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Objectives: To identify the current challenges and opportunities in compensation and recognition for pharmacist-provided immunizations across the lifespan and to establish guiding principles for pharmacist-provided immunization compensation and recognition. Data sources: 22 stakeholders gathered on June 29, 2011, at the American Pharmacists Association (APhA) headquarters in Washington, DC, for a meeting on immunization compensation that was convened by APhA and the Academy of Managed Care Pharmacy. Participants included representatives from community pharmacy practices (chain, grocery, and independent), employers, national consumer health and advocacy organizations, national pharmacy and public health organizations, health plan representatives, pharmacy benefit managers, and health information technology, standards, and safety organizations. Key immunization leaders from TRICARE Management Activity, the Centers for Medicare & Medicaid Services, the National Vaccine Program Office of the Department of Health & Human Services, and the Centers for Disease Control and Prevention (CDC) also participated in the meeting. Summary: The increased numbers of pharmacists providing vaccination services and the availability of pharmacist-provided immunizations to populations in need of vaccines has continued to increase. This has resulted in a rise in the percentage of patients who receive vaccines at pharmacies. Pharmacists are now working to leverage their ability to identify people with key risk factors (e.g., diabetes, heart disease or previous myocardial infarction), encourage them to receive their CDC-recommended vaccinations, and administer the required vaccine. Challenges and opportunities in compensation and recognition for pharmacist-provided immunizations across the adult lifespan persist. Variability in state practice acts, reimbursement and compensation processes and systems, and mechanisms for documentation of vaccine services create substantial differences in how pharmacist-provided immunizations are delivered throughout the United States. Conclusion: Pharmacist-provided immunizations are clinically sound, are cost effective, are readily accessible, and support our nation's public health goals. Pharmacists have demonstrated that patient vaccination rates have improved through expansion of pharmacist-provided immunizations. The profession should continue efforts to collaborate with other immunization stakeholders and expand a pharmacist scope of practice that is built around a uniform and recognized standard of immunization provision and that supports the provision of all CDC-recommended vaccines through pharmacy-provided immunizations. [ABSTRACT FROM AUTHOR]

This paper analyses the process of generalisation of an innovative government-led public practice in the healthcare sector. The scaling and embedding involved in this generalisation process are assumed to be dependent on the multiple implementation processes (consecutive or simultaneous) that lead to a routine use of the innovation in different adopters. This paper, therefore, proposes the use of a configurational theory approach to conceptualise each implementation of the innovation during the generalisation process and shed light on the generalisation's scaling and embedding efforts. It suggests a set of recommendations and practices for generalisation managers, most notably: i) they should regard generalisations as organic processes where their main role is to create space for experimentation, learning and negotiation, and ii) they should adopt different modes of governance to identify adequate mechanisms and strategies and guide their actions. This configurational perspective allows them to monitor and manage the evolution of implementations, informs the valuable learning processes that take place in a generalisation and has been found to be a useful tool to support the crucial collaboration among the actors involved in a generalisation. • Configurational model for innovation implementations in generalisations • Model useful for managing scaling and embedding of government-led public practices • Configurational perspective informs valuable learning processes in generalisations. • Tool useful to support managerial actions to promote generalisation • Framing adequate to leverage the use of flexibility within socio-technical systems [ABSTRACT FROM AUTHOR]

The characteristic features of 21st-century corporate capitalism – monopoly and financialization – are increasingly being recognized by public health scholars as undermining the foundations of human health. While the "vectors" through which this is occurring are well known – poverty, inequality, climate change among others – locating the root cause of this process in the nature and institutions of contemporary capitalism is relatively new. Researchers have been somewhat slow to study the relationship between contemporary capitalism and human health. In this paper, we focus on one of the leading causes of death in the United States; cancer, and empirically estimate the relationship between various measures of financialization and monopoly in the US healthcare system and cancer mortality. The measures we focus on are for the hospital industry, the health insurance industry, and the pharmaceutical industry. Using a fixed effects model with different specifications and control variables, our analysis is at the state level for the years 2012–2019. These variables include data on population demographic controls, social and economic factors, and health behavior and clinical care. We compare Medicaid expansion states with non-Medicaid expansion states to investigate variations in state-level funded health insurance coverage. The results show a statistically significant positive correlation between the HHI index in the individual healthcare market and cancer mortality and the opioid dispensing rate and cancer mortality. • We analyze how corporate capitalism is related to cancer mortality. • Recently, corporate capitalism has become more common in the healthcare industry. • We find a correlation between hospital net revenue, profit, and cancer mortality. • There is a link between the HHI index in insurance markets and cancer mortality. [ABSTRACT FROM AUTHOR]

This paper seeks to theorize the mechanism by which socially responsible innovation can provide high quality care for patients within the U.S. health care system. By analyzing three exemplary case studies of health care innovation using content analysis, we reveal the mechanism for socially responsible innovation and also suggest places for future implementation. Socially responsible innovation has already taken place in India through design problem solving (at Aravind Eye Care System), and in the United States through both the Chronic Care Model (across hundreds of hospitals), and Lean Management™ principles (at ThedaCare in Wisconsin). Unlike previous theories of organizational learning such as incrementalism and design problem solving, socially responsible innovation puts the patient at the center of systemic health care solutions. Also unlike previous definitions of socially responsible innovation, our conceptualization provides a mechanism for practical application. When analyzing the three exemplary cases of socially responsible innovation, we drew out elements of previous mechanisms of organizational learning (e.g., psychological safety, trial and error, and positive applied theory, etc.) to create a novel reflective mechanism: cycles of actualization. This new reflective mechanism promotes continuous development and implementation of ideal models of practice. Finally, this paper suggests that medical waste management could benefit from socially responsible innovation. If the U.S. health care system adopted socially responsible innovation, facilities could think more holistically about their duties, enacting patient-centered change, and creating a culture of medicine that promotes learning, reflection, and action. [ABSTRACT FROM AUTHOR]

The strongest economic crisis ever known, started in 2008, destroyed much of the social achievements. Although the European Union had to deal with this situation by designing common policies, the member states have handled this crisis in many different ways. Nevertheless, not all the countries had the same possibilities for manage their economic policies inside a common currency area. These states involved in the EuroZone have faced some restrictions due to their belonging to a currency area, so they have had to design alternative economic policies to the monetary one. The main objective of this paper is to assess the acceptance of the restrictive policies on public health expenses due to economic crisis and the implemented economic policy, from the point of view of citizens. This paper hypothesized that this acceptance or not depends on citizens perception of adequate use of the public health care system. A survey was conducted among the main social actors involved on healthcare system: the general population and health professionals. And for testing the hypotheses a means comparison ( t -test and ANOVA) and Structural Equation Modeling (SEM) has been developed using data from that survey. Outcomes from those econometric exercises show a general disagreement with the cuts in health expenses, but in a level very related with citizen’s perceptions of overuse of public health services. [ABSTRACT FROM AUTHOR]

