Assessment of COVID-19 outbreaks in long-term care facilities

BACKGROUND

The B.1.167.2 (Delta) variant quickly became the predominant circulating SARS-CoV-2 strain in the USA during summer 2021. Missouri identified a high number of outbreaks in long-term care facilities (LTCFs) across the state with low vaccination rates among LTCF staff members and poor adherence to mitigation measures within local communities.

AIM

To describe COVID-19 outbreaks that occurred in Missouri LTCFs impacting staff and residents during the surge of the Delta variant.

METHODS

Outbreaks of COVID-19 in 178 LTCFs were identified by the Missouri Department of Health and Senior Services. Case data from LTCFs with the highest burden of disease were analysed to assess disease transmission, vaccination status, and outcomes among residents and staff. Additional investigational measures included onsite visits to facilities with recent COVID-19 outbreaks in communities with substantial transmission to assess mitigation measures.

FINDINGS

During April 22^nd to July 29^th, 2021, 159 COVID-19 cases among 72 staff members and 87 residents were identified in 10 LTCFs. More than 74.7% of resident cases were vaccinated compared to 23.6% of staff cases. Vaccinated residents had a lower proportion of hospitalizations and deaths reported compared to unvaccinated residents. Data analysis and contact-tracing efforts from a sample of the facilities suggest that staff members were likely a major factor in introducing SARS-CoV-2 virus into the facilities. Adherence to COVID-19 mitigation measures varied at the visited facilities.

CONCLUSION

Data showed that vaccination rates varied between staff cases and resident cases in facilities with high-burden outbreaks. Differences were identified in mitigation practices in at least two facilities.

Standardizing Electronic Health Record Data on AD/ADRD to Accelerate Health Equity in Prevention, Detection, and Treatment

Improving the prevention, detection, and treatment of Alzheimer's disease and Alzheimer's disease related dementias (AD/ADRD) across racial, ethnic, and other diverse populations is a national priority. To this end, this paper proposes the development of the Standard Health Record for Dementia (SHRD, pronounced "shared") for collecting and sharing AD/ADRD real-world data (RWD). SHRD would replace the current unstandardized, fragmented, or missing state of key RWD with an open source, consensus-based, and interoperable common data standard. This paper describes how SHRD could leverage the best practices of the Minimal Common Oncology Data Elements (mCODETM) initiative to advance prevention, detection, and treatment; gain adoption by clinicians and electronic health record (EHR) vendors; and establish sustainable business and governance models. It describes a range of potential use cases to advance equity, including strengthening public health surveillance by facilitating AD/ADRD registry reporting; improving case detection and staging; and diversifying participation in clinical trials.

Humeral shaft fracture and radial nerve palsy in Korean soldiers: focus on arm wrestling related injury

INTRODUCTION

Humeral shaft fractures can lead to radial nerve injury and may require surgery and rehabilitation. We determined the causative events of humeral fracture, including arm wrestling, in young Korean soldiers and examined whether humeral fracture is related to demographic characteristics and the presence of radial nerve palsy.

METHODS

We reviewed 7.5 years (July 2012 to June 2019) of medical records covering patients who had experienced a humeral shaft fracture after entering military service and had received surgery for open reduction and internal fixation. Data were obtained on basic demographics, initial event provoking the fracture, presence of radial nerve palsy, initial and follow-up severity of the weakness, and any discharge from military service because of prolonged radial nerve palsy.

RESULTS

Of 123 cases, arm wrestling was the leading cause (52.8%). A high energy injury, such as falling from a height (11.4%), and sports related slips (10.6%) were other causes. All humeral shaft fractures caused by forceful contraction were spiral, while 40% of the fractures caused by external force related events were of a transverse type. The percentage of left-sided fractures was significantly higher for fractures arising from an external force than in those caused by forceful contraction related events. Radial nerve palsy was found in 34 patients (27.6%), and 16 were discharged from the military because of prolonged radial nerve palsy 6 months after the fracture. The causative events and other factors did not affect the presence of radial nerve palsy.

