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PubMed1993

Black America: from community health care to crisis medicine.

This study traces the major policy shifts in medical care that have affected disadvantaged African-Americans and the response of this community's medical leadership to these changes. Since World War II policy has passed through three major phases. The first--engagement--ran from the mid-1960s through the mid-1970s. During this phase a community health policy orientation prevailed as national government targeted resources to health care programs for needy blacks and other poor Americans. From the late 1970s to the mid-1980s the period of submersion occurred: black community health professionals and political leaders experienced a new-found inclusion in health policy debate, but, at the same time, broader policy-making circles in government and health care reduced medical resources for the inner-city poor. Finally, in the third phase--crisis recognition--a network developed of community health advocates who seek to reorient the health system so that it addresses needs within urban American's "New Ghettos."

Black or African American↗

PubMed2004

Marriage promotion and missing men: African American women in a demographic double bind.

Since 1996, state legislators, members of the U.S. Congress, and more recently President George W. Bush, have called for the protection of monogamous, heterosexual marriage and the promotion of marriage among poor women. The thrust of this policy making is directed at African American families, among which female headship doubled between 1965 and 1990. This doubling is temporally associated with enacting the legislation directed toward the War on Drugs, which resulted in a tripling of the African American prison population. In Syracuse, New York, the swelling African American population behind bars has resulted in a skewed sex ratio, in which women significantly outnumber men. The authors use national, state, and local epidemiological, environmental, and ethnographic data to argue that the proliferation of marriage-promotion policies is heterosexist and blames African American women for demographic realities over which they have little control.

Black or African American↗

PubMed1994

Planning oral health care for the elderly in Israel for the years 2000 and 2025.

The methodology and conclusions of this workshop are reported here because the problems requiring solution are not unique to Israel. They will increasingly have wide geographical and political application. The population of Israel since its establishment in 1948 has increased about sixfold. The numbers of the elderly (65+) have increased about tenfold. The current situation must be examined and estimates obtained for the next ten years. Only thus can the system be enabled to cope with the problem as it develops. The chosen method was a carefully preplanned, multisectorial workshop. Recommendations were discussed, amended and finalised. The recommendations of the workshop included: Baseline national data is urgently required. Guidelines are required for selecting specific target populations to which priority should be given. The current favourable situation of adequate oral health manpower in Israel makes it possible to encourage providers of oral health care towards treatment for the elderly. It is essential that the appropriate health authorities allocate sufficient funds for the following urgent purposes: the conduct of a national survey of the elderly population; the establishment of oral health units on a trial basis in some selected hospitals; support institutions of higher education to facilitate training in geriatric dentistry. CONCLUSIONS. The workshop was multidisciplinary because it was necessary to include all the expertise and experience available as vital elements of the policy making process. This type of workshop was found to be an effective tool for planning oral health services.

Aged↗

PubMed2005

Cultural circuits of climate change in U.K. broadsheet newspapers, 1985-2003.

This article argues for a cultural perspective to be brought to bear on studies of climate change risk perception. Developing the "circuit of culture" model, the article maintains that the producers and consumers of media texts are jointly engaged in dynamic, meaning-making activities that are context-specific and that change over time. A critical discourse analysis of climate change based on a database of newspaper reports from three U.K. broadsheet papers over the period 1985-2003 is presented. This empirical study identifies three distinct circuits of climate change-1985-1990, 1991-1996, 1997-2003-which are characterized by different framings of risks associated with climate change. The article concludes that there is evidence of social learning as actors build on their experiences in relation to climate change science and policy making. Two important factors in shaping the U.K.'s broadsheet newspapers' discourse on "dangerous" climate change emerge as the agency of top political figures and the dominant ideological standpoints in different newspapers.

Journal Article↗

PubMed1983

Informed consent and patient decision making: two decades of research.

Patient consent to medical treatment has been a subject of concern within the United States professional communities for over two decades. This paper traces the development of research literature on patient decision making and informed consent to medical treatment in three fields of research: medicine, law and the social sciences. A general model for stages in the development of scientific specialties is applied as a test for the development of informed consent as a specialty interest in each research field. Results indicate a relatively advanced stage of development within medicine and law. Research in the social science disciplines tend to lag behind in terms of cumulative number of publications. In addition, social science research which is potentially relevant to the ethical and policy issues of consent in medical treatment appears to lack a clear programmatic thrust, with little attention given to the policy implications of the work. In contrast, the medical and legal literatures indicate a direct concern with social policy and reflect attempts on the part of physicians and lawyers to influence the policy making process.

