO QUALITY IMPROVEMENT: Since the early 1990s, more and more organizations, individuals, and professional groups have begun to perceive health care regulations and other external control mechanisms as ineffective. Attempts have been made to replace periodic, restrictive activities with systematic continuous quality improvement efforts. Systems of voluntary accreditation are being developed and fostered. Groups have started meeting to develop medical practice guidelines and conduct peer review. Concern about quality of health care services is now reflected in the Polish legislation for the first time, as well as in numerous local and nationwide projects and publications. CONCLUSION: Despite some successes, the pioneers of quality improvement (QI) still have a long way to go. Continuation of educational activities and creation of a system of motivation for the development, of QI in primary care should be prioritized and encouraged.

Health Care Reform↗

PubMed2006

An assessment of the dental public health infrastructure in the United States.

OBJECTIVES: The National Institute of Dental and Craniofacial Research commissioned an assessment of the dental public health infrastructure in the United States as a first step toward ensuring its adequacy. This study examined several elements of the U.S. dental public health infrastructure in government, education, workforce, and regulatory issues, focused primarily at the state level. METHODS: Data were drawn from a wide range of sources, including original surveys, analysis of existing databases, and compilation of publicly available information. RESULTS: In 2002, 72.5% of states had a full-time dental director and 65% of state dental programs had total budgets of 1 million dollars or less. Among U.S. dental schools, 68% had a dental public health academic unit. Twelve and a half percent of dental schools and 64.3% of dental hygiene programs had no faculty member with a public health degree. Among schools of public health, 15% offered a graduate degree in a dental public health concentration area, and 60% had no faculty member with a dental or dental hygiene degree. There were 141 active diplomates of the American Board of Dental Public Health as of February 2001; 15% worked for state, county, or local governments. In May 2003, there were 640 U.S. members of the American Association of Public Health Dentistry with few members in most states. In 2002, 544 American Dental Association members reported their specialty as Dental Public Health, which ranged from 0 in five states to 41 in California. Just two states had a public health dentist on their dental licensing boards. CONCLUSIONS: Findings suggest the U.S. dental public health workforce is small, most state programs have scant funding, the field has minimal presence in academia, and dental public health has little role in the regulation of dentistry and dental hygiene. Successful efforts to enhance the many aspects of the U.S. dental public health infrastructure will require substantial collaboration among many diverse partners.

American Dental Association↗

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↗

PubMed2005

Unique issues in research and evaluation in rural and remote locations: is there a place for specific research training?

BACKGROUND: There is increased interest in building research capacity in rural health research in Australia and internationally. In Australia, the Primary Health Care Research Evaluation and Development program funded by the Australian Government has supported this move. Overall this program aims to build the quantum of primary healthcare research to underpin clinical practice, health systems improvement, and policy. In order to achieve this objective, one strand of the program aims to build research capacity among practitioners. In implementing this program in rural and remote areas of the west of South Australia, the Spencer Gulf Rural Health School has identified methodological and research design issues faced by practitioners who are researching in their communities. These issues include problems encountered in living and researching in the same location and accessing small-scale statistical information. We were interested to know whether there was interest in a formal course (Rural Research and Evaluation) that would address these issues and provide information about community-based research designs. METHODS: A cross-sectional anonymous survey was designed and sent to 141 organisations in the health, human service, and local government sectors in regional South Australia. Respondents were asked to evaluate the demand and interest for a new course--Rural Research and Evaluation. The term 'rural' was used to refer to both rural and remote locations. Information was sought on the respondent's role in the organisation, current level of research participation, views about the proposed course content, and factors that the respondent thought would facilitate or inhibit their participation. The majority of questions were close-ended. RESULTS: Sixty surveys were returned giving a 42.5% response rate. Data were analysed using descriptive statistics. A high level of research and evaluation activity was reported with 80% of respondents undertaking research or evaluation as part of their professional role. There was also agreement that all the proposed topics were important to be included in a course. Each of the topics was ranked at four or five on a five-point scale by at least 58% of respondents. The topic 'understanding evaluation methodologies' was ranked at four or five by 85% of respondents, making it the most highly ranked topic. There was also consensus about the features respondents thought would make the course attractive for them to study. Over half (62%) of the respondents ranked having lecturers with a broad rural research background at five, very important, on a five-point scale. Almost half (48%) of the respondents ranked online delivery at five, a very important factor in making the course attractive to study. CONCLUSIONS: Those interested in research and evaluation may have been more likely to return the survey and there may have been respondent bias in this regard. Therefore the results must be interpreted with caution. However, the level of agreement with the proposed course topics may suggest that these reflect important issues in undertaking research and evaluation in rural and remote locations. If this is the case there is value in discussion about how these issues are dealt with in different contexts in order to overcome some of the barriers to effective research.

Cross-Sectional Studies↗