Deprivation in London wards: mortality and unemployment trends in the 1980's

"This paper describes the use of current estimates of population and economic activity for London's wards in developing small area social indicators. The particular focus is on changes in the spatial pattern of mortality and unemployment differences in the 1980s in relation to the wider incidence of deprivation in wards. A conditional model of change is developed for mortality and unemployment indices to assess whether spatial differences are widening over time and how far changes in these indices are linked to social class and deprivation. The evidence is of widening unemployment differences, and a slight widening in premature mortality."

Family planning funding through four federal-state programs, FY 1997

CONTEXT

The maternal and child health (MCH) and the social services block grants have long played an important role in the provision of family planning services in the United States. The extent to which states have incorporated family planning services into the newer federally funded, but state-controlled, programs--Temporary Aid to Needy Families (TANF) and the State Children's Health Insurance Program (CHIP)--has yet to be identified.

METHODS

The health and social services agencies in all U.S. states, the District of Columbia and five federal jurisdictions were queried regarding their family planning expenditures and activities through the MCH and social services block grants and the TANF program in FY 1997. In addition, the states' CHIP plans were analyzed following their approval by the federal government. Because of differences in methodology, these findings cannot be compared with those of previous attempts to determine public expenditures for contraceptive services and supplies.

RESULTS

In FY 1997, 42 states, the District of Columbia and two federal jurisdictions spent $41 million on family planning through the MCH program. Fifteen states reported spending $27 million through the social services block grant. Most of these jurisdictions indicated that they provide direct patient care services, most frequently contraceptive services and supplies. Indirect services--most often population-based efforts such as outreach and public education--were reported to have been provided more often through the MCH program than through the social services program. MCH block grant funds were more likely to go to local health departments, while social services block grant funds were more likely to be channeled through Planned Parenthood affiliates. Four states reported family planning activities funded under TANF in FY 1997, the first year of the program's operation. Virtually all state plans for the implementation of the CHIP program appear to include coverage of family planning services and supplies for the adolescents covered under the program, even when not specifically required to do so by federal law.

CONCLUSIONS

Joining two existing--but frequently overlooked--block grants, two new, largely state-controlled programs are poised to become important sources of support for publicly funded family planning services. Now more than ever, supporters of family planning services need to look beyond the traditional sources of support--Title X and Medicaid--as well as beyond the federal level to the states, where important program decisions are increasingly being made.

Reforming health service delivery at district level in Ghana: the perspective of a district medical officer

Many countries in sub-Saharan Africa face the problem of organizing health service delivery in a manner that provides adequate quality and coverage of health care to their populations against a background of economic recession and limited resources. In response to these challenges, different governments, including that of Ghana, have been considering or are in the process of implementing varying degrees of reform in the health sector. This paper examines aspects of health services delivery, and trends in utilization and coverage, using routine data over time in the Dangme West district of the Greater Accra region of Ghana, from the perspective of a district health manager. Specific interventions through which health services delivery and utilization at district level could be improved are suggested. Suggestions include raising awareness among care providers and health managers that increased resource availability is only a success in so far as it leads to improvements in coverage, utilization and quality; and developing indicators of performance which assess and reward use of resources at the local level to improve coverage, utilization and quality. Also needed are more flexibility in Central Government regulations for resource allocation and use; integration of service delivery at district level with more decentralized planning to make services better responsive to local needs; changes in basic and inservice training strategies; and exploration of how the public and private sectors can effectively collaborate to achieve maximum coverage and quality of care within available resources.

Modelling the spatial distribution of teenage conception rates within Wessex

This study attempts to determine which factors account for the spatial variation in teenage conception rates within the former Wessex Regional Health Authority and what factors account for the eventual outcomes of these conceptions. Postcoded data on all teenage conceptions from 1991 to 1994 were collected and related to census ward level information and indicators of accessibility to family planning services. The results show that the variation in teenage conception rates and conception outcomes is principally determined by the age of the teenager, deprivation levels, the presence of certain homogeneously distinct groups and the distance to the nearest youth-oriented family planning clinic.

Poor people on the move: county-to-county migration and the spatial concentration of poverty

"Poverty rates in high-poverty and low-poverty rural [U.S.] counties, and, thus, the spatial concentration of poverty, are affected by poverty-specific differences in in-migration and out-migration patterns. These patterns are investigated using 1985-90 county-to-county migration data from the decennial census. Effects on poverty rates of four migration flows (in- and out-migration of poor, in- and out-migration of nonpoor) are quantified, and their impacts on spatial concentration of poverty are assessed. The effect of selected county characteristics on the migration of the poor and nonpoor in nonmetro counties [is] estimated."

Primary care physicians' perceptions of adolescent pregnancy and STD prevention practices in a Nova Scotia county

INTRODUCTION

This study was carried out to determine the predisposing, enabling, and reinforcing factors related to practice behaviors in the prevention of adolescent pregnancy and sexually transmitted diseases (STDs), and to assess physicians' "ideal" history taking and service provision versus their actual practice in this clinical area.