Advances in genetic testing and the aggressive marketing of genetic tests by commercial diagnostic laboratories have driven both consumer demand and the need for unbiased information about how tests should guide healthcare delivery. This paper uses the countervailing powers framework to explore the role of state public health agencies as arbiters of quality and safety, specifically through their efforts to encourage physicians to follow evidence-based recommendations for screening for hereditary cancers. Social scientists have often viewed actions by the state to regulate cost, quality, or safety as a threat to physician autonomy. This paper draws on case studies from two US states—Michigan and Connecticut—to better understand the specific role of state public health agencies, and especially whether their activities to encourage adherence to evidence-based recommendations bolster or subvert the interests of other parties in the healthcare arena. We find that lacking authority to compel provider to follow evidence-based recommendations, they improvised ways to foster compliance voluntarily, for example, by emphasizing the role of the physician as gatekeeper, thus affirming the importance of physician autonomy and clinical judgment. Both states also used public health surveillance data to make rare diseases visible and illustrate gaps between recommendations and practice. Finally, they both showed that following evidence-based recommendations could align the professional and market interests of healthcare stakeholders. Both states employed similar strategies with similar effects, despite substantial differences in the regulatory climate and organizational capacity. Taken as a whole, their activities orchestrated a countervailing response that checked the profit-seeking motives of commercial laboratories. Our findings demonstrate that rather than eroding physician autonomy, state action to monitor healthcare quality and encourage adherence to evidence-based recommendations can actually reinforce physician authority. [ABSTRACT FROM AUTHOR]

This paper is one in a series developed through a process of expert consensus to provide an overview of questions of current importance in research into engagement with digital behavior change interventions, identifying guidance based on research to date and priority topics for future research. The first part of this paper critically reflects on current approaches to conceptualizing and measuring engagement. Next, issues relevant to promoting effective engagement are discussed, including how best to tailor to individual needs and combine digital and human support. A key conclusion with regard to conceptualizing engagement is that it is important to understand the relationship between engagement with the digital intervention and the desired behavior change. This paper argues that it may be more valuable to establish and promote "effective engagement," rather than simply more engagement, with "effective engagement" defined empirically as sufficient engagement with the intervention to achieve intended outcomes. Appraisal of the value and limitations of methods of assessing different aspects of engagement highlights the need to identify valid and efficient combinations of measures to develop and test multidimensional models of engagement. The final section of the paper reflects on how interventions can be designed to fit the user and their specific needs and context. Despite many unresolved questions posed by novel and rapidly changing technologies, there is widespread consensus that successful intervention design demands a user-centered and iterative approach to development, using mixed methods and in-depth qualitative research to progressively refine the intervention to meet user requirements. [ABSTRACT FROM AUTHOR]

This paper introduces and discusses key issues in the economic evaluation of digital health interventions. The purpose is to stimulate debate so that existing economic techniques may be refined or new methods developed. The paper does not seek to provide definitive guidance on appropriate methods of economic analysis for digital health interventions. This paper describes existing guides and analytic frameworks that have been suggested for the economic evaluation of healthcare interventions. Using selected examples of digital health interventions, it assesses how well existing guides and frameworks align to digital health interventions. It shows that digital health interventions may be best characterized as complex interventions in complex systems. Key features of complexity relate to intervention complexity, outcome complexity, and causal pathway complexity, with much of this driven by iterative intervention development over time and uncertainty regarding likely reach of the interventions among the relevant population. These characteristics imply that more-complex methods of economic evaluation are likely to be better able to capture fully the impact of the intervention on costs and benefits over the appropriate time horizon. This complexity includes wider measurement of costs and benefits, and a modeling framework that is able to capture dynamic interactions among the intervention, the population of interest, and the environment. The authors recommend that future research should develop and apply more-flexible modeling techniques to allow better prediction of the interdependency between interventions and important environmental influences. [ABSTRACT FROM AUTHOR]

Objective: To identify attitudes towards pharmacy characteristics and promotional methods for selected pharmacy public health services (lifestyle advice and screening for cardiovascular risk factors) among different sectors of the general public. Study design: Cross-sectional survey, using a previously validated questionnaire. Methods: Three survey methods were used, across 15 areas of England, to maximize diversity: face-to-face; telephone; and self-completion of paper questionnaires. Responses to closed questions regarding characteristics and promotion were quantified and differences among sub-groups explored by univariate and multivariate analysis. Results: In total, 2661 responses were available for analysis: 2047 face-to-face; 301 telephone; and 313 paper. There were strong preferences for a pharmacy near to home or doctor's surgery and for long opening hours, particularly among employed people and nonwhites. Fifty percent preferred not to use a pharmacy in a supermarket, particularly older people, the retired, those of lower education and frequent pharmacy users. Personal recommendation by health professionals or family/friends was reported as most likely to encourage uptake of pharmacy public health services, with older people and males being less likely and frequent pharmacy users more likely to perceive any promotional method as influential. Posters/leaflets were preferred over mass-media methods, with fewer than 30% perceiving the latter as potentially influential. Conclusion: Pharmacists, pharmacy companies and service commissioners should use promotional methods favoured by potential users of pharmacy public health services and be aware of differences in attitudes when trying to reach specific population sub-groups. For personal recommendation to be successful, good inter-professional working and a pro-active approach to existing customers are needed. [ABSTRACT FROM AUTHOR]

Ageism and age discrimination are terms used in best practice statements and in the literature to define negative attitudes towards older people and towards people because of their age (whether old or young). However, ‘old age’ is a nebulous concept with definitions ranging from the over 50s to the over 85s. In seeking to explore ageism and age discrimination within health care, this paper discusses the concept of ‘old’ and discusses the findings of a narrative review of the literature on these two concepts. Results show that negative attitudes have been perceived by users of health care services, but the reasons are not clear. Such attitudes are usually reported in acute health care settings, where targets and quick turnover are encouraged. Thus people, usually those with complex needs, who require longer periods of recuperation and rehabilitation following an episode of ill health, are troublesome to staff working in a system geared up for early discharges. This type of service user is usually over the age of 85. Recommendations from this paper include the need for acute frailty units, with well trained staff, where frail older people can be comprehensively assessed, receive timely and targeted care, followed by a supported discharge. [ABSTRACT FROM AUTHOR]

Abstract: This paper summarises some of the research that Ken Eason and colleagues at Loughborough University have carried out in the last few years on the introduction of Health Information Technologies (HIT) within the UK National Health Service (NHS). In particular, the paper focuses on three examples which illustrate aspects of the introduction of HIT within the NHS and the role played by the UK National Programme for Information Technology (NPfIT). The studies focus on stages of planning and preparation, implementation and use, adaptation and evolution of HIT (e.g., electronic patient records, virtual wards) within primary, secondary and community care settings. Our findings point to a number of common themes which characterise the use of these systems. These include tensions between national and local strategies for implementing HIT and poor fit between healthcare work systems and the design of HIT. The findings are discussed in the light of other large-scale, national attempts to introduce similar technologies, as well as drawing out a set of wider lessons learnt from the NPfIT programme based on Ken Eason's earlier work and other research on the implementation of large-scale HIT. [Copyright &y& Elsevier]

