General practice encounters for psychological problems in rural, remote and metropolitan areas in Australia

OBJECTIVE

Previous Australian research suggests there is very little difference in the prevalence of mental health disorders across rural, remote and metropolitan areas. However, mental health specialists are particularly scarce in rural and remote areas and some researchers have argued that non-metropolitan residents rely heavily on general practitioners (GPs) for mental health care. This article investigated rates of GP services for psychological problems across rural, remote and metropolitan areas.

METHOD

The Bettering the Evaluation and Care of Health (BEACH) program, Medicare and Pharmaceutical Benefits Scheme data were used in this report. Data included all psychological, depression and anxiety problems reported as managed by GPs and prescriptions for mental health medications (written and filled). Problem and medication rates are given per 100 patient encounters and per 1000 population.

RESULTS

Only a few regional differences were evident in the rate of psychological problems and prescriptions for mental health medications per 100 GP-patient encounters. However, rural and remote residents visited GPs less frequently than their metropolitan counterparts. Lower rates of GP encounters for psychological problems were evident for residents of most non-metropolitan areas (per 1000 population). Additionally, GPs prescribed mental health medications at half the rate for residents of remote areas than capital cities.

CONCLUSIONS

General practitioners provide fewer mental health services per capita in non-metropolitan areas. This difference could represent completely untreated psychological problems or fewer follow-up consultations. While non-metropolitan residents have limited access to specialists, rates of GP encounters for psychological problems are also very low.

Serological studies of monoclonal RH antibodies with RH1 (D), RH2 (C), RH3 (E) and RH5 (e) variant RBCs

One hundred and forty five Mabs against RH antigens were tested. In this paper, we chose to detail reactivity of MoAbs directed against variant RBCs of the CNRGS collection for which we studied the molecular background. Because we developed procedures to identify variants of the RhD, RhC, RhE and Rhe antigens, we were especially interested in finding new monoclonal antibodies that could help us to characterize more accurately these variants. Therefore, we drew parallels between our procedures and results obtained with the 2001 workshop antibodies.

Living circumstances of children and adults with mental retardation or developmental disabilities in the United States, Canada, England and Wales, and Australia

The purpose of this article was to collate evidence to describe where people with mental retardation or developmental disabilities live in five developed countries: United States, Canada, England, Wales, and Australia. Family homes are important dwelling places for people with mental retardation. They are the home of the great majority of children with mental retardation and a considerable proportion of adults with mental retardation. The likelihood of placement outside the family home increases with adulthood and progressively as people age. Adults with mental retardation live in a wide variety of settings, with formal residential provision frequently dependent on the arrangements that the authorities responsible for providing service support have chosen to make. There has been a considerable move away from accommodating people in large segregated and geographically isolated institutions in the countries considered. However, the current range of accommodation includes much with a distinctively different character to the homes where other citizens live. Many people still live in larger groups than would be ordinarily found in typical homes and this may necessitate departure from the architectural norm. In all of the countries considered, there has been a recent trend towards small community settings, compatible with typical housing architecture. This appears furthest advanced in the U.S. but is discernible elsewhere. Availability of residential services at a national level varies between 100 and 155 places per 100,000 total population. Regional variation within countries is even greater. In no case is the national availability considered adequate to meet the demand arising from changing need or expectations. MRDD Research Reviews 7:115-121, 2001. (c) 2001 Wiley-Liss, Inc.

Barriers to exercise in African American women with physical disabilities

OBJECTIVE

To examine what factors African American women with one or more physical disabilities perceive as barriers to exercise and how they rank them.

SETTING

Department of Disability and Human Development at a major university.

STUDY DESIGN

Data were collected through telephone interview using a newly developed instrument (Barriers to Physical Exercise and Disability [B-PED]) that addressed issues related to physical activity and the subjects' disability.

SUBJECTS

Fifty subjects were asked questions about their participation and interest in structured exercise.

RESULTS

The four major barriers were cost of the exercise program (84.2%), lack of energy (65.8%), transportation (60.5%), and not knowing where to exercise (57.9%). Barriers commonly reported in nondisabled persons (eg, lack of time, boredom, too lazy) were not observed in our sample. Only 11% of the subjects reported that they were not interested in starting an exercise program. The majority of subjects (81.5%) wanted to join an exercise program but were restricted by the barriers reported.