CONCLUSION

Arm wrestling was the leading cause of humeral fracture in young Korean soldiers but the chance of developing comorbid radial nerve palsy did not differ from that of other causes. These epidemiologic findings in this young active group may help in understanding the causes of humeral shaft fracture in soldiers and in the wider young population.

The neighbourhood effects of geographical access to tobacco retailers on individual smoking behaviour

OBJECTIVE

To investigate whether neighbourhood measures of geographical accessibility to outlets selling tobacco (supermarkets, convenience stores and petrol stations) are associated with individual smoking behaviour in New Zealand.

METHODS

Using geographical information systems, travel times from the population-weighted centroid of each neighbourhood to the closest outlet selling tobacco were calculated for all 38,350 neighbourhoods across New Zealand. These measures were appended to the 2002/03 New Zealand Health Survey, a national survey of 12, 529 adults. Two-level logistic regression models were fitted to examine the effects of neighbourhood locational access upon individual smoking behaviour after controlling for potential individual- and neighbourhood-level confounding factors, including deprivation and urban/rural status.

RESULTS

After controlling for individual-level demographic and socioeconomic variables, individuals living in the quartiles of neighbourhoods with the best access to supermarkets (OR 1.23, 95% CI 1.06 to 1.42) and convenience stores (OR 1.19, 95% CI 1.03 to 1.38) had a higher odds of smoking compared with individuals in the worst access quartiles. However, the association between neighbourhood accessibility to supermarkets and convenience stores was not apparent once other neighbourhood-level variables (deprivation and rurality) were included.

CONCLUSIONS

At the national level, there is little evidence to suggest that, after adjustment for neighbourhood deprivation, better locational access to tobacco retail provision in New Zealand is associated with individual-level smoking behaviour.

The demographic and social class basis of inequality in self reported morbidity: an exploration using the Health Survey for England

STUDY OBJECTIVES

To assess the relative contribution of age and social class to variations in the prevalence of a selection of self reported health problems. To examine the implications of observed variations for research on health inequalities.

DESIGN

Secondary analysis of the Health Survey for England (1991-1997) using morbidities that are particularly prone to class effects. A statistical measure of the "relative class effect" is introduced to compare the effects of adjusting for social class and age.

MAIN RESULTS

There is substantial variation in the relative importance of the age and class distributions of different diseases. Age effects often overshadow those of class even for conditions where an apparently strong social gradient exists. Only for self reported mental health among women does the social gradient exceed the age gradient. Within the context of a dominating age gradient, social gradients are relatively high for mental health and general health for both sexes. Variation in the relative strengths of the social gradients between the sexes are observed for angina symptoms.

CONCLUSIONS

Given variations in the "relative class effect", analysis recognising the distinct contributions of age, sex, and social class to specific morbidities is advocated as a transparent and robust approach to the assessment of morbidity based inequality.

Geographies of need and the new NHS: methodological issues in the definition and measurement of the health needs of local populations

For a variety of purposes it is increasingly necessary to establish the health needs of local populations. Following a critique of existing proxies of need, this paper presents and evaluates an alternative which draws upon epidemiological evidence concerning the age, sex and social class distribution of morbidity in order to estimate the prevalence of specific conditions in designated populations. By way of demonstrating the insights to be gained through the use of these indicative prevalence rates, the paper considers the treatment of ischaemic heart disease in a sample of 539 practices and presents evidence regarding the significance of deprivation and rurality in determining health service use relative to needs.