Behavioral Research↗

PubMedDate not supplied

[Open questions in the interpretation of daily time-series studies on air pollution and health. Part I: estimate of exposure].

This paper is a commentary to the MISA study (Meta-analysis of the Italian studies on short-term effects of air pollution). The interpretation of the relationships observed in the time-series analyses is not straightforward. I will review a number of open questions: the exposure estimates; the meaning of the daily mortality and hospitalisation rates, in terms of impact on life expectancy, incidence of specific diseases, exacerbation of pre-existing chronic diseases; the pattern of the estimated dose-response curves; the role of possible effect modifiers; the hypotheses about the underlying mechanisms. These interpretative problems often present overlapping aspects. Some of the pending answers are relevant for policy making. For editorial reasons this review is divided into two parts. This first paper focuses on the exposure estimates. The second part, to be published in the next issue of this journal, will deal with the meaning of the outcome variable, the shape of the dose-response curves, possible effect modifiers and underlying mechanisms.

Air Pollution↗

PubMed2005

Combating HIV/AIDS in Mainland China: an epidemiological review of prevention and control measures.

Two decades have already passed since the first HIV/AIDS case was described in 1981. Cumulatively, over 20 million people have unfortunately lost their lives, and more than 40 million people are now living with HIV, and most of them are from developing countries. China, as the biggest developing country, has an impact on the epidemic of HIV/AIDS. From the first case of AIDS diagnosed in Mainland China in 1985, the epidemic has spread at an alarming rate. The feature of HIV/AIDS spread in Mainland China concerns its geographical characteristics that can be described as occurring in three phases. According to data from World Health Organization (WHO), it was estimated that about 840,000 people are living with HIV/AIDS in China, and 80,000 of them have already developed AIDS. WHO warned that, if there were no effective preventive measures adopted, that the number of HIV/AIDS infected cases would reach 10 million in China by 2010. In this study, we described the current situation of the epidemic of HIV/AIDS, as well as an historic review. The development of policy-making and the control measures are also highlighted. The experience from China described in this study would hopefully be for more public awareness of this crisis that is threatening all the citizenry of China.

Acquired Immunodeficiency Syndrome↗

PubMed1986

[Education-service integration].

The article broadly reviews the conceptual basis of the integration of service and education and the history of the process and of the programs in progress in the countries of the Americas. A study of the different definitions given and uses made of the concept and practice yields a definition of the integration of services and education as "a process of progressive articulation between institutions providing health services and those imparting instruction in the health field in order to improve health care and guide the generation of knowledge and the training of personnel on the basis of the epidemiological profile of a given region and population. This ongoing education process takes place in the course of work, which it is capable of changing by virtue of its own momentum." This definition embodies the features common to all those used: The process itself, articulation between teaching and service establishments, and objectives. The story of the process in the Old World is briefly reviewed; its stages in the New World are considered at greater length, and the positions taken by the Pan American Health Organization since 1963 are stated. The emphasis today is on the technical cooperation provided in the different aspects of the process: institutional and program development, program supervision, the setting of standards and priorities for research, personnel utilization, etc. The article closes with an account of the mechanisms for interaction (formal, informal, operational, and policy-making) and a discussion of the different fields, practices and coverage that have been affected by this process, and comes to the conclusion that the integration of service and education has been essential to the student's training in exposing him to the practical realities of the local and general situation of his country.

Health Occupations↗

PubMed1983

Assessing the cost-effectiveness of prevention.

In an era of limited resources, cost-effectiveness analysis and cost-benefit analysis (CEA/CBA) can be significant policy-making aids. Because the often stated belief that prevention is cost-effective has not been systematically examined, we surveyed about 250 CEA/CBA articles concerning prevention. We found that few authors have followed generally accepted methodological standards, which raised questions concerning the validity of their findings and conclusions. In addition, prevention itself is a problem in CEA/CBA because of such factors as the long intervals between interventions and outcomes, problems which have rarely been considered in the CEA/CBA prevention literature. At the same time, a number of high quality studies concerning prevention indicates that United States policy makers have not aggressively pursued significant opportunities to improve health through prevention, for example by immunizing the elderly and by screening for and treating hypertension. We recommend that analysts follow general methodological principles in CEA/CBA prevention studies to assure both valid and credible results.