This paper presents the findings of a Europe-wide survey that investigates the impact of COVID-19 on Healthcare Clowning Organisations and encourages the healthcare community to reflect on the role of medical clowning within the healthcare system. Online survey. The survey was conducted in June 2020. Forty organisations from 21 countries across Europe responded through a mix of closed and open-ended answers. During the pandemic, 36 out of 39 of the surveyed organisations (with one non-response) had to postpone or cancel their artistic activities. As the crisis continued, 34 out of 40 of them managed to adapt their in-person activities, but the impact of virtual and distanced interactions with the beneficiaries was generally perceived as lower than that of in-person activities. In open responses, many Healthcare Clowning Organisations criticised the exclusion of medical clowns from healthcare institutions in times when the need for psychosocial support was particularly acute. The healthcare sector should reconsider the important role the medical clowns play within healthcare settings, and allow for more inclusive and flexible safety regulations that take into consideration the holistic well-being of vulnerable groups, especially children, the elderly, and medical staff. [ABSTRACT FROM AUTHOR]

Abstract: Internationally, there is wide cross-country heterogeneity in government responses to dual practice in the health sector. This paper provides a uniform theoretical framework to analyze and compare some of the most common regulations. We focus on three interventions: banning dual practice, offering rewarding contracts to public physicians, and limiting dual practice (including both limits to private earnings of dual providers and limits to involvement in private activities). An ancillary objective of the paper is to investigate whether regulations that are optimal for developed countries are adequate for developing countries as well. Our results offer theoretical support for the desirability of different regulations in different economic environments. [Copyright &y& Elsevier]

Highlights • Relational event models reveal significant time-specific variation in network effects. • Aggregate estimates mask fine-grained time-specific variations in social mechanisms. • Differences are revealed between degree-based and volume-based effects. • Social mechanisms affect the dynamics of interorganizational relations differently at different points in time. • The effect of past events on future events decays rapidly. Abstract The generative mechanisms controlling change in interorganizational relations are typically assumed to be time-independent, i.e., operate homogeneously and synchronously over time. In this paper we consider some of the implications of violating this assumption. We adopt and extend statistical models for relational events to reveal time-specific variations in mechanisms underlying interorganizational relations observed within a small community of health care organizations. We find that aggregate estimates of parameters associated with mechanisms of theoretical interest mask fine-grained temporal variation in relational events sequences. We discuss the implications of this result for studies of interorganizational relations – and social networks more generally. [ABSTRACT FROM AUTHOR]

Abstract: This paper emphasises the importance of recognising the global South as a key site for understanding the patterning of geographies of health voluntarism. Feeding into a broader critique of neoliberal health and development policies, the paper explores what a case study of health promoters in a popular settlement in Lima, Peru, can add to our understanding of practices of health voluntarism rooted in distinct places, emphasising the uneven and gendered nature of such voluntary activity. In particular, the paper considers the ways in which urban community spaces are negotiated, inhabited and shaped by volunteer women health workers, arguing that an exploration of these everyday practices provides a more nuanced picture of the role of voluntarism in healthcare provisioning under neoliberal regimes. [ABSTRACT FROM AUTHOR]

Ongoing healthcare system reform is one of the most important issues in China. There is an increasing awareness that public health education should be reformed to meet the demands of public health practice. This paper summarizes the current status of increasing public healthcare demand and public health service capacity in China, especially in less-developed provinces, and introduces the current public health educational system and public health administration structure. The paper also provides evidence for a considerable gap between public health education and practice, and suggests possible measures to bridge the gap. [ABSTRACT FROM AUTHOR]

This paper will argue that the UK has seen several phases of public health improvement since the Industrial Revolution, and that each of these can be linked to major shifts in thinking about the nature of society and health itself. The authors are not, however, attempting to delineate firm sequences of events (or imply causality) as this would require a level of analysis of the relationship between economy, society and culture which is beyond the scope of this paper. Rather, it is suggested that each phase of health improvement can be thought of in metaphorical terms as a 'wave'. The first wave is associated with great public works and other developments arising from social responses to the profound disruptions which followed the Industrial Revolution. The second wave saw the emergence of medicine as science. The third wave involved the redesign of our social institutions during the 20th Century and gave birth to the welfare state. The fourth wave has been dominated by efforts to combat disease risk factors and the emergence of systems thinking. Although a trough of public health activity continues from each wave, none exerts the same impact as when it first emerged. This paper will discuss the complex challenges of obesity, inequality and loss of wellbeing, together with the broader problems of exponential growth in population, money creation and energy usage. [ABSTRACT FROM AUTHOR]

Introduction: This paper provides the first detailed analysis of the NIH prevention research portfolio for primary and secondary prevention research in humans and related methods research.Methods: The Office of Disease Prevention developed a taxonomy of 128 topics and applied it to 11,082 projects representing 91.7% of all new projects and 84.1% of all dollars used for new projects awarded using grant and cooperative agreement activity codes that supported research in fiscal years 2012-2017. Projects were coded in 2016-2018 and analyzed in 2018.Results: Only 16.7% of projects and 22.6% of dollars were used for primary and secondary prevention research in humans or related methods research. Most of the leading risk factors for death and disability in the U.S. were selected as an outcome in <5% of the projects. Many more projects included an observational study, or an analysis of existing data, than a randomized intervention. These patterns were consistent over time.Conclusions: The appropriate level of support for primary and secondary prevention research in humans from NIH will differ by field and stage of research. The estimates reported here may be overestimates, as credit was given for a project even if only a portion of that project addressed prevention research. Given that 74% of the variability in county-level life expectancy across the U.S. is explained by established risk factors, it seems appropriate to devote additional resources to developing and testing interventions to address those risk factors. [ABSTRACT FROM AUTHOR]

Managing people with diabetes and cancer during palliation constitutes a daunting challenge. Cancer, diabetes and treatment toxicity could be seen as a "Bermuda Triangle" for physician and health care professionals in general. Based on literature review, the present paper stresses the distinctive aspects that diabetes and cancer together involve and bring out. Considering the simultaneous care approach as the basement of our perspective, we explore the areas of palliative intervention for which the specific features of persons with diabetes and cancer emerge: pain manifestation and treatment, response to opioids, psychosocial and communication aspects, infection-related susceptibility and complications. The overall impact of suffering that these two diseases in association involve requires new awareness and a cultural attitude towards new network based approaches in order to strengthen the person-centered health care in this field. [ABSTRACT FROM AUTHOR]

