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The analyses presented in this paper document the impact of a community mobilization effort in Cameroon. Between 1997 and 1998, a local non-governmental organization worked with community associations, Njangi, in one urban and one rural location to promote knowledge and positive practices concerning family planning, sexually transmitted diseases, and treatment of common childhood diseases. Based on a multi-tiered structure, the project involved selecting and training two prominent and influential members of each community as "relais" or middlemen. The "relais" then trained mobilizers from participating Njangis to provide relevant information and help to mobilize their fellow members in favor of the positive attitudes and practices promoted by the project. The project was evaluated using baseline and follow-up measurement of pertinent indicators, and service statistics. Results suggest that the intervention had significant influence in the rural location with noticeable positive effects on knowledge and practices of family planning, knowledge and attitudes about HIV/AIDS and STIs, and use of health services. In the urban location, for programmatic and extraneous factors, the intervention was not effective. The paper discusses the lessons learnt from the intervention and offers pertinent suggestions for replicating the intervention in rural settings. KEY WORDS: family planning; community mobilization; Cameroon; HIV/AIDS.

The paper examines the controversy surrounding legislative proposals in New York State that would require amending the public health law's stringent confidentiality provisions; the legislation calls for "unblinding" the results of a 7-year old statewide HIV seroprevalence study that tests newborns for HIV antibodies in order to track the incidence of HIV infection among parturient women. The pivotal point is made that mandatory disclosure of the test results is tantamount to mandatory testing of the mother, since presence (or absence) of HIV antibodies conclusively reveals the mother's HIV status. The author presents the history of the epidemiological study and documents the ongoing discussion of mandatory testing, within the medical, bioethical and public health community. Citing numerous papers, including the report of the Subcommittee on Newborn Screening of the New York State AIDS Advisory Council, the author - a member of both the council and its subcommittee - argues against the principle of mandatory testing in general and "unblinding" of the seroprevalence survey in particular. Besides making a strong argument from the ethical viewpoint, the paper provides ample medical data to support the argument that mandatory testing of newborns is poor public health policy that would be essentially ineffectual in the effort to stem the spread of HIV.

This paper argues that a system of unblinded, universal testing, counseling and treatment for pediatric HIV should be implemented immediately in New York State. First, it argues that New York's health and social services bureaucracies, in conjunction with special interests that do not represent the interests of children, have resisted efforts to have infants tested and treated for HIV. Second, the paper suggests that the campaign against universal infant screening and treatment reflects our society's continuing, calculated decision to ignore the complexity of the HIV/AIDS epidemic. Third, the paper outlines a plan for a prompt and comprehensive system of HIV testing, counseling and treatment for infants and children, as well as for their parents and families, who are HIV-positive. In the process of articulating the above positions, the paper documents the failure of universal blinded infant HIV screening in New York since 1987. It further explores the inadequacies of the proposed efforts by state and city regulatory authorities to improve the testing and counseling available for pediatric HIV. Although encouraged by New York State's recent move aggressively to test and treat HIV-positive infants and children in foster care, the paper argues that this effort must be expanded to apply to the entire newborn population. Finally, the paper examines in detail the limitations of testing and counseling provided to children in the foster care system.

This paper describes the first year of an ongoing village health care and economic development project in the Krong Buk district of Dak Lak province in Vietnam's Central Highlands. The project serves 21 villages with a total population of just over 15,000. Most belong to ethnic minority groups. Physicians from the province capital of Boun Me Thuot were trained by a multi-disciplinary team of American health care workers to be trainers and supervisors of 21 village health care workers (VHWs). Two months later, a VHW from each village was trained in primary and preventive health care by the physician-supervisors. Since this initial training, each VHW has been provided with materials, medicines and monthly supervision by the physician-supervisors. The health care component has been complemented by an economic development project based on a system of small loans. Data from the first year of monthly reports and from a baseline survey are presented in this paper. KEY WORDS: Vietnam; ethnic minorities; primary health care; health care development.

In order to address the growing burden of chronic diseases in the Americas, the Pan American Health Organization implemented the Women as Agents of Change project in Panama and Trinidad & Tobago. The project focused on low income, middle aged women and promoted increased physical activity, intake of 5 servings of fruits and vegetables daily, and yearly screening for cervical cancer. One hundred women per country participated in the 6 week program which consisted of weekly meetings and participation in a behavior change curriculum. Gollwitzer's theory of implementation intentions and the theory of social support provided the methodology for the design of the curriculum. At baseline, end of project, and at 6 months, participants completed physical activity and fruit and vegetable consumption surveys. Results show an increase in consumption in Panama between the pre and posttests, though the increase was not maintained at the 6 month period. Physical activity decreased in both countries over the intervention period, likely due to misreporting on the pretest. Notably, most participants reported on the 6 month follow up survey that they had continued or intensified the behavior changes they undertook during the project. The paper describes barriers identified by the participants as well as strategies they devised to overcome them. KEY WORDS: chronic disease; women; developing countries; social support.