Kunbi-Boshin-Hangam-Tang stimulates nitic oxide production through activation of nuclear factor-kappaB

The objective of the currently study was to determine the effect of Kunbi-Boshin-Hangam-Tang (KBH-Tang) on the production of nitric oxide (NO). Stimulation of RAW 264.7 cells with KBH-Tang after the treatment of recombinant interferon-gamma (rIFN-gamma) resulted in increased NO synthesis. KBH-Tang partially increased NO synthesis by itself. When KBH-Tang was used in combination with rIFN-gamma, there was a marked cooperative induction of NO synthesis in a dose-dependent manner. This increase in NO synthesis was reflected as increased amount of inducible NO synthase (iNOS) protein. NO production was inhibited by NG-monomethyl-L-arginine (NGMMA). Furthermore, activation of nuclear factor (NF)-kappaB was increased by KBH-Tang. These results suggest that KBH-Tang may stimulate the NO production through the activation of the NF-kappaB.

Inhibition of immunologic and nonimmunologic stimulation-mediated anaphylactic reactions by water extract of white eggplant (solanum melongena)

We investigated the effect of water extract of Solanum melongena(SMWE) on immunologic and nonimmunologic stimulation-mediated anaphylactic reactions. Nonimmunologic anaphylactic reaction was induced by compound 48/80 injection. Oral administration of SMWE (1 g kg(-1)) completely inhibited compound 48/80-induced anaphylactic reaction. Immunologic anaphylactic reaction was generated by sensitizing the skin with anti-dinitrophenyl (DNP) IgE followed 48 h later with an injection of antigen. Oral administration of SMWE (0.01--1 g kg(-1)) significantly inhibited passive cutaneous anaphylactic reaction activated by anti-DNP IgE to between 83.10 +/- 1.67% and 70.17 +/- 2.17%. SMWE (0.01--1 mg ml(-1)) also inhibited histamine release activated by compound 48/80 to between 93 +/- 2.65 and 70 +/- 1.50%. Moreover, SMWE (0.01--1 mg ml(-1)) had a significant inhibitory effect on IgE-induced tumor necrosis factor (TNF)-alpha secretion from rat peritoneal mast cells. These results indicate that SMWE inhibits immunologic and nonimmunologic stimulation-mediated anaphylactic reactions and TNF-alpha secretion from mast cells.

Health Action Zones: the "third way" of a new area-based policy?

The notion of the action zone has emerged as a key feature of New Labour's approach to social policy. There is some debate about whether Labour's area-based policies reflect the Old Left, the New Right or the "third way". This paper critically examines these issues for Health Action Zones (HAZs). First, it outlines the development of HAZs and their main features. It then examines the themes that may have underpinned the HAZ strategy. Finally it examines critiques of HAZs in the light of wider debates about area-based strategies. It is concluded that HAZs fit well with some of New Labour's key themes, and may have some characteristics of a third way in that they incorporate features of both the "Old Left" of the Black Report and the New Right of competitive, bidding exercises. Moreover, they have addressed some of the main criticisms of earlier area-based policies, arguably being based on place rather than people poverty. However, some of the issues regarding their designation illustrate unresolved problems.

Consumed with worry: 'unsafe' alcohol consumption and self-reported problem drinking in England

Using data from the 1994 Health Survey for England, logistic multivariate multilevel modelling techniques are used to investigate the simultaneous effect of individual demographic characteristics and socio-structural factors on self-reported problem drinking as revealed by CAGE scores and 'unsafe' levels of alcohol consumption. Whilst the influence of key socio-structural variables is broadly similar for both unsafe alcohol consumption and high CAGE scores, there are notable exceptions when results are examined by tenure group: those in the rented sector are more likely to be problem drinkers as revealed by CAGE, but less likely to consume 'unsafe' amounts of alcohol. Both dimensions of drinking behaviour are influenced by the consumption patterns of others in the household, with both likelihoods increasing as the average consumption of others in the household rises. After taking into account individual compositional variables, the research indicates that there is very little evidence for geographical variation remaining in these two dimensions of drinking behaviour. It is found that the proportion of the population whose drinking behaviour may be classed as (potentially) problematic via the CAGE responses is substantially less than the proportion consuming above recommended 'safe' levels. The research concludes, however, that the two measures are broadly similar in their relationship to social and structural variables. Tenure provides an exception to this conclusion and indicates a continuing need to take account of housing circumstances in developing an understanding of drinking behaviour.