CONCLUSION

African American women with a physical disability are interested in becoming more active but are limited in doing so because of their inability to overcome several barriers to increased physical activity participation.

Synthesis of research on the costs of institutional and community-based care

Cost studies in the long-term care field are reviewed, with emphasis on those relating to people with developmental disabilities. Studies frequently stressed the cost-effectiveness of community programs but often had significant methodological problems. Among the predominant findings in the literature were: 1) the generally lower average costs per client in community programs versus institutional programs; 2) unexplained wide cost ranges in similar community programs; and 3) significant cost shifts among federal, state, and local governments associated with deinstitutionalization initiatives. The implications of these findings for public officials and the advocacy community are discussed.

Physical activity patterns of African-American women with physical disabilities

There is a dearth of research on the exercise and activity patterns of persons with disabilities, particularly minority women with disabilities. This lack of information makes it difficult for public health officials to set policy guidelines for this segment of the population.

PURPOSE

The purpose of this study was to survey the exercise and activity patterns of African-American women with severe physical disabilities (N = 50).

METHODS

The Physical Activity and Disability Survey (PADS) was created for subjects who have a severe limitation in movement and function (e.g., limited ability to stand or walk, needs an assistive aid to ambulate, needs assistance with activities of daily living). Reliability data were obtained on the PADS for interrater, test-retest, and internal consistency on the two subscales (Exercise and Activity). The Exercise subscale had an interrater reliability of 0.83 and test/retest reliability of 0.85. The Activity subscale had an interrater reliability of 0.68 and test/retest reliability of 0.66. Cronbach's alpha for internal consistency was 0.78 for the Exercise subscale and 0.68 for the Activity subscale.

RESULTS

Results showed very low levels of exercise and general activity patterns in African-American women with physical disabilities. Only 8.2% of the sample participated in leisure-time physical activity, and only 10% engaged in aerobic exercise three or more days per week for at least 15 min. Unstructured physical activity (e.g., work-related activity, housework, gardening, shopping) was nearly absent.

CONCLUSION

Our data suggest that the extremely low levels of self-reported physical activity in African-American women with severe physical disabilities expose them to a higher risk of secondary health conditions.

Overweight prevalence in persons with Down syndrome

Prevalence of overweight among the general population has been reported to be 33% for males and 36% for females. We undertook this study to establish overweight prevalence data in a cohort with Down syndrome and to stratify the incidence of overweight by living arrangement. We measured Body Mass Index (BMI) in 283 persons with Down syndrome and found a higher prevalence of overweight in this group compared to the general population. Individuals with Down syndrome living in a family setting had a higher incidence of overweight than did those living in a group home setting. Overweight prevalence among persons with Down syndrome should be considered a major public health concern that warrants further attention from researchers, practitioners, family members, and individuals with Down syndrome.

Toward family and community mental retardation services in Massachusetts, New England, and the United States

Current trends in mental retardation services in the Commonwealth of Massachusetts were investigated using the New England region, the state of Michigan, and the United States as comparative frames of reference. Our goal was to analyze recent structural, financial, and programmatic trends in Massachusetts and the New England region to close state institutions and implement community and family support services. Massachusetts in particular illustrates the policy choices and challenges facing many American states engaged in restructuring their service delivery systems. New England is an extremely dynamic and innovative region that is providing significant national leadership in the provision of alternatives to institutional care.

Research on physical activity and disability: an emerging national priority

Despite the voluminous amount of research that has been published in the field of exercise science over the past three decades, there remains a paucity of information on the activity patterns and physiological responses to exercise in persons with disabilities. In an era when physical activity has grown to new heights in terms of its importance in promoting health and preventing disease, many questions pertaining to how it affects the lives of individuals with physical disabilities remain unanswered. The purpose of this paper is to review the prevalence of disability in the United States and to present recommendations for future research on physical activity and disability. A related objective of this paper is to encourage exercise scientists to undertake research on this increasingly significant group of American citizens.

Flow cytometric evaluation of non anti-RH1(D) monoclonal Rh antibodies

IgG non anti-RH1(D) monoclonal Rh antibodies were evaluated by flow cytometry. The values obtained with these antibodies were less strong than those obtained with anti-RH1(D) antibodies. For a significant number of antibodies, the signal was not high enough to give reliable results for the antibody specificity. Despite these drawbacks, flow cytometry was an efficient tool to appreciate the variation of reactivity by different antibodies with normal or variant cells. These variations were not always obvious by serological means.