Since the Alma-Ata Conference in 1978 reiterated the goal of "Health for All by the Year 2000", health service delivery programs promoting the primary health care approach using community health workers (CHWs) have been established in many developing countries. These programs are expected to improve the cost-effectiveness of health care systems by reaching large numbers of previously underserved people with high-impact basic services at low cost. However, there is a dearth of data on the cost-effectiveness of CHW programs to confirm these views. This may be because conventional approaches to economic evaluation, particularly cost-effectiveness, tend not to capture the institutional features of CHW programs. Therefore, this paper aims to examine the means by which economic methods can be extended to provide evidence regarding the cost-effectiveness of CHWs in developing countries. KEY WORDS: community health workers; cost-effectiveness; review.

Individuals who wish to receive independent assistance to resolve access to care health problems have limited options. The Health Consumer Alliance (HCA) is an independent, coordinated effort of nine legal services organizations that provide free assistance to low-income health consumers in 10 California counties. The need for the HCA stems from the vast number of health consumers with unanswered questions and unresolved problems relating to access to care issues, among both insured and uninsured populations. However, little is known about the effectiveness of independent consumer assistance centers. This paper examines the effectiveness of a network of independent consumer assistance programs in resolving consumer problems and consumers' level of satisfaction with services received. As the project evaluators, we conducted telephone surveys with 1,291 users of the HCA to assess if this independent program resolved consumer problems, and to measure the level of satisfaction among HCA users. Specifically, we asked questions about the HCA's influence on problem resolution, consumer satisfaction, health insurance status and use of preventive care services. From 1997 to 2001, more than 46,000 consumers contacted the seven health consumer centers (HCCs). According to our sample of respondents, results show that the HCCs are an important resource for low-income Californians trying to access health care. After contacting the HCCs, 62 percent of the participants report that their problems were resolved. In addition, 87 percent of the participants said the HCCs were helpful and 95 percent said they would be likely to contact the HCC again if necessary. KEY WORDS: evaluation; access to care; consumer assistance center; Ombuds program.

Recruitment of community participants for clinical research studies is a challenging task. When possible, community-based recruitment efforts should involve members of the targeted community in the planning, community preparation, and actual recruitment process. It becomes even more difficult to recruit study participants from the community when the research involves an invasive procedure, or when diverse target groups require that a variety of recruitment methods be used. The Community Health and Stress Evaluation (CHASE) Study was designed to determine the role of psychosocial and biobehavioral factors in the etiology of coronary heart disease. It involved both an invasive medical procedure (a spinal tap) and the collection of survey and medical information from Black and White persons in different socioeconomic status (SES) groups. Interestingly, we experienced the greatest difficulty in recruiting lower SES white persons, while groups that typically are "difficult to find" (such as Blacks) were actually easiest to recruit for the study. This paper describes the background of the CHASE study, the community recruitment methods used, and the results of the recruitment efforts by race, gender and SES gradient. We present an evaluation of the community recruitment component, why we think differences occurred, and the lessons learned from the experiences that may be applied to similar studies. KEY WORDS: community; recruitment; socioeconomic status; gatekeepers; race.

This paper describes the characteristics of HIV-related hospitalizations in Illinois and compares these to nationally available data. We used HIV-related hospitalization data abstracted from an administrative dataset maintained by state mandate. Overall, HIV-related hospitalizations decreased in Illinois between 1996 and 2000. The proportion of hospitalizations for infants also decreased. However, trend analyses indicated that both the proportion of hospitalizations involving females and the mean age of hospitalized patients increased while the proportion of hospitalizations ending in mortality and the average charge per hospitalization decreased during the observation period. Small area analyses found significant regional variations in the proportion of hospitalizations ending in in-hospital mortality, costs of a hospitalization and rate of decline in the percent of hospitalization over time. Compared to national data, HIV-related hospitalizations in Illinois were more expensive, less likely to end in mortality and less likely to involve females. These results indicate that evaluation of data at several geographic levels can provide healthcare policy makers with essential information at each level of analysis. KEY WORDS: HIV; regional trends; hospital costs.