Cost-Benefit Analysis↗

PubMed2001

Micronutrient deficiency in children.

Malnutrition increases morbidity and mortality and affects physical growth and development, some of these effects resulting from specific micronutrient deficiencies. While public health efforts must be targeted to improve dietary intakes in children through breast feeding and appropriate complementary feeding, there is a need for additional measures to increase the intake of certain micronutrients. Food-based approaches are regarded as the long-term strategy for improving nutrition, but for certain micronutrients, supplementation, be it to the general population or to high risk groups or as an adjunct to treatment must also be considered. Our understanding of the prevalence and consequences of iron, vitamin A and iodine deficiency in children and pregnant women has advanced considerably while there is still a need to generate more knowledge pertaining to many other micronutrients, including zinc, selenium and many of the B-vitamins. For iron and vitamin A, the challenge is to improve the delivery to target populations. For disease prevention and growth promotion, the need to deliver safe but effective amounts of micronutrients such as zinc to children and women of fertile age can be determined only after data on deficiency prevalence becomes available and the studies on mortality reduction following supplementation are completed. Individual or multiple micronutrients must be used as an adjunct to treatment of common infectious diseases and malnutrition only if the gains are substantial and the safety window sufficiently wide. The available data for zinc are promising with regard to the prevention of diarrhea and pneumonia. It should be emphasized that there must be no displacement of important treatment such as ORS in acute diarrhea by adjunct therapy such as zinc. Credible policy making requires description of not only the clinical effects but also the underlying biological mechanisms. As findings of experimental studies are not always feasible to extrapolate to humans, the biology of deficiency as well as excess of micronutrients in humans must continue to be investigated with vigour.

Breeding↗

PubMed1984

Policy shifts and organizational adaptation: a review of current developments.

Changes in the operations and structure of local mental health centers are occurring in response to policy and funding shifts at the state and federal levels. Clinical and administrative staffing changes reflect both cutbacks in funding for traditional outpatient and inpatient services, as well as increases in partial care, community, residential and case management services. Centers are diversifying their funding sources, especially through increased revenues from Medicare-Medicaid sources. Governing boards remain active in center policy making, with few changes in their composition. Current adaptation strategies focus mainly on enhancing efficiency, reviewing service costs, expanding services to more viable markets, and improving business practices. These actions and strategies are compared to findings from previous studies, and their implications are discussed.

Ambulatory Care↗

PubMed1995

Implementation of community care policy in the United Kingdom: will it be achieved?

In the United Kingdom, the provision of health and social care within the community is the subject of major reform. This reform is aimed at reducing the dominance of the state as provider of welfare services whilst encouraging the independent sector to provide the bulk of services through competition and market forces. The purpose of this paper is to discuss the implementation of government policy with respect to health and social care in the community. The policy recommended in the 1989 White Paper Caring for People, which is sanctioned in the National Health Service (NHS) and Community Care Act (1990), is the focus for discussion. Implementation theory is used as a framework to explore the modification and reshaping which inevitably accompanies the translation of government policy into reality. The nature of any actual or potential deficit between stated policy and community care reform in practice is examined against this theoretical background. An historical stance is taken in order to place current policy into the wider context and consider what determinants may have led to the radical proposals for community care, and indeed other sectors of public service. A consideration of predominating philosophies is prudent to an analysis of government policy-making and therefore the values and beliefs of 'new public management' are employed as a conceptual framework underpinning current reform. The feasibility of a quasi-market in the delivery of health and social care is considered and some of the main issues which may result in implementation deficit with respect to the implementation of Caring for People are examined.

Communication↗

PubMed1990

Postcolonial nursing education in Trinidad and Tobago.

In this article the impact of the developed nations on basic nursing education in Trinidad and Tobago in the postcolonial period is discussed and analyzed. Subsequent to self-government in 1956, the national government, in its efforts to become independent of its reliance on Great Britain, turned to the United States and Canada for technical and financial aid. Consequently, sources such as the World Bank, Inter-American Development Bank, Pan American Health Organization/World Health Organization, and the Canadian International Development Agency were major avenues for the provision of ideas, concepts, and values in health planning and policy making with primary health care endorsed by the government. Nursing education was thus influenced by these industrialized concepts and values. The impact of socioeconomic and nursing events in the Caribbean region coupled with local initiatives taken by the indigenous leadership to improve nursing education resulted in a program that was an amalgamation of British, North American, and indigenous features.