Risk and protection: the discourse of confinement in contemporary mental health policy

Confinement has regained respectability in the discourses of contemporary UK mental health policy. This development reflects concern about violent offences by people with mental health problems and is rooted in claims about the 'failure' of community care. Confinement is presented as a strategic response to the risks and dangers posed by particular fractions of the population of mental health service users. Using two key policy statements issued by the Department of Health and associated discussions in the health services management press, the confinement theme is explored and assessed. The paper notes its emergence as a consequence of the spatial impacts of deinstitutionalization and its specific origins in response to violent offences by people with mental health problems. The notion that the growing emphasis on confinement presages a return to the asylum is considered and rejected. Rather, the paper stresses the importance of discourses of protection, safety, risk and dangerousness in understanding the turn to confinement.

Inhibition of mast cell-mediated anaphylaxis by sochungryong-tang

According to traditional Asian philosophy, sochungryong-tang (S-Tang) is a prescription for treating exterior syndrome. In this study, we investigated the effect of S-Tang on mast cell-mediated anaphylaxis. S-Tang completely inhibited compound 48/80-induced systemic anaphylactic shock at a dose of 100 mg/kg. When S-Tang was given as pretreatment at concentrations ranging from 1 to 1000 mg/kg, the serum histamine levels induced by compound 48/80 were reduced in a dose-dependent manner. S-Tang inhibited the local anaphylaxis activated by anti-dinitrophenyl (DNP) IgE antibody, and also inhibited the histamine release from the rat peritoneal mast cells by compound 48/80 or anti-DNP IgE. These results indicate that S-Tang may contain substances with actions that inhibit mast cell degranulation.

Activation of caspase cascades in Korean mistletoe (Viscum album var. coloratum) lectin-II-induced apoptosis of human myeloleukemic U937 cells

Mistletoe lectins are of high biological activity and exert cytotoxic effects. We have previously shown that Korean mistletoe, Viscum album var. coloratum, lectin-II specifically induces apoptotic cell death in cancer cells, not normal lymphocytes. The destructive mechanism by mistletoe lectins on tumor cells was mediated by activation of c-JUN N-terminal kinase (JNK)/stress-activated protein kinase. Herein, we investigated the involvement of caspase cascade and its proteolytic cleavage effects on biosubstrates of human myeloleukemic U937 cells by D-galactoside and N-acetyl-galactosamine-specific Korean mistletoe lectin-II. Mistletoe lectin-II induced ladder pattern DNA fragmentation and activation of caspase-3, -8, and -9 of U937 cells, but not caspase-1 protease, in a time- and dose-dependent manner. Consistent with catalytic activation of protease, both poly(ADP-ribose) polymerase (PARP) and protein kinase C-delta (PKC-delta) are also cleaved in mistletoe lectin-II-treated U937 cells. An inhibitor of caspase-3-like protease, DEVD-CHO peptide, significantly inhibited mistletoe lectin-II-induced apoptosis, PARP cleavage, and fragmentation of DNA. These results provide the evidence that Korean mistletoe lectin-II induces apoptotic death of U937 cells via activation of caspase cascades.

Suppression of immunoglobulin E-mediated anaphylactic reaction by Alpinia oxyphylla in rats

We investigated the effect of Alpinia oxyphylla water extract (AOWE) on immunoglobulin E (IgE)-mediated anaphylaxis activated by anti-dinitrophenyl (DNP) IgE antibody. AOWE dose-dependently suppressed passive cutaneous anaphylaxis (PCA) when intraperitoneally or orally administered. On the other hand, it showed weak suppressive activity when administered intravenously. AOWE dose-dependently suppressed anaphylactic histamine release from rat peritoneal mast cells (RPMC) activated by anti-DNP IgE antibody. However, AOWE had a significant augmenting effect on anti-DNP IgE antibody-induced tumor necrosis factor-alpha secretion from RPMC. These results indicated that AOWE may possess strong antianaphylactic action and also suggest that differential activity following administration routes may be caused by difference of bioavailability.