METHODS

Twenty-six of 37 physicians in a single county in Nova Scotia took part in a face-to-face interview.

RESULTS

Analysis of predisposing factors found that, for seven of 10 areas related to knowledge of the epidemiology of adolescent pregnancy and STDs, fewer than 50% of male physicians were able to give correct responses. All physicians believed this to be an important area for prevention, and 89% that prevention is possible, but only 62% believed that their own prevention efforts are effective. Respondents were about equally likely to view schools and physicians as having responsibility for prevention of adolescent pregnancy and STDs. Significant enabling factors included high levels of perceived personal comfort and skill, but time factors and opportunities to interact with adolescents sufficiently frequently to carry out prevention were seen as barriers. Most physicians (68%) agreed that the physician fee schedule was a negative reinforcing factor. Male physicians and those in rural practice were significantly more likely to have larger gaps between those preventive practices they saw as desirable and those they actually performed.

Strengthening local health care management in Bolivian districts through participatory operational research

The purpose of this article is to demonstrate how the use of a participatory health care management and problem-related research methodology may help strengthen health service management and the capacities of local health care personnel. The text refers to five studies carried out in three Bolivian health districts from 1993-1995, in an Operational Research Project, conducted by an Italian N.G.O. (Cooperazione Internazionale) in agreement with the local Ministry of Health and P.A.H.O./W.H.O. The object of these studies was to assess the main problems in health care delivery and to define and implement appropriate solutions. The studies utilized a methodology based on the principles of operational research and continuous quality improvement. During the process some positive aspects and difficulties were met. The positive aspects were: the applied character of the research focused on the solution of a problem; the study of a problem related to health service management; the use of modern and simple techniques adapted to local knowledge; on-the-job training of health care personnel during the research process. Lack of a generic 'culture of research' and poor health personnel training were the main difficulties encountered. National health authorities should take these points into account to define or readjust policies on health service research, health workers' academic education and in-service training. Insisting on developing human resources and allowing them to achieve and expand their potential is the key factor for getting developing countries out of their current crisis and toward reaching a truly human and sustainable development.

Local government reorganisation in Scotland and Wales

This article describes the new local authority structure that comes into effect in Scotland and Wales on 1 April 1996. The relationship between the new 'unitary' authorities and other administrative areas is discussed briefly and some key demographic data are presented. References are given to other sources of statistical information.

Early marriage among rural and urban females of south India

Data on 2972 marriages in rural areas and 1180 marriages in urban areas of North Arcot Ambedkar district of South India, during 1982-88, were analysed. The mean age at marriage of females was 18.6 in the rural and 19.6 in the urban area. The proportion of females married before attaining the legal age of 18 years was higher among the rural community (36.8%) than in the urban community (28.9%). Univariate analysis revealed an association between early age at marriage and the socioeconomic variables religion, caste, consanguinity, marital distance, spousal age difference, education and occupation of both bride and bridegroom, and socioeconomic status of the family. Multivariate analysis showed an independent relationship of marital distance and bridegroom's occupation with early age at marriage of females in the rural area alone and the bridegroom's education in the urban area alone. Consanguinity, spousal age difference and bride's education were found to be independently related with early age at marriage of females in both rural and urban areas.

An evaluation of population projection errors for census tracts

"In this article we evaluate the accuracy and bias of projections of total population and population by age group for census tracts in three counties in Florida. We use [U.S. census] data from 1970 and 1980 and several simple extrapolation techniques to produce projections for 1990; we then compare these projections with 1990 census counts and evaluate the differences. For the total sample, we find mean absolute errors of 17%-20% for the three most accurate techniques for projecting total population and find no indication of overall bias. For individual age groups, mean absolute errors range from 20%-29%." This is a revised version of a paper presented at the 1993 Annual Meeting of the Population Association of America.

Contraceptive use and attitudes in reunified Germany

Contraceptive use and attitudes were assessed in a random sample of 1064 German women. The majority (76%) of the sexually active, fertile women who were not pregnant and did not wish to get pregnant at the time of the survey were using very reliable contraceptive methods, namely oral contraceptives (OCs), intrauterine devices (IUDs) or sterilization. Comparison with a previous survey showed that contraceptive practice in West Germany had improved considerably since 1985. Attitudes towards the most reliable methods available (OCs, IUDs and sterilization) were found to be ambivalent. Perceived side effects and health risks were a particular matter of concern to the respondents. Although most respondents (88%) recognized that condoms prevent the transmission of AIDS, 66% of those who had occasional sexual partners did not use barrier methods. It is concluded that German contraceptive practice is reasonably effective and that if attitudes were to become more realistic the level of effectiveness could even be raised.

Age-specific migration and regional diversity

"This author examines patterns of age-specific migration between 1980 and 1990 for a small, growing region, the Pacific Northwest of the U.S.A., with the purpose of assessing the degree of geographic diversity in experience. A simple typology of the expected spatial and structural pattern of age-specific migration is proposed. Cluster analysis is used to group counties on the basis of age-specific rates of net migration. Even this fairly small region is found to exemplify most of the patterns that might be expected to occur in the nation as a whole."