Health characteristics and behaviors of adults with mental retardation residing in three living arrangements

Three hundred and twenty-nine subjects (aged 17-70 years) residing in an institution (N = 184), group home (N = 39), or with one or more family members (N = 106) were evaluated on body composition, blood lipids, and health behaviors. Subjects in the institutional group had lower body weights than those in the group home and natural family settings (p < .001) and also had lower BMIs and percent body fat levels compared to those in the natural family (p < .001). The institutional group also had lower total cholesterol and LDL-C levels than the group home and natural family groups (p < .001) and lower TG and ratio of total cholesterol to HDL-C than the natural family group (p < .01). Although overall use was quite limited, residents in the group home setting smoked more cigarettes, drank more alcohol and coffee, and exercised less than those in the institution and natural family (p < .001). Group home residents also exercised less. Health promotion and disease prevention initiatives for persons with mental retardation living in group homes, in supported living placements, and with their natural families should be undertaken and carefully evaluated.

Using Medicaid fee-for-service data to develop community health center policy

This article presents an analysis of fee-for-service Medicaid data for King County, Washington. This analysis was conducted using Department of Social and Health Services billing records for patients of the community health centers of Seattle-King County (14 primary care sites), the Seattle-King County Department of Public Health (9 primary care sites), and Harborview Medical Center (a large tertiary facility with a primary care outpatient clinic associated with the University of Washington) from January through June, 1992. The complete billing records of all patients who utilized any one of the 24 sites were made available. These records were used to review utilization patterns and patient costs. The implications for community health centers regarding Medicaid managed care, health care reform, and population-based management are discussed.

Costs of family care for adults with mental retardation and related developmental disabilities

"Out-of-pocket" spending by families supporting an adult family member with mental retardation or related developmental disability was characterized and estimated. Annualized nonreimbursed spending among a sample of 99 Chicago-area households was evaluated through survey and telephone interview across 10 categories of routine daily living expenses and disabilities-related services. The average annual out-of-pocket cost was $6,348. Average pre-tax income for the sample households was $37,657. Although wealthier households reported higher levels of spending, the percentage of household income represented by out-of-pocket costs increased significantly as family incomes decreased. Results were discussed in the context of families as a focus for service planning and public policy and the importance of the family to the nation's system of care.

Compensation and turnover of direct-care staff in developmental disabilities residential facilities in the United States. II: Turnover

A representative sample of more than 1,600 residential facilities nationwide was surveyed. Direct-care staff turnover was significantly higher in privately operated community facilities than in public institutions. Turnover was generally higher in private than in publicly operated community facilities. The most consistent correlate of turnover for all types of facilities was wages. Intra- and extra-organizational factors made unique contributions in predicting turnover.

Cardiovascular risk factor levels in adults with mental retardation

Cardiovascular risk factors in a population of adults with mental retardation were examined. The subjects resided in three types of settings (16+ bed facility, group home, and natural family) and were measured on the following parameters: blood lipids, obesity, and smoking. The data were compared to a nonretarded population and to the guidelines established by the National Cholesterol Education Program. Results indicated that adults with mental retardation had cardiovascular risk profiles similar to those of individuals without mental retardation in the Framingham Offspring Study and that to the extent that cardiovascular health is a concern to the general population, it must also be a concern for individuals with mental retardation.

Compensation and turnover of direct-care staff in developmental disabilities residential facilities in the United States. I: Wages and benefits

This study was based on a representative national sample of more than 1,600 residential facilities serving individuals with developmental disabilities in all 50 states and the District of Columbia. The mean starting wage for direct-care workers in publicly operated institutions in FY 1990 was approximately 31% more than the wage for similar workers in privately operated facilities. The mean starting wage in private facilities was only about 3% above the poverty level for a family of three. Wages, in real economic terms, have declined significantly during the last decade. The wage differential between public and private facilities has doubled during the past 10 years. Implications of these findings for the field and for future research were discussed.