Predicting small-area health-related behaviour: a comparison of smoking and drinking indicators

Health-related behaviours are of central importance to health promotion and to the promotion of enhanced population health. In the UK, localised knowledge of the quantitative dimensions of health-related behaviours is traditionally attained by conducting a costly sample survey. Such surveys seldom generate reliable data at scales more local than that of the health authority, they also need to be repeated regularly. This paper outlines an alternative framework for generating statistics on small-area health related behaviours using routinely available data from the annual Health Survey for England (N = 17,000) and the decennial Population Census. Using a multilevel modelling approach nesting individuals within postcode sectors within health authorities, and focusing on the prevalence of smoking and 'problem' drinking, the paper comprises four sections: a consideration of the modelling strategy, a comparison of the smoking and drinking models, an outline of the estimation strategy, and the presentation and discussion of ward-level estimates of smoking and drinking behaviour for England. The paper concludes that the method is better at estimating smoking than drinking but that it offers a feasible, cheap and more informative alternative to the survey approach to the generation of information on smoking and drinking behaviour.

Problems of providing health care in British island communities

Issues and problems relating to the funding and provision of health services to islands are examined with particular reference to the island communities of Britain. The results of a telephone survey of key representatives of relevant health authorities in the British Isles indicate the general problems faced by health care providers in island localities. The Isle of Wight is used as a case study and exemplar of the specific difficulties faced in island settings. The paper concludes by examining the relevance of current resource allocation policy to island contexts.

Smoking and deprivation: are there neighbourhood effects?

Debate has centred on whether the character of places plays an independent role in shaping individual smoking behaviour. At the small-area scale, particular attention has focused on whether measures of neighbourhood deprivation predict an individual's smoking status independent of their own personal characteristics. This study applies multilevel modelling techniques to data from the British Health and Lifestyle Survey and ward (local neighbourhood) level deprivation scores based on four variables from the national Census. Results suggest that after taking account of a large range of individual characteristics, both as main effects and interactions, together with complex structures of between-individual variation, measures of neighbourhood deprivation continue to have an independent effect on individual smoking status. In addition, significant between-ward differences in smoking behaviour remain which cannot be explained either by population composition or ward-level deprivation. The study suggests that the character of the local neighbourhood plays a role in shaping smoking behaviour.

The shape of things to come

Geographical boundaries have always been significant in the NHS. The planned reconfiguration of NHS regions including the establishment of a pan-London region, will have consequences across the whole of the service. The proposed changes will strengthen the power of central government in terms of policy and resource allocation. It is not clear whether boundary changes have any impact on patient care. Boundary changes create pressure for further reorganizations.

Context, composition and heterogeneity: using multilevel models in health research

This paper considers the use of multilevel models in health research. Attention focuses on the structure and potential of such models and particular consideration is given to their use in elucidating the importance of contextual effects in relation to individual level social and demographic factors in understanding health outcomes, health-related behaviour and health service performance. Four graphical typologies are used to outline the questions that multilevel models can address and the paper illustrates their potential by drawing on published examples in a number of different research areas.

Ethics and the police surgeon: compromise or conflict?

Police surgeons play an important role in the British criminal justice system. Professionally located between the two worlds of medicine and the law, they face ethical dilemmas which derive from the dual nature of their role. The development of the police surgeon service has seen the emergence of three further dualisms within the police surgeon role. These are the forensic-therapeutic divide, the specialist-generalist division, and the issue of dependence or independence with regard to the police. These internal dualisms are discussed and their implications explored. Attention then turns to a consideration of three issues which demonstrate the nature of the ethical dilemmas facing the British police surgeon: the particular articulation of the (police) doctor-patient relationship, the matter of consent, and the subject of confidentiality. Both these ethical issues and the nature of the police surgeon role are explored through the primary analysis of survey and interview data collected from a national sample of police surgeons and police services, and the secondary analysis of key documents on the police surgeon, the paper concludes that specific ethical guidance is needed to address the forensic aspects of the police surgeon role.