Abortion services in the United States, 1991 and 1992

According to a survey by The Alan Guttmacher Institute, 1,529,000 abortions were performed in 1992, the lowest number of abortions since 1979. The abortion rate has gradually declined, from a high of 29 per 1,000 women of reproductive age in 1981 to 26 per 1,000 in 1992. The number of hospitals, clinics and physicians' offices that provide abortions--2,380 in 1992--has been declining at a rate of about 65 a year. Most of the decline has occurred among hospitals; the number providing abortions decreased by 18% between 1988 and 1992. Most U.S. counties (84%) have no known abortion provider, and in nonmetropolitan areas, 94% of counties have no provider. Among metropolitan areas, 33% have either no abortion provider or none that serves at least 50 women per year. Among states, North Dakota and South Dakota have only one provider each. Most abortions (69%) are performed in abortion clinics, and only 7% are performed in hospitals. Fewer than 1% of women who have an abortion are hospitalized for the procedure.

HIV counselling and care programmes at the district level in Ghana

The district hospital is the focus for the presentation of HIV-related disease in rural sub-Saharan Africa. Patients require not only medical care, but often economic support and counselling for themselves and their families. Psychosocial support should be provided at the hospital and in the home, the latter often being the preferred option. A team approach to HIV disease care and counselling, with careful selection and support of staff, and appropriate training in counselling skills is essential. A primary health care approach at the district level, mobilizing community participation and intersectoral support is necessary. Community Health Outreach Departments, as integral parts of the district hospital, are recommended and could pilot low-cost HIV hospital and home-care programmes.

The mapping of small-area census data--a consideration of the role of enumeration district boundaries

The author analyzes information available from recent British censuses for census enumeration districts (EDs). "A study of Newcastle upon Tyne EDs shows that ED boundaries do not, in fact, mark the boundaries of distinct areas. The presumption against the use of ED boundaries for cartographic representation is reinforced."

[Migration and integration policies within the Andean Pact]

"After a review of the institutions belonging to the 1969 Andean Pact, migration topics within this context are analyzed, considering three main issues: labor migration,...circulation of persons, where a series of agreements tending to simplify procedures at bordersites are still not practically in force for reasons concerning internal safety, drug traffic and unemployment, and migration across borders as related to borderline integration, which was dealt with in the Macchu Picchu Summit in 1990 and in a Decision Project in 1991." The five pact countries are Bolivia, Chile, Colombia, Ecuador, and Peru. (SUMMARY IN ENG)

[Abortion among female students and employees of a Brazilian university]

In Brazil, the subject of induced abortion is controversial and considered by some to be a serious public health problem. On the other hand there are little data available as to its frequency and general characteristics. The difficulty encountered in obtaining reliable information is to be explained by the illegality of abortion that inhibits women from talking about their experience, and most studies are carried out in hospitals and thus succeed in identifying only those women who have complications. A study was carried out in 1990, involving all the female graduate students and employees of a Brazilian university. Data was obtained through a questionnaire that was returned by mail, anonymously. This paper presents some of the results relating to the frequency of miscarriage and abortion in this population. Significantly more students than employees were less than 25 years old (85% and 13.7% respectively); fewer students were married or in a common-law union (11% of students as against 56% of employees) and four times fewer students than employees had never been pregnant (15% and 65%). Nine percent of the students and 14% of the employees had had at least one abortion. When only sometime pregnant women were taken into consideration, over half the students (59%) and 20% of the employees had had an abortion. Differences between the two groups were maintained when considered by age, both for miscarriage and abortion. Students of less than 25 years of age presented the highest percentage of abortion.

Sexual networking in provincial Thailand

Thailand is currently experiencing a major HIV epidemic, spread primarily through heterosexual contact. Patronage of prostitutes is relatively common. In-depth, open-ended interviews were conducted in a Central Thai province with a purposive sample of 181 urban men who had had sexual relations with at least two different women during the prior year. Additional qualitative information is provided by interviews with 50 women. The most common network pattern for men was a combination of commercial and noncommercial sexual relationships. Men reported that they commonly used condoms when they engaged in sex with prostitutes, but condom use was lowest for men who were the most frequent patrons. In noncommercial, nonmarital relationships, men screen partners for risk rather than practice safe sex, and condom use is generally low. Persons involved in noncommercial sexual networks are largely unaware that their partner may link them to a larger network of sexual contacts and associated risks of HIV infection. Men who have both commercial and noncommercial sexual partners can be found throughout the social strata. A program that focuses only on the closed commercial sex network will address only partially the real risk situations.

Restructuring federalism: the impact of Reagan policies on the family planning program

Through fiscal cutbacks and structural changes, Reagan's federalism assaulted the ethos of public health. In assessing the effects of Reagan policies on a basic public health program, family planning services, we find a substantial decrease in spending for this program, a reduction in the numbers of patients served, and increased variation among the states in the provision of services to low-income women. These effects are comparable with findings from other studies on the impact of Reagan's federalism upon social programs and have manifold implications for public health.