After the collapse of the Former Soviet Union a health reform process was undertaken in Georgia beginning in 1994. This process was intended to encompass all aspects of the health-care sector and to transform the Soviet-style health system into one that was directed towards quality of care, improved access, efficiency, and a strengthened focus on Primary Health Care (PHC). Health sector reform fundamentally changed the ways health care is financed in Georgia. There has been a transition to program-based financing, and payroll-tax-based social insurance schemes have been introduced. Despite these measures, the performance of the health system is still disappointing. All health programs are severely under-funded, and when the majority of the population is unemployed or self-employed, collection of taxes seems impossible. Overall, Georgian consumers are uninformed about the basic principles of health reforms and their entitlements and therefore do not support them. The analysis introduced in this paper of the current situation in Georgia establishes that the rush to insurance-based medicine was more a rush from the previous system than a well-thought-out policy direction. After 70 years of a Soviet rule, the country had no institutional capacity to provide insurance-based health care. To achieve universal coverage, or at least ensure that the majority of the population has access to basic health services, government intervention is essential. In addition, educating the public on reforms would allow the reform initiators to fundamentally change the nature of the reform process from a "top-down" centralized process to one that is demand-driven and collaborative. KEY WORDS: health reform; health financing; state medical insurance; health status.

The present study aimed to find the awareness level of cancer information among Asian Americans in the Delaware Valley region (Pennsylvania and South Jersey). A cross-sectional self-report survey was conducted with a sample of 1374 Asian Americans including Chinese, Korean, Vietnamese and Cambodians. The sample was collected by using a stratified-cluster proportional sampling technique. This paper assessed self-reported smoking behaviors, knowledge of smoking cessation methods, availability of health professional's advice in quitting smoking in the past 12 months, awareness of the National Cancer Institute's Cancer Information Service, knowledge of, and interest in participation in cancer clinical trials for identified Asian smokers. Overall, the level of awareness of cancer information services among the four subgroups was low. Among current and former smokers, only 31% had been advised by a health care professional to quit smoking. Forty-three percent used at least one smoking cessation method to quit in the past. The results also reveal an increased awareness level among those who had health insurance, higher education and were less likely to speak their native language. Significant differences on cancer awareness existed among the four ethnic groups as well. This study suggests urgent needs to educate Asian Americans about important cancer control issues and services and highlights the differences in baseline knowledge and attitudes among the various ethnic groups. KEY WORDS: awareness, cancer information; tobacco; Asian Americans.

The HIV epidemic disproportionately affects historically underserved members of racial/ethnic minorities. This paper compares HIV service use patterns for 653 Asians and Pacific Islanders (APIs) with those of other racial and ethnic minority clients (N = 28,201) at three selected Ryan White Comprehensive AIDS Resource Emergency (CARE) Act grantee sites in California. Study results show a relatively high proportion of APIs with advanced HIV disease. APIs use hospital-based HIV clinics at relatively high rates, and they use HIV case management, housing assistance, day/respite care, food/nutrition, substance abuse treatment, and health education services in relatively low numbers. Research suggests that social, cultural, and economic factors may influence health seeking behaviors and providers' practices. While there are relatively few APIs living with HIV in the US, the rate of API population growth from immigration underscores the need for service providers to take into account cultural and social factors to improve access to treatment. KEY WORDS: AIDS; services; Asian Pacific Islanders.

The purpose of this paper is to examine current health care literature (1980-2000) regarding the microbiology of the home environment, to summarize evidence of transmission within the home, and to assess effectiveness of cleaning practices and products. The home environment, particularly the kitchen and bathroom, serves as a reservoir of large numbers of microorganisms, particularly Enterobacteriacae, and infectious disease transmission has been demonstrated to occur in 6-60% of households in which one member is ill. Current food preparation and cleaning practices provide multiple opportunities for intra-household member spread. Routine cleaning is often sufficient, but in cases of household infection, may not adequately reduce environmental contamination. The effectiveness of disinfectants varies considerably and depends on how they are used as well as their intrinsic efficacy. The behavioral aspects of infection prevention in the home (e.g., foodhandling and cleaning practices) warrant increased public attention and education. KEY WORDS: hygiene; foodborne illness; disinfection.