Health-related behaviour in context: a multilevel modelling approach

Recent attempts to place individual health-related behaviour in context have been judged largely unsuccessful. This paper examines how this situation might be improved and is especially concerned with the role of quantitative methodologies. It is argued that, whilst recent developments in social theory help provide important theoretical guidelines, they can only be implemented with difficulty in empirical health-related behaviour research if traditional quantitative methodologies are used. It is suggested that the best way to implement social theory within a quantitative framework is to apply the newly developed technique of multilevel modelling. This paper offers an overview of the multilevel approach and outlines its significance for health-related behaviour research. In addition, it details a number of ways in which the multilevel framework can be extended so as to achieve further improvements in the conceptualization of health-related behaviour. To illustrate the value of the technique, the paper finishes by considering one of these extensions in detail and applying it to data recording smoking behaviour in the United Kingdom.

Defining localities for health planning: a GIS approach

The National Health Service in Britain is undergoing far-reaching changes. While District and Regional Health Authorities are currently merging, professionals agree that primary health care is most efficiently managed at the local level. This paper uses geographical information systems (GIS) capabilities to identify a nested hierarchy of localities for the management of primary health care in West Sussex, England. GIS coverages were developed which contained key criteria for defining local areas, including nodes or focal points of service provision, edges which act as physical or psychological barriers to movement, districts such as official administrative areas and interaction criteria such as journey to work, school and family doctor (GP) surgeries. Central to the derivation of the localities was a large matrix of patient to GP flows based on postcoded data. Once managed, these data revealed clear geographical patterns of patient to GP allegiance. A large-scale field survey obtained supporting information on the perception of areas from local residents.

Psychiatric morbidity: a multilevel approach to regional variations in the UK

STUDY OBJECTIVE

To establish whether regional variations in psychiatric morbidity in Britain constitute a distinctive geography of mental health arising from factors that are context-specific at area level or whether these variations are an artifact generated by sampling fluctuations and differing population compositions in areas.

DESIGN

Multilevel modelling techniques were applied to data from the 1984-85 health and lifestyle survey. The outcome was the prevalence of psychiatric morbidity as recorded by the application of the general health questionnaire in this survey.

SETTING

The analysis was undertaken simultaneously at the individual level, electoral ward level, and regional level for England, Wales, and Scotland.

PARTICIPANTS

A total of 6572 adults were selected from the electoral register.

MAIN RESULTS

Regional variations were detected in crude aggregate general health questionnaire scores but these were found to be the result of sampling fluctuations and varying regional population compositions rather than higher level contextual effects. There was certainly no evidence of a clear north-south distinction in psychiatric morbidity as was suggested by earlier work. In addition, the local neighbourhood did not seem to have any importance beyond the type of people who lived there. A number of individual characteristics was shown to be associated with mental wellbeing but a large degree of individual variation remained unexplained.

CONCLUSIONS

In terms of low level psychiatric disturbance it seems that the characteristics of individuals have greater importance than the characteristics of areas, although the latter may still operate as important mediating factors. Multilevel modelling represents a robust statistical method of examining area variations in health outcomes and further work needs to be conducted, particularly on more serious psychiatric conditions.

Do places matter? A multi-level analysis of regional variations in health-related behaviour in Britain

A number of commentators have argued that there is a distinctive geography of health-related behaviour. Behaviour has to be understood not only in terms of individual characteristics, but also in relation to local cultures. Places matter, and the context in which behaviour takes place is crucial for understanding and policy. Previous empirical research has been unable to operationalize these ideas and take simultaneous account of both individual compositional and aggregate contextual factors. The present paper addresses this shortcoming through a multi-level analysis of smoking and drinking behaviours recorded in a large-scale national survey. It suggests that place, expressed as regional differences, may be less important than previously implied.