Personal and family distress in homeless adolescents

Previous research has indicated that homeless children exhibit high rates of behavioral and emotional problems and come from families characterised by conflict and rejection. Further, some evidence exists to show that family variables may relate to adolescent distress differently for homeless males and females. In this study, 117 homeless adolescents were compared to a sample of non-homeless youths on the self reported incidence of personal and family problems. The homeless children reported the highest incidence of all behavioral and emotional problems, parental marital discord, overprotection, and the lowest levels of parental care and acceptance. Sex effects were not evident in reported levels of personal or family problems. However, substantially more variance in the adolescents level of behavioral and emotional disturbance was predictable from family measures for females than males. Overall, the results point to the importance of incorporating family distress models in the understanding and remediation of adolescent homelessness.

Prevalence of obesity in adults with mental retardation: implications for health promotion and disease prevention

The purpose of this study was to determine the incidence of obesity among 364 adults (mean age, 36.8 years) with mental retardation living in four residential settings. Skinfold measurements were used to measure adiposity. Results indicated that rates of obesity were significantly higher among females, subjects with severe mental retardation had the lowest overall rates of obesity, and the institutional group had the lowest incidence of obesity. These findings indicate a need for more investigation into the caloric intake and energy expenditure of adults with mental retardation, specifically focusing on level of retardation and living arrangement.

Community mental health and mental retardation services in the United States: a comparative study of resource allocation

OBJECTIVE

Preliminary studies suggest that during the 1980s, spending for community mental retardation services in the United States may have grown much more rapidly than spending for community mental health. The primary objective of this study was to test empirically the validity of this thesis on a national basis. An additional objective was to determine why such a distinction in community spending patterns might have evolved nationally.

METHOD

The study used states as the units of analysis and employed a five-factor hierarchical regression to predict variance in mental health and mental retardation spending. Factors were state size, state wealth, degree of federal assistance, state civil rights activity, and strength of consumer advocacy groups. Strong roles for the civil rights and consumer advocacy factors were hypothesized. A collateral opinion survey in the 10 states exhibiting the greatest within-state difference in community mental health and mental retardation spending was also completed.

RESULTS

Community mental retardation spending grew nearly four times more rapidly than community mental health spending in the 1980s. The consumer advocacy and civil rights factors were strongly associated with spending for community mental retardation services in the states, but these factors did not predict spending for community mental health services.

CONCLUSIONS

Study recommendations included strengthening mental health family and consumer advocacy groups in the states and promoting systematic exchange between the mental health and mental retardation fields through joint state planning initiatives, studies, and conferences. The need for Medicaid reform is a unifying theme in both the mental health and mental retardation fields.

Current and future trends in state-operated mental retardation institutions in the United States

Results of a national study of state-operated institutional care in the United States were presented. The relations among census reduction, staffing level, and resident cost were explored. Resident cost escalated dramatically in recent years, primarily because staffing levels in the states remained relatively stable, whereas the institutional census continued to decline. Econometric projections suggest that by the year 2000, the institutional census will fall below 55,000 persons, cost per resident will rise to more than $113,000 per year, and 28 to 51 institutions will close.

Politics, public policy, and the development of community mental retardation services in the United States

Data emanating from the community services component of the Third National Study of Public Spending for Mental Retardation and Developmental Disabilities was analyzed. An empirical model of community services spending in the states was tested in a hierarchical regression analysis using cumulative community services fiscal effort in the states across 1977-1988 as the dependent variable. Strength of consumer advocacy organizations in the states coupled with states' historical orientations toward the adoption of policies promoting racial equality were highly significant predictors of state-by-state variance in community spending patterns. The implications of this and other findings emerging from the national study were discussed.

Expression of LFA-1 by a lymphoblastoid cell line from a patient with monosomy 21: effects on intercellular adhesion

Monosomy 21 (M21) is a rare aneuploid condition which in certain cases leads to reduced levels of chromosome 21 gene products. We have prepared an Epstein-Barr virus lymphoblastoid cell-line (LCL) from patient with M21 who has immunological abnormalities, and analysed the expression of lymphocyte function-associated antigen-1 (LFA-1). This heterodimeric leucocyte integrin consists of CD11a (alpha) subunits non-covalently associated with CD18 (beta) subunits coded, respectively, by genes on chromosomes 16 and 21. To determine whether monosomy 21 results in decreased expression of LFA-1, monoclonal antibodies were used to compare the expression of CD11a and CD18 on the M21 LCL with LCL from trisomy 21 (Down's syndrome, T21), normal controls and a possible case of leucocyte adhesion deficiency. In addition, phorbol-ester-induced homotypic adhesion, an LFA-1-mediated effect, was compared in these LCLs. The results are consistent with a gene dosage mediated reduction of LFA-1 expression by the M21 LCL.