With the current wave of Asian immigration to the United States, awareness of their use of traditional medicine, often in combination with Western medicine, is an increasingly salient issue for health care professionals. This paper describes the use of traditional and Western medicine by Korean American elderly and factors that are associated with their health-seeking behaviors and health service utilization. Data were obtained from a convenience sample of 205 Korean elderly immigrants through interview. The findings revealed that health service utilization among Korean American elderly covered a broad spectrum of health resources, including the use of Western medicine, the traditional Korean medicine (hanbang), or both Western and traditional clinics. In addition, health insurance status and the source of health care were found to relate to the types of health service that Korean American elderly chose to utilize. Better understanding of patterns of health service utilization may improve the quality of health care by increasing health providers' cultural sensitivity and facilitating adequate communication between Asian immigrant clients and their care providers. Implications for research and practice are discussed. KEY WORDS: traditional medicine; Korean American elderly; health service utilization.

This paper discusses the results from the field test of a multimedia health education intervention, designed to provide breast cancer education for low income Latinas. The purpose of the field test was to ascertain whether the intervention produced significant changes in breast cancer knowledge and attitude, and screening intentions. A total of 1197 Latina women participated in the field study at six different sites. The majority of the participants were under 65 years of age, foreign-born with less than eight years of education and a weekly household income that fell in the lowest income quintile for 1998 (<$350.00). Participants were randomly assigned to a control or intervention condition. The control group was interviewed about their breast cancer knowledge, attitude and mammography intentions prior to exposure to the intervention, and served as the baseline group. Women in the intervention group exhibited higher knowledge scores than the pretest group (Chi sq., p [less than or equal to] 0001). Never-screened women exhibited the largest differences in knowledge scores relative to the baseline sample. The intervention also increased the likelihood of women seeking information about a mammogram. KEY WORDS: Latinas; Hispanic women; multimedia; breast cancer; mammography.

This paper examines the local popular tradition of unorthodox cancer healers and treatments in the Appalachian South. An in-depth case study of an unorthodox cancer healer is presented which focuses on his recruitment to the role of healer, the origin and method of his cancer treatment, and a profile of his client population. The case study is followed by a discussion of other unorthodox healers of cancer in the region for the purpose of elucidating the distinction between the local and mass popular traditions of unorthodox cancer medicine. There is an historically deep and enduring tradition of unorthodox cancer treatments in the Appalachian South, and no doubt other regions of the U.S. as well, which should be considered for a better understanding of the health care alternatives available and the health seeking behavior of individuals who use them.

This paper explores the dynamics of health and health care in Cuba during a period of severe crisis by placing it within its economic, social, and political context using a comparative historical approach. It outlines Cuban achievements in health care as a consequence of the socialist transformations since 1959, noting the full commitment by the Cuban state, the planned economy, mass participation, and a self-critical, working class perspective as crucial factors. The roles of two external factors, the U.S. economic embargo and the Council of Mutual Economic Cooperation (CMEA), are explored in shaping the Cuban society and economy, including its health care system. It is argued that the former has hindered health efforts in Cuba. The role of the latter is more complex. While the CMEA was an important source for economic growth, Cuban relations with the Soviet bloc had a damaging effect on the development of socialism in Cuba. The adoption of the Soviet model of economic development fostered bureaucracy and demoralization of Cuban workers. As such, it contributed to two internal factors that have undermined further social progress including in health care: low productivity of labor and the growth of bureaucracy. While the health care system is still consistently supported by public policy and its structure is sound, economic crisis undermines its material and moral foundations and threatens its achievements. The future of the current Cuban health care system is intertwined with the potentials for its socialist development.

This paper reviews the research literature concerning health and selected behavioral effects of caffeine. Epidemiological and laboratory findings are reviewed to determine the health risks associated with both acute and chronic caffeine exposure. Common sources of caffeine, its properties, and physiological effects are considered. The relationships between caffeine and various health conditions are examined including caffeine's association with heart disease, cancer, and benign breast disease. Caffeine's possible contribution to enhanced exercise performance is discussed along with a brief overview of caffeine's effects on mental and emotional health. Over 100 references cited in this review were part of a more extensive literature base obtained from several on-line services including MEDLINE and LEXIS/NEXIS medical data bases. Other sources of relevant literature included manual searches of research journals and the use of selected references from appropriate articles. The relationship between caffeine consumption and various illnesses such as cardiovascular disease and cancer remains equivocal. Prudence might dictate that pregnant women and chronically ill individuals exercise restraint in their use of caffeine, although research suggests relatively low or nonexistent levels of risk associated with moderate caffeine consumption.