Curriculum↗

PubMed1990

Philosophical integrity and policy development in bioethics.

Critically examining what most people take for granted is central to philosophical inquiry. Philosophers who accept positions on policy making commissions, tasks forces, or committees cannot, however, play the same uncompromisingly critical role in this capacity as they do in the classroom or in their personal research or writing. Still, philosophers have much to contribute to such bodies, and they can do so without compromising their integrity or betraying themselves as philosophers.

Advisory Committees↗

PubMedDate not supplied

Ethical issues and approaches in stem cell research: from international insights to a proposal.

In recent years and months, human stem cell research has dominated many scientists' interests, the media, public debate, and social policy. This paper aims to consider, first, the major scientific data on stem cell research that are available. Second, I reflect on them by examining how they shaped policies in Europe and the United States. I also point to current changes in policy-making concerning the creation of ad hoc committees to address this novel issue and how, in a few instances, different ethical positions are part of the documents produced. In other words, diverse approaches are not solved but kept in tension. Finally, I suggest that the current state of research on human stem cell will benefit from an ethics of risk.

Embryo Research↗

PubMed1998

Health policy for the aged. We don't study the right people.

A review of articles on aging published during one year in seven major U.S. journals in the fields of general medicine, public health and gerontology showed that only a minority of studies took into consideration the factual attributes of the population. Only 53% of the articles included any basic demographic information, usually age. Race was mentioned in 37%, but only 3% studied blacks or Hispanics; socioeconomic status was given in 25%, marital status in 9%, and education in 19%. Regardless of whether demographic factors were detailed in the description of the study, they were rarely used in the analysis. We conclude that information obtained in the course of studies of the elderly may not reflect the actual needs of this population group which must be recognized as heterogeneous. More specific and refined data are needed to set priorities and make policy decisions.

Age Factors↗

PubMed2003

Economic issues in the use of office spirometry for lung health assessment.

The National Lung Health Education Program (United States) has recently recommended using office spirometry to screen for subclinical lung disease in adult smokers. No published studies evaluate the economic consequences of this recommendation. This review article outlines the issues that must be considered when evaluating the costs and health benefits of office spirometry. Much of the available data on the effectiveness of screening is from studies that included smoking cessation interventions, making it difficult to determine the effects of screening alone. The sensitivity and specificity of screening spirometry are not known, but may not be important in the economic model, because even false positive test results are beneficial if they lead to smoking cessation. Costs to be considered include those of spirometry itself, of implementing and maintaining screening and smoking cessation programs, and of their consequences, ie, reduced morbidity (lower short term health care costs) and mortality (perhaps higher long term health care costs). Despite these unique challenges, data are available to perform economic analyses regarding screening spirometry. Such analyses should play a role in future clinical policy making. Even modest quit rates attributable to screening spirometry may result in highly favourable cost effectiveness ratios.

Adult↗

PubMed2005

Concept of a nutritious food: toward a nutrient density score.

The American diet is said to be increasingly energy-rich but nutrient-poor. To help improve the nutrient-to-energy ratio, the 2005 Dietary Guidelines for Americans recommend that consumers replace some foods in their diets with more nutrient-dense options. Such dietary guidance presupposes the existence of a nutrient density standard. However, a review of the literature shows that the concept of a nutritious food is not based on any consistent standards or criteria. In many cases, healthful foods are defined by the absence of problematic ingredients-fat, sugar, and sodium-rather than by the presence of any beneficial nutrients they might contain. Past attempts to quantify the nutrient density of foods have been based on a variety of calories-to-nutrient scores, nutrients-per-calorie indexes, and nutrient-to-nutrient ratios. The naturally nutrient rich (NNR) score, which is based on mean percentage daily values (DVs) for 14 nutrients in 2000 kcal food, can be used to assign nutrient density values to foods within and across food groups. Use of the NNR score allows consumers to identify and select nutrient-dense foods while permitting some flexibility where the discretionary calories are concerned. This approach has implications for food labeling, nutritional policy making, and consumer education. The Food and Drug Administration has considered approving nutrient claims based on the ratio of a beneficial nutrient to the food's energy content, as opposed to a specified minimum amount of a nutrient per serving size. Given the current dietary trends, the nutrient density approach can be a valuable tool for nutrition education and dietary guidance.

Biological Availability↗