VLSI implementation of synaptic weighting and summing in pulse coded neural-type cells

Presents the hardware realization for synaptic weighting and summing using pulse-coded neural-type cells (NTCs). The basic information processing element (NTC) encodes the information into the form of pulse duty cycles using voltage-controlled resistors, for which a pulse duty cycle modulation technique is proposed. Summation is executed by a simple capacitor circuit as a current integrator. Layouts and measurements on a fabricated integrated design are included.

Multilevel assessment of immunisation uptake as a performance measure in general practice

OBJECTIVE

To provide a measure of general practitioners' performance regarding uptake of immunisation against pertussis, taking account of the impact of patient characteristics on levels of uptake.

DESIGN

Multilevel model of immunisation status against six measures of patient characteristics (level 1 predictor variables) with practice constraints as level 2 variables.

SETTING

126 practices in southern England.

SUBJECTS

2048 infants identified from infant surveillance and immunisation records.

MAIN OUTCOME MEASURES

Top 10 practices with respect to uptake of pertussis immunisation according to a "null" model (model A) and according to a model that included six level 1 variables (model B); differences in ranking between the two models.

RESULTS

Practices with low numbers of infants' requiring immunisation had imprecise and unstable uptake rates (range 0%-100%). With the multilevel procedure, after controlling for patient characteristics, practices in suburban catchment areas comprised largely of mature or young professionals performed best. Most improved performances when patient characteristics were taken into account were in practices in areas with a stable population and local authority housing--one such practice improved its ranking by 47 places.

CONCLUSIONS

Crude uptake rates are inadequate performance indicators. Alternative approaches suggest that praiseworthy efforts to raise immunisation rates in unpromising areas are unrewarded by simple target based assessments.

Ecological and individual effects in childhood immunisation uptake: a multi-level approach

Analyses of childhood immunisation uptake have traditionally been conducted at either the ecological or the individual scale. In this paper the problems stemming from these distinct strategies are explored and the potential of a multi-level modelling approach taking simultaneous account of processes at both levels is discussed. This discussion is set in the context of a case-study of pertussis immunisation uptake using data gathered from routine child health surveillance and immunisation uptake monitoring. The role of multi-level modelling in medical geographic research is briefly evaluated.

Loaves & fishes by the sea. One answer to resource allocation

How can community units ensure that services are provided on the basis of need rather than history? This article describes the efforts being made in Portsmouth and South East Hampshire (one of the country's largest health authorities) to meet this fundamental challenge. The approach taken is to match information on workloads, health care needs and neighbourhoods to facilitate effective resource management.

Conceptions of space and community in British health policy

Several recent United Kingdom health policy initiatives include ideas implicitly or even explicitly involving geographical space as a central theoretical construct. Neighbourhood nursing is perhaps the best known recent example. These initiatives are not without common features, and the paper commences with a typology of the roles which geographical space plays in health policy. A second section gives specific consideration to neighbourhood nursing. Thirdly the paper outlines the social theoretic debates surrounding geographic inputs to health policy: ideas such as community and locality. It is suggested that spatial conceptions in health policy reflect a complex amalgam of sociological assumptions which might fruitfully be considered in the light of Giddens' concept of locale.

Health education and baseline data: issues and strategies in nutrition campaigning

A central problem for health education is the lack of baseline data concerning relevant issues such as smoking, alcohol consumption or nutrition. In the absence of this information there is little detailed knowledge of the public's habits or willingness to change those habits. Furthermore, the social context and spatial variation of these factors is unknown. Often the only way in which suitable information can be acquired is through social surveys. This paper uses a case study of a nutrition survey to outline a general framework for the collection of baseline data. The approach centres around postcode based data linkage. The effectiveness of the approach is considered and its shortcomings noted.