Abstract: Priority-setting has become one of the biggest challenges faced by health decision-makers worldwide. Fairness is a key goal of priority-setting and Accountability for Reasonableness has emerged as a guiding framework for fair priority-setting. This paper describes the processes of setting health care priorities in Mbarali district, Tanzania, and evaluates the descriptions against Accountability for Reasonableness. Key informant interviews were conducted with district health managers, local government officials and other stakeholders using a semi-structured interview guide. Relevant documents were also gathered and group priority-setting in the district was observed. The results indicate that, while Tanzania has a decentralized public health care system, the reality of the district level priority-setting process was that it was not nearly as participatory as the official guidelines suggest it should have been. Priority-setting usually occurred in the context of budget cycles and the process was driven by historical allocation. Stakeholders’ involvement in the process was minimal. Decisions (but not the reasoning behind them) were publicized through circulars and notice boards, but there were no formal mechanisms in place to ensure that this information reached the public. There were neither formal mechanisms for challenging decisions nor an adequate enforcement mechanism to ensure that decisions were made in a fair and equitable manner. Therefore, priority-setting in Mbarali district did not satisfy all four conditions of Accountability for Reasonableness; namely relevance, publicity, appeals and revision, and enforcement. This paper aims to make two important contributions to this problematic situation. First, it provides empirical analysis of priority-setting at the district level in the contexts of low-income countries. Second, it provides guidance to decision-makers on how to improve fairness, legitimacy, and sustainability of the priority-setting process. [Copyright &y& Elsevier]

Abstract: This paper provides formal specification of interactions in typical public health surveillance systems involving healthcare agencies at local, state and federal levels. Although few standards exist for exchange of healthcare information, there is a general lack of formal models of the protocols involved in the interactions between the agencies. The quality of medical care provided is an end result of a well designed choreography of diverse services provided by different healthcare entities. One of the major challenges in this field appears to be explicit formal specification of such interactions. Such formal specification work is the first step leading to both design and verification of important properties of public healthcare systems. -calculus is a formal modeling technique for precise specification of semantics in interacting concurrent systems where mobility is involved. Two different configurations of public health surveillance systems are modelled using -calculus in this paper. [Copyright &y& Elsevier]

This paper analyzes the redistributive effect and progressivity associated with the current health care financing schemes in the Occupied Palestinian Territory, using data from the first Palestinian Household Health Expenditure Survey conducted in 2004. The paper goes beyond the commonly used “aggregate summary index approach” to apply a more detailed “disaggregate approach”. Such an approach is borrowed from the general economic literature on taxation, and examines redistributive and vertical effects over specific parts of the income distribution, using the dominance criterion. In addition, the paper employs a bootstrap method to test for the statistical significance of the inequality measures. While both the aggregate and disaggregate approaches confirm the pro-rich and regressive character of out-of-pocket payments, the aggregate approach does not ascertain the potential progressive feature of any of the available insurance schemes. The disaggregate approach, however, significantly reveals a progressive aspect, for over half of the population, of the government health insurance scheme, and demonstrates that the regressivity of the out-of-pocket payments is most pronounced among the worst-off classes of the population. Recommendations are advanced to improve the performance of the government insurance schemes to enhance its capacity in limiting inequalities in health care financing in the Occupied Palestinian Territory. [Copyright &y& Elsevier]

Abstract: Quality of care research has reached some agreement on concepts like structure, process and outcome, and non-clinical versus clinical processes of care. These concepts are commonly explored through surveys measuring patient experiences, yet few surveys have focused on patient, or “user”, priorities across different quality dimensions. Population surveys on priorities can contribute to, although not replace participation in, policy decision making. Using 105,806 survey interview records from the World Health Organization''s (WHO''s) general population surveys in 41 countries, this paper describes the relative importance of eight domains in the non-clinical quality of care concept WHO calls “health systems responsiveness”. Responsiveness domains are divided into interpersonal domains (dignity, autonomy, communication and confidentiality) and structural domains (quality of basic amenities, choice, access to social support networks and prompt attention). This paper explores variations in domain importance by country-level variables (country of residence, human development, health system expenditure, and “geographic zones”) and by subpopulations defined by sex, age, education, health status, and utilization. Most respondents selected prompt attention as the most important domain. Dignity was selected second, followed by communication. Access to social support networks was identified as the least important domain. In general, convergence in rankings was stronger across subpopulations within countries than across countries. Yet even across diverse countries, there was more convergence than divergence in views. These results provide a ranking of quality of care criteria for consideration during health reform processes further to the usual emphasis on clinical quality and supply-side efficiency. [Copyright &y& Elsevier]

Abstract: It has long been recognised that respondent characteristics can impact on the values they give to health states. This paper reports on the findings from applying a non-parametric approach to estimate the covariates in a model of SF-6D health state values using Bayesian methods. The data set is the UK SF-6D valuation study, where a sample of 249 states defined by the SF-6D (a derivate of the SF-36) was valued by a sample of the UK general population using standard gamble. Advantages of the nonparametric model are that it can be used to predict scores in populations with different distributions of characteristics and that it allows for an impact to vary by health state (whilst ensuring that full health passes through unity). The results suggest an important age effect, with sex, class, education, employment and physical functioning probably having some effect, but the remaining covariates having no discernable effect. Adjusting for covariates in the UK sample made little difference to mean health state values. The paper discusses the implications of these results for policy. [Copyright &y& Elsevier]

Abstract: Gait dysfunction is a common functional complaint of clients who seek medical care. Gait dysfunction can be caused by musculoskeletal disorders such as osteoarthritis or fractures, or it can be caused by neuromuscular disorders such as multiple sclerosis or cerebrovascular accident. Decisions made by health care providers working with these clients could be enhanced by the availability of valid and reliable gait measurement. Valid and reliable gait measurement is possible with laboratory-based motion analysis systems, but these are not universally available. Several portable systems collect footfall data and provide a relatively inexpensive alternative to sophisticated motion analysis systems. However, data collected by these portable systems cannot be used with confidence because of the lack of verification of the validity and reliability of the data they collect about movement. This paper describes a novel method of examining test–retest reliability and concurrent validity that produces a signal with minimal variation. To produce repetitive distance and timing events, a cylindrical weight was rolled across the field of both the laboratory motion analysis system and the system to be evaluated. Measures of the weight''s movement were taken simultaneously with both systems. A reference point was chosen to allow for comparison between the systems. The spatial measure that was compared between systems was the horizontal distance between successive repetitions of the reference point''s vertical position. The temporal measure that was compared between systems was the time between successive repetitions of the reference point''s vertical position. The method described in this paper provides a minimally variable repetitive signal that can be used to investigate concurrent validity of gait analysis systems. [Copyright &y& Elsevier]