Historical and contemporary issues in nursing home reform

Historical developments leading to the enactment of nursing home reform legislation (P.L. 100-203) were discussed. The results of the nursing home component of a nationwide University of Illinois at Chicago study of public mental retardation/developmental disabilities spending were also presented. Approximately 51,000 individuals with mental retardation and related conditions resided in nursing homes in 1989. The cost of their care was approximately $900 million annually. Within the first 12 months of the enactment of P.L. 100-203, 46 states had requested an extension to the original mandated services deadline imposed under that legislation. Under P.L. 100-203 guidelines, state agencies estimated that nearly 40% of all nursing home residents with mental retardation might need to be relocated to alternative settings. Implementation issues were also discussed.

Family reactions to institutional closure

Determinants of families' reactions to their relatives' relocation (from a large developmental disability institution that was closing to smaller institutions) were examined. Ninety-four families responded to two surveys sent during closure and one year later asking about (a) reactions to the closure, (b) relative's medical status, (c) involvement with their relative, (d) appraisal of the situation, and (e) social support. Over time, families reported less stress and dissatisfaction with closure. Family reactions during closure were related to the relative's medical status, involvement with their relative, and appraisal of the situation, whereas family reactions one year later were related to appraisal, involvement with their relative, and social support.

National study of public spending for mental retardation and developmental disabilities

Results of a nationwide study of public mental retardation/developmental disabilities (MR/DD) spending in the states during Fiscal Years 1977 through 1986 were summarized. Trends identified included: (a) continuing growth in spending for community services, (b) contraction of total spending for institutional operations, and (c) predominance of ICF/MR support in large (16+ beds) congregate care settings. Periodic replication of the study was recommended as was additional research to identify the political and economic determinants of state MR/DD spending.

State government financial effort in mental retardation

A comparative analysis of the level of financial effort exhibited in the states for financing mental retardation services was presented. States were ranked on a criterion (aggregate personal income) that compensated for differences in each state's financial capacity. During the FYs 1977-1984 period, on a nationwide basis, state governments spent increasingly more of their own funds for community services and increasingly less for institutional operations; however, combined institutional and community services spending was relatively stable. A hierarchical multiple regression analysis on three economic variables was performed: state size, wealth, and degree of federal assistance. All were very poor predictors of community services fiscal effort, implying the presence of more complex determinants of mental retardation spending. Degree of federal assistance was an important, inversely related, predictor of institutional fiscal effort.

Governmental spending for mental retardation and developmental disabilities, 1977-1984

A study of public spending for mental retardation and developmental disabilities in fiscal years 1977 through 1984 reveals that combined state and federal government spending grew by 23 percent despite diminished growth in federal spending after passage of the Omnibus Budget Reconciliation Act of 1981. Combined state and federal expenditures for community services grew by 40 percent, primarily because of an unprecedented rise in state spending. Total state and federal spending for institutional services plateaued, as a 26 percent drop in state appropriations was offset by an infusion of federal dollars, mostly through the Intermediate Care Facilities for the Mentally Retarded program. Federal, state, and local expenditures in fiscal 1984, estimated to total $16.49 billion, are assessed, and future trends in the financing of institutional and community services in the U.S. are discussed.

Deinstitutionalization of the retarded: trends in public policy

Essential public policy features of the national movement to return institutionalized mentally retarded people to community settings include issues related to institutional census trends, class action litigation, cost "savings," and funding. The deinstitutionalization of retarded people is following a different course from that of the mentally ill; it started later and is occurring more gradually. Right-to-habilitation lawsuits in Alabama and Pennsylvania illustrate the class action suit; gains from litigation in the 1970s have been mixed, however. Comprehensive community care is not necessarily any cheaper than comparable institutional care. Trends in state construction expenditures, the Reagan Administration's proposal for block grants, and impending human services budget cuts are current funding issues. So that advocates of the disabled can more closely monitor future developments in state and federal policy, three continuing annual studies are proposed: a comparison of states' funding of programs for retarded people; and evaluation of nationwide data obtained in accreditation surveys; and a historical and contemporary description of the operations of each of the 50 state service systems.