Objective: Resident research teams were established at this community hospital in the 1997 academic year. Research productivity, including publications and presentations in the years before establishing research teams and the 8 years subsequent to establishment of research teams with faculty mentors, was reviewed. Methods: Each team is supported by a research specialist who provides assistance with project design, data evaluation, statistical analysis, manuscript editing, and preparation of research presentations. Every resident is assigned to a research team that meets monthly. The teams consist of a 4th- or 5th-year resident, 2nd- or 3rd-year resident, surgical intern, research team mentor, and research specialist. The resident is required to be an active contributing co-investigator on 1 team project per year, contributing to the development and performance of the study, participating in writing the manuscript, and must be able to defend the study. By the end of the third year, the resident is required to complete 1 individual project that is submitted to the postgraduate competition for residents. In addition, a completed manuscript must be ready to submit to a peer-reviewed journal. Promotion can be denied if the appropriate time has not been devoted to research. Minimum completion requirements include a case report and a presentation at a national or regional meeting. The research registry was reviewed for all presentations and publications given by the surgical residents during the 8 years before the teams were established and the 8 years after the teams were formed. Results: In the 8 years before the establishment of research teams, 60 papers were published. After the establishment of research teams, 77 papers were published. During the 8 years before research teams were being established, 69 presentations were given. During the subsequent 8 years with the use of mentoring and research teams, 92 presentations were given. The research teams resulted in a 33% increase in presentations and a 13% increase in publications. Conclusions: Establishment of research teams and mentoring can help stimulate research interest and activity. Continuity on research teams throughout the 5-year residency is also crucial for the progression and development, duration, and completion of projects. Continuity of the mentor and research specialists also helps facilitate productivity and completion of the task. This method has been highly successful in improving the research presentations and publications in a community-based hospital residency. [Copyright &y& Elsevier]

Abstract: Background: Quality assurance has acquired increasing prominence in contemporary healthcare systems and there has been an ‘explosion’ of audit activity. Some authors have begun to investigate the impact of audit activity on organisational and professional cultures. This paper considers data from a wider study of the management of the ‘problem’ nurse. Nurses and managers had contrasting perceptions of the value of different methods of assessing ward standards and their views are presented here. Design and setting: The study involved organisational case studies in three healthcare Trusts in the north of England. The fieldwork for this study was funded by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting under their research scholarship programme. Methods: Multiple methods were employed including observation, interviewing and documentary analysis. A total of 144 informal interviews were carried out with ward nurses and their managers. Findings: The study demonstrated different viewpoints regarding the surveillance of nursing standards at top management, middle management and ward levels. The paper considers the discrepancies between these different viewpoints. Conclusion: None of the participants placed a high value on audit as a method of assessing ward standards. Complaints data and informal methods were more highly valued by managers. Ward nurses stressed the importance of presence and vigilance in assuring high standards of nursing care. [Copyright &y& Elsevier]

A brief glance through the national papers and medical press shows the depth of concern with the cost of delivering high quality, free at the point of access healthcare to the population. However, at a time of increasingly greater demands being placed on public health systems across the globe, the question of how we can make health and healthcare both accessible to everyone and sustainable in the tong term is being posed. In this paper we provide an insight into how England is responding to these challenges. [ABSTRACT FROM AUTHOR]

Abstract: This paper considers how internationally supported medical research is understood and interpreted by its actual and potential study subjects, exposing the limits to bioethical discourses amidst economic inequalities and contrasting socio-cultural worlds. It focuses on the Medical Research Council (MRC) Laboratories in The Gambia and particularly their Pneumococcal Vaccine Trial (PVT) that was conducted jointly with the Gambian government during 2001–2004. In many respects this was an exemplar of international best practice in trial communication and informed consent procedures. Yet ethnographic and survey research finds that Gambian parents’ perspectives on participation are shaped not by trial specificities, but by broader, historically shaped views and experiences of the MRC as an institution. There is a pervasive view that the MRC offers good, free medication to participants, but that it also ‘steals blood’. Widespread concerns with blood-stealing emerge from local frames of understanding in which blood is treated as a tradeable good, in which blood accumulation and depletion in bodily processes relates to its exchange in hospital and medical research practices, and in which transactions can be more or less (un)reasonable. Yet such thinking, rooted in an ‘economy of blood’, has been overlooked by medical research staff and indeed by historians and anthropologists of Africa whose analyses of blood-stealing have been overly transfixed on rumour and the occult. This paper argues that such cultural framings, which guide local critical commentary on trans-national research orders, require serious attention and need to inform open dialogues between scientists and the public if medical research in resource-poor settings is to continue to be sustainable and politically legitimate. [Copyright &y& Elsevier]

Abstract: The paper uses interviews and observational data gathered among a group of UK scientists and civil servants responsible for managing a study examining the possible transmission to humans of Borna disease virus (BDV), a disease primarily of farm animals. From a science and technology studies perspective, the paper examines the social processes whereby this scientific problem (possible human transmission) was constituted as a worthy topic of scientific investigation, came to receive funding, and was subjected to independent review. It appears that BDV research displays only some of the characteristics of ‘post-normal science’ with little participation by extended peer communities. Civil servants and scientists reported social interests that were complex and both fractionated and cross-occupational. An important motivation for engaging in the research was the need to maintain investment in pre-existing scientific resources (assay development, virus stocks and an existing epidemiological cohort). In respect of translation theory, influence was a two-way street, with civil servants eager to enrol scientists and represent the interests of science, and with scientists presenting themselves as defenders of the public good. Despite the dynamic character of scientific debate, the ‘career’ of BDV investigation appears to have ended in disengagement, rather than closure. [Copyright &y& Elsevier]

Abstract: Economic considerations are often cited as important determinants of health-seeking behavior. This paper describes a situation in peri-urban Tanzania where user fees do not constitute the primary reason why mothers delay seeking prompt treatment at a public health facility for their young, febrile children. Mothers commonly believe that they are dealing with an ordinary fever and not malaria or any other serious illness complicated by fever. Hence, they engage in extended home-based treatment. Drawing upon an ethnographic study, this paper illustrates how cultural knowledge about disease symptomatology, cultural meanings associated with febrile illness, gender relations, and patterns of communication between health care providers and mothers significantly influence outcomes for childhood febrile illnesses. It is argued that an overemphasis on the correlation between user fees and treatment delays with regard to childhood illnesses tends to divert attention from other significant cultural factors and existing structural constraints that influence the dynamics of health care seeking and health outcomes. At a time when calls to implement artemisinine-based combination therapy as one of the front-line strategies in Tanzania are increasingly frequent, there is a need to pay closer attention to the contextual factors and socio-cultural dynamics that influence patterns of treatment-seeking for childhood malaria. [Copyright &y& Elsevier]

Abstract: Trust is central to good relationships between patients and health-care providers because, firstly, patient uncertainty about health conditions requires them to have confidence in a doctor''s motives and decisions, and secondly, trust facilitates communication and patient focus which encourages people to utilise health services. This paper focuses on patient trust because of its effect on treatment-seeking behaviour and the treatment costs incurred by poor households. Drawing from other studies the paper distinguishes between trust based on the perceived technical competence of the provider, and on inter-personal dimensions of quality of care. Trust is also analysed at two inter-related levels: personal trust that is built through face-to-face encounters with providers; and more abstract institution-level trust. The paper applies these notions of trust to examine treatment-seeking behaviour in two poor urban communities in Colombo, Sri Lanka. Household survey data and qualitative data show that people from a range of income groups preferred to use public providers for more serious illnesses because public services were free and they trusted the technical competence of public providers at both a personal and institutional level. The data also show, however, that inter-personal quality of care was lacking in the public sector and that residents from the two communities, including a considerable minority of the poorest, preferred to use private providers for moderate acute illnesses. People were willing to pay for private services because it saved time, doctors listened and they could build better relationships with private doctors. Despite the strengths of Sri Lanka''s public health sector, poor relationships act as an access barrier and push a range of income groups to the private sector. The threat to access and affordability posed by these poor relationships should be the focus of current reform debates. [Copyright &y& Elsevier]

Summary: Objective:: Medical terminological systems (TSs) play an increasingly important role in health care by supporting recording, retrieval and analysis of patient information. As the size and complexity of TSs are growing, the need arises for means to audit them, i.e. verify and maintain (logical) consistency and (semantic) correctness of their contents. This is not only important for the management of TSs but also for providing their users with confidence about the reliability of their contents. Formal methods have the potential to play an important role in the audit of TSs, although there are few empirical studies to assess the benefits of using these methods. Methods and material:: In this paper we propose a method based on description logics (DLs) for the audit of TSs. This method is based on the migration of the medical TS from a frame-based representation to a DL-based one. Our method is characterized by a process in which initially stringent assumptions are made about concept definitions. The assumptions allow the detection of concepts and relations that might comprise a source of logical inconsistency. If the assumptions hold then definitions are to be altered to eliminate the inconsistency, otherwise the assumptions are revised. Results:: In order to demonstrate the utility of the approach in a real-world case study we audit a TS in the intensive care domain and discuss decisions pertaining to building DL-based representations. This case study demonstrates that certain types of inconsistencies can indeed be detected by applying the method to a medical terminological system. Conclusion:: The added value of the method described in this paper is that it provides a means to evaluate the compliance to a number of common modeling principles in a formal manner. The proposed method reveals potential modeling inconsistencies, helping to audit and (if possible) improve the medical TS. In this way, it contributes to providing confidence in the contents of the terminological system. [Copyright &y& Elsevier]

The current structure of the health care system in Chad, which is characterized by a weak public health system and a nascent and largely unaffordable private sector, raises questions about how low-income households manage illnesses. These questions are also compelling because of claims about the potential of oil-related investments to restructure the current landscape of care over the next 25-30 years. This paper focuses on household strategies for treating episodes of malaria reported in an on-going, longitudinal study of household health and access to care in Chad. Treatment of malaria outside the health care system is widespread in endemic areas, therefore it is not surprising that low-income households in this study rely heavily on unregulated drug markets for care. However, the paper shows how self- medication and the use of these drug markets are shaped by the current organization and delivery of care, and are not simply the outcome of a lack of information about the dangers associated with such practices. The paper also shows the consequences of this particular constellation of services for health in low-income households. We see, for example, the emergence of regimes for managing illness that consist of keeping debilitating symptoms at bay through the use of intermittent, sub-optimal therapies that provide a temporary reprieve but not a 'cure.' We also see that households ignore health problems-absorbing them into the experience of everyday life-that might elsewhere demand attention. When illnesses appear as crises it is often because cash-strapped households are unable to sustain this type of management regime, and easily treatable problems spiral out of control. Whether and how the experiences of the low- income households described in this paper will be impacted by the public investment of oil revenues in the health sector is the question our longitudinal study is designed to address. [ABSTRACT FROM AUTHOR]

The desirability of using the private sector to deliver public services is widely debated internationally. Understanding the nature of contracts that initiate and govern such public-private partnerships, and the extent to which they can define the performance of private providers, is key in addressing the questions that underlie this debate. Such understanding has to be gained through better knowledge of all the influences upon contractual relation- ships. Environmental and institutional factors have been highlighted as one set of influences in need of more attention. This paper presents case studies of three contracts for primary care services in Southern Africa. It reports aspects of the institutional and environmental context in which they operate, and reflects on the nature of publicly financed primary care as a service to be contracted out. An urban-based private sector contract for a sub-set of primary care services was found to operate very differently from rural-based public sector contracts, which attempted to provide broader coverage. The latter contracts were more loosely defined and operated in a more relational manner. Important environmental influences on incomplete contractual relationships explored here are the nature of the market, scope of services, management capacity and involvement of a public purchaser. The paper illustrates some of the practical challenges for low- and middle-income countries in pursuing a policy of contracting with private providers for public primary care services, and particularly highlights the difficulties of deciding how to divide up responsibility between the public and private sectors and yet maintain a comprehensive service delivery system. [ABSTRACT FROM AUTHOR]

The paper explores the attitudes of medical physicians towards adverse incident reporting in health care, with particular focus on the inhibiting factors or barriers to participation. It is recognised that there are major barriers to medical reporting, such as the 'culture of blame'. There are, however, few detailed qualitative accounts of medical culture as it relates to incident reporting. Drawing on a 2-year qualitative case study in the UK, this paper presents data gathered from 28 semi-structured interviews with specialist physicians. The findings suggest that blame certainly inhibits medical reporting, but other cultural issues were also significant. It was commonly accepted by doctors that errors are an `inevitable' and potentially unmanageable feature of medical work and incident reporting was therefore `pointless'. It was also found that reporting was discouraged by an anti-bureaucratic sentiment and rejection of excessive administrative duties. Doctors were also apprehensive about the increased potential for managers and non-physicians to engage in the regulation of medical quality through the use of incident data. The paper argues that the promotion of incident reporting must engage with more than the ubiquitous 'culture of blame' and instead address the 'culture of medicine', especially as it relates to the collegial and professional control of quality. [ABSTRACT FROM AUTHOR]

In November 2002 the World Bank published a report on the Argentine health sector. The report accurately portrays the complexity and severity of the problems facing the health care system. It stresses that these problems are not purely a product of the country's economic collapse, noting that the system has suffered from long-standing structural problems and inefficiencies. Curiously, the report makes no mention of the leading role played by the World Bank in health reform efforts during the 1990s. This paper demonstrates that these reforms did much to worsen pre-existing weaknesses of the sector. The paper criticises the content of the reform agenda and the manner in which it was produced, arguing that these were reforms in which considerations of public health were less significant than conformity to the wider model of neo-liberal social and economic development prevailing at the time. It also highlights problems of implementing the reform agenda, which reduced the coherency of the reforms. The paper goes on to examine the impact of the crisis, noting links with the preceding reforms. It identifies a number of insights and lessons of potential value to other countries which are pursuing similar policies. [ABSTRACT FROM AUTHOR]

In 2002, the third Public Health Status and Forecasts report was published, containing up-to-date information about Dutch public health and health care. A striking finding was that although life expectancy (LE) in The Netherlands increased between 1980 and 2000, the LE of men is rising less rapidly than the European Union (EU) average. The LE of Dutch women is stagnating and has now fallen below the EU average. These and many other unfavourable trends in the health status of the Dutch population were found to be largely due to unhealthy behaviour. One of the policy recommendations therefore was to strengthen the investments in prevention in order to reverse the stagnation in health status. In response to the findings, the Ministry of Health, Welfare and Sport published the National Prevention Paper. This Paper states that the Ministry, within the existing prevention policy, will pay more attention to healthy behaviour, stressing the responsibility of citizens as well as the societal responsibility of other parties, such as business communities, schools, health insurers and care suppliers. The prevention of specific diseases (diabetes, psychosocial problems, heart diseases, cancer, musculosceletal disorders, asthma and chronic obstructive pulmonary disease) has been given priority status. In this article, we present the major findings regarding the health status of the Dutch population and discuss the implications for prevention policy. [ABSTRACT FROM AUTHOR]

The transition resulting from the break-up of the Soviet Union significantly affected the health care systems and population health status in the newly independent States. The available body of evidence suggests that contraction of public resources resulting from economic slowdown has led to the proliferation of out-of-pocket payments and private spending becoming a major source of finance to health service provision to the population. Emerging financial access barriers impede adequate utilization of health care services. Most transition countries embarked on reforming health systems and health care financing in order to tackle this problem. However, little evidence is available about the impact of these reforms on improved access and health outcomes.This paper aims to contribute to the assessment of the impact of health sector reforms in Georgia. It mainly focuses on changes in the patterns of health services utilization in rural areas of the country as a function of implemented changes in health care financing on a primary health care (PHC) level. Our findings are based on a household survey which was carried out during summer 2002. Conclusions derived from the findings could be of interest to policy makers in transitional countries.The paper argues that health financing reforms on the PHC level initiated by the Government of Georgia, aimed at decreasing financial access barriers for the population in the countryside, have rendered initial positive results and improved access to essential PHC services. However, to sustain and enhance this attainments the government should ensure equity, improve the targeting mechanisms for the poor and mobilize additional public and private funds for financing primary care in the country. [Copyright &y& Elsevier]

This paper presents findings from a study of the context and processes of provider mergers in the NHS in England. Mergers are an example of organisational restructuring, a key lever for change in the UK health care sector and elsewhere, although it is only one strategy for organisational change. The framework for the study is key themes from the organisational change literature: the complexity of the effects of change; the importance of context; and the role of organisational culture. The drivers for health care mergers and the evidence for these are analysed.Using documentary analysis and in-depth qualitative interviews with internal and external stakeholders, the first part of the paper reports on stated and unstated drivers in nine mergers. This provides the context for four in-depth case studies of the process of merger in the second and third years post-merger.Our study shows that the contexts of mergers, including drivers of change, are important. Merger is a process without clear boundaries, and this study shows problems persisting into the third year post-merger. Loss of management control and focus led to delays in service developments. Difficulties in the merger process included perceived differences in organisational culture and perceptions of ‘takeover’ which limited sharing of ‘good practice’ across newly merged organisations. Merger policy was based on simplistic assumptions about processes of organisational change that do not take into account the dynamic relationship between the organisation and its context and between the organisation and individuals within it. Understanding the process of merger better should lead to a more cautious approach to the likely gains, provide understanding of the problems that are likely in the period of change, and anticipate and avoid harmful consequences. [Copyright &y& Elsevier]

This paper combines multiple cross-sections of data drawn from the National Population Health Survey and Canadian Community Health Survey to confirm the existence of the ‘healthy immigrant effect’, specifically that immigrants are in relatively better health on arrival in Canada compared to native-born Canadians, and that immigrant health converges with years in Canada to native-born levels. The paper finds robust evidence that the healthy immigrant effect is present for the incidence of chronic conditions for both men and women, and results in relatively slow convergence to native-born levels. There is only weak evidence in terms of self-assessed health status. The inclusion of controls for region of origin and year of arrival does not account for the observed effects, although region of origin is an important determinants of immigrant health. The paper then considers some alternative explanations for the observed differences, and support is found for the idea that the healthy immigrant effect reflects convergence in physical health rather than convergence in screening and detection of existing health problems. [Copyright &y& Elsevier]

This paper explores the potential use of grid technology in healthcare, from the perspective of a European health authority in a Regional Healthcare Network (RHCN) seeking to model the effects of a proposed hospital closure programme. The paper reviews the strategic implications of using a ‘grid-based’ application to enable the collation and analyses of public health information (PHI) to support healthcare planning and capital development. The paper also considers relevant issues in relation to the analysis of data extracted from Electronic Health Records (EHR) systems and Patient Management Systems (PMS), across many hospitals and Primary Healthcare Centres (PHCC) in a region, via a grid-based application. The potential for the use of the grid to support PHI in compute and data intensive tasks is discussed, together with a proposed way forward for the development of a grid-based RHCN PHI service.The paper is based on an earlier paper presented by David Piggott at the First European HealthGrid Conference held in Lyons, France on 17th January 2003, together with subsequent research undertaken by Trinity College Dublin into the use of the grid to support healthcare impact assessment and planning applications. [Copyright &y& Elsevier]

This paper considers how the information provided by economic evaluation for decision-makers can fail to optimise use of health resources and how assessment of the relative cost-effectiveness of health care interventions can be misleading unless heterogeneity within populations is taken into account. The cost-effectiveness of an intervention is not a point estimate but an average chosen from within a distribution of different results. The normal interpretation of the distribution around that point is often mistakenly assumed to be the ‘white noise’ of measurement error. In reality this variance is a combination of measurement error and true heterogeneity of results.There remains an overemphasis on pursuing certainty which stems from the fact that the methods involved were originally devised to measure dichotomous outcomes not continuous ones such as cost-effectiveness ratios. It is argued in this paper that more consideration be given to the heterogeneous nature of costs and effects across populations in analysis and policy making. [Copyright &y& Elsevier]

Difficult health care encounters often do not translate into expressions of dissatisfaction with care. This paper focuses on the ‘non-expression’ of dissatisfaction with care in the accounts of 12 people in Canada who provided care to a relative or friend who died of breast cancer.The analysis foregrounded in this paper began from the observation that as difficult health care experiences were elaborated, speakers located health professionals’ actions in relation to various situational factors, including the fact of a (cancer) death and conditions of constraint in the health system. Set alongside these two realities, expressions of dissatisfaction tended to be disarmed. Results of this study suggest that the cost of articulating dissatisfaction with care is high where the cared-for person has died, and the perceived value of focusing on difficult experiences is low. Further, respondents in this study took the specificity of the situation and the setting into account in formulating beliefs about the care outcomes for which health professionals could be held responsible. When conditions in the health system and the disease process of advanced cancer were positioned in talk as ‘ultimate limits’ on health professionals’ actions, perceived lapses in care were excused. [Copyright &y& Elsevier]

The paper contributes to the use of social choice and welfare theory in health economics by developing and applying the integration of claims framework to health-care rationing. Related to Sen's critique of neo-classical welfare economics, the integration of claims framework recognises three primitive sources of claim: consequences, deontology and procedures. A taxonomy is presented with the aid of which it is shown that social welfare functions reflecting these claims individually or together, can be specified. Some of the resulting social choice rules can be regarded as generalisations of health-maximisation and all have normative justifications, though the justifications may not be universally acceptable. The paper shows how non-linear programming can be used to operationalise such choice rules and illustrates their differential impacts on the optimal provision of health-care. Following discussion of relations to the capabilities framework and the context in which rationing occurs, the paper concludes that the integration of claims provides a viable framework for modelling health-care rationing that is technically rigorous, general and tractable, as well as being consistent with relevant moral considerations and citizen preferences. [ABSTRACT FROM AUTHOR]

Rwanda is the country with the highest enrolment in health insurance in Sub-Saharan Africa. Pivotal in setting Rwanda on the path to universal health coverage (UHC) is the community-based health insurance (CBHI), which covers more than three-quarters of the population. The paper seeks to explain how Rwanda, one of the poorest countries in the world, managed to achieve such performance by understanding the political drivers behind the CBHI design and implementation. Using an analytical framework relying on political settlement and ideas, it engages in process-tracing of the critical policy choices of the CBHI development. The study finds that the commitment to expanding health insurance coverage was made possible by a dominant political settlement. CBHI is part of the broader efforts of the regime to foster its legitimacy based on rapid socio-economic development. Yet, CBHI was chosen over other potential solutions to expand access to healthcare because it was also the option the most compatible with the ruling coalition core ideology. The study shows that pursuing UHC is an eminently political process but explanations solely based on objective “interests” of rulers cannot fully account for the emergence and shape of social protection programme. Ideology matters as well. Programme design compatible with the political economy of a country but incompatible with ideas of the ruling coalition is likely to run into political obstructions. The study also questions the relevance for poor countries to reach UHC relying on pure CBHI models based on voluntary enrolment and community management. [ABSTRACT FROM AUTHOR]

Introduction: Over the past 2 decades, drug-related deaths have grown to be a major U.S. public health problem. County-level differences in drug-related mortality rates are large. The relative contributions of social determinants of health to this variation, including the economic, social, and healthcare environments, are unknown.Methods: Using data from the U.S. Centers for Disease Control and Prevention Multiple-Cause of Death Files (2006-2015, analyzed in 2017); U.S. Census Bureau; U.S. Department of Agriculture Economic Research Service; Agency for Healthcare Research and Quality; and Northeast Regional Center for Rural Development, this paper modeled associations between county-level drug-related mortality rates and economic, social, and healthcare environments. Spatial autoregressive models controlled for state fixed effects and county demographic characteristics.Results: The average county-level age-adjusted drug-related mortality rate was 16.6 deaths per 100,000 population (2006-2015), but there were substantial geographic disparities in rates. Controlling for county demographic characteristics, average mortality rates were significantly higher in counties with greater economic and family distress and in counties economically dependent on mining. Average mortality rates were significantly lower in counties with a larger presence of religious establishments, a greater percentage of recent in-migrants, and counties with economies reliant on public (government) sector employment. Healthcare supply factors did not contribute to between-county disparities in mortality rates.Conclusions: Drug-related mortality rates are not randomly distributed across the U.S. Future research should consider the specific pathways through which economic, social, and healthcare environments are associated with drug-related mortality. [ABSTRACT FROM AUTHOR]

This paper delivers empirical evidence on how transfers that serve as an informal insurance mechanism are affected by a formal and country-wide health insurance scheme. Using the fifth and fourth waves of the Ghanaian Living Standard Household Survey, we investigate the extent to which the implementation of the National Health Insurance Scheme affects health-related outcomes and making or receiving informal transfers. Our findings suggest that there is a reduction of out-of-pocket expenditures for health services and a significant crowding out of informal transfers. We conclude that the provision of formal health insurance does not only relieve ill individuals from out-of-pocket expenditures, but also their network partners from making informal transfers. [ABSTRACT FROM AUTHOR]

This paper discusses the health challenges faced by countries in Latin America. These challenges have two dimensions: those related to the health needs of populations and those related to the way in which health systems are responding to these needs. The main conclusion is that in order to improve health conditions and move towards universal health coverage, Latin American countries need to design a new generation of policy innovations based on the separation of the three main functions of health systems: financing, delivery and stewardship. [ABSTRACT FROM AUTHOR]

Background: The incidence of liquefied petroleum gas (LPG)-related burns has increased over recent years, and it has become a serious public health issue in developing countries such as India and Turkey. This paper aims to investigate the epidemiological characteristics of LPG-related burns to provide assistance and suggestions for planning prevention strategies.Methods: A 5-year retrospective study was conducted in patients with LPG-related burns admitted to the Department of Burns & Wound Care Center, Second Affiliated Hospital of Zhejiang University, College of Medicine, between 1st January 2011 and 31st December 2015. Information obtained for each patient included age, gender, education status, occupation, medical insurance, average hospital cost, length of hospital stay, monthly distribution of incidence, place of burns, mechanism of burns, extent of burns, site of burns, accompanying injuries, and treatment outcomes.Results: For the first 4 years (2011-2014), the yearly incidence of LPG-related burns was at approximately 10% of all burns; however, in the fifth year (2015) alone, there was a surge to 26.94%. A total of 1337 burn patients were admitted during this period. Of these, 195 patients were admitted because of 169 LPG-related accidents; there were 11 accidents involving more than one victim. LPG-related burns occurred most frequently in patients aged 21-60 years (73.85%). The majority of injuries occurred from May to August (56.41%), and the most common place was home (83.08%, 162 patients). Gas leak (81.03%) was the main cause of LPG-related burns, followed by inappropriate operation (7.69%) and cooking negligence (2.05%). The mean burn area was 31.32±25.40% of TBSA. The most common sites of burns were the upper extremities (37.47%), followed by the head/face and neck (24.80%) and lower extremities (19.95%). The most common accompanying injuries included inhalation injury (23.59%), shock (8.71%), and external injury (7.18%). The average hospital stay was 22.90±19.47days (range 2-84 days). Only 48 patients (24.62%) had medical insurance, while 124 patients (63.59%) had no medical insurance. The average hospital cost of the no medical insurance group was significantly higher (p<0.0001) than that of the medical insurance group. In addition, 72.73% of patients who left against medical advice (LAMA) were uninsured. The number of patients who recovered at our hospital was 165 (84.62%), while 22 patients (11.28%) LAMA. The overall mortality rate was 4.10% (8 patients).Conclusion: Our study shows that the exponential increase in LPG-related burns is alarming. This calls for rigorous precautions. Because gas leak was the main cause of LPG-related burns, any part of LPG stove system that shows signs of weathering should be replaced regularly. In addition, we also found that most of the LAMA patients were uninsured. Thus, comprehensive medical insurance should be involved early in the recovery process to assure a safe and adequate discharge. [ABSTRACT FROM AUTHOR]