Acquired Immunodeficiency Syndrome (AIDS) has become the biggest problem facing the health profession of Thailand today. The Ministry of Public Health reports that there are 400,000 individuals in Thailand already infected with the Human Immunodeficiency Virus (HIV) and is predicting that 4 million will be infected by the year 2000. This explosive epidemic first occurred among intravenous drug abusers (IVDAs) and subsequently spread to other high risk groups, especially prostitutes. The heterosexual population was next affected. The AIDS problem in Thailand was seen close-up by this writer, then a fourth year medical student, studying during an international health elective. At all three hospitals where I worked, I encountered large numbers of AIDS related admissions. Ten percent of medical beds at a Bangkok hospital were occupied by patients with AIDS related problems. In comparison, two hospitals located in the northern province of Chiang Mai had 15-20% and 30-40% of their beds occupied by patients with AIDS complications. Opportunistic infections were the primary reason for admissions. This paper describes the current AIDS epidemic in Thailand and the preventive measures being undertaken to combat it. Strategies to combat AIDS focus on preventive measures. The current program in Thailand emphasizes AIDS education and awareness, the promotion of condom usage, decreasing needle sharing, the screening of donated blood, and the development of the GP160 vaccine. The program, however, has been undermined by the country's well organized sex industry. Without a clear commitment from the Thai government, Thailand faces serious health and economic consequences from this epidemic in the coming decade.

This paper documents the frequency of alcohol consumption and concurrent use of alcohol and medications in a random sample of elderly community dwellers. Further, a profile of older persons who are likely to be drinking alcohol is developed and the extent to which they are at potential clinical risk due to their concurrent use of alcohol with prescription and over-the-counter medications is explored. While approximately 43 percent are abstainers, the majority of older respondents reported using alcohol. Older drinkers who take one or more drugs which place them at potential risk for negative drug-alcohol interactions represent one-quarter of this sample but are often overlooked in estimating the extent of alcohol problems in the elderly. By far, the most common risk was from the use of OTC pain medications and alcohol (19 percent). The multivariate analyses revealed that sex, educational attainment, and religious affiliation are important factors to consider in developing a profile of older people who are at risk for alcohol-related ADRs. Implications for health care and social service professionals who work with elderly community-dwellers are discussed.

This paper presents a Community Health Education System which is cost-effective, sustainable, strongly community-based, and directed at improving the health status of rural women in Indochina (Kampuchea, Laos and Vietnam). The system is developed through a series of steps which are concerned with the education of Community Health Education Units (in national ministries of health) and, at the village level, among community health workers, women's groups, and other women. The ultimate aim is the establishment of a community health education program in Indochinese villages.

Studies of the HIV risks of crack-cocaine using women have focused on those living in the inner city, urban areas of the country. However, reports indicate that the rates of syphilis and HIV infection have shown greater increases in rural areas than in urban ones. This paper reports the findings of a comparative study of 60 female crack-cocaine users, 25 from rural southeast Georgia and 35 from Miami, Florida, to determine their drug using and sexual practices, as well as their knowledge about AIDS and HIV transmission. Their patterns of initial and continuous drug use were similar, as were their sexual practices. However, the Miami women were more likely to have had a greater number of sexual partners than the Georgia women. Both groups were knowledgeable about AIDS and the transmission of HIV, yet all participated in activities that put them at high risk for HIV infection and transmission. Some 12 percent of the 60 respondents reported testing positive for HIV. The study suggests that at least within these populations, there are few differences between rural and urban crack using women in terms of their crack use, sexual practices, and potential for HIV infection and transmission.

In 1985, residents of a suburban community in South Florida became concerned when several young women were diagnosed with breast cancer. First as individuals, then through a community-based effort, they attempted to gain attention and action on what they believed to be a cluster of breast cancer. Through their efforts to find out whether some agent or toxic exposure existed in the community that might have caused breast cancer, the women formed a community-based organization. This paper describes the activism of the women to resolve the issue through an epidemiologic study of the breast cancer occurrence in their community. Furthermore, it substantiates the need and role of rational community response in resolving community threats and concerns.

This paper explores the relationship between risky sexual behavior and issues of gay identity in homosexual men. We identify three main conceptual categories important to gay identity: sexual identity, gay social interaction, and identity development milestones. Each of these categories are analyzed as to their predictive effect on risky sexual behavior related to the threat of HIV, at six-month and eighteen-month intervals. The results suggest that successful integration into a gay network plays a role in reducing risky sexual behavior among homosexual men, regardless of the chronological timing of personal events marking a gay man's "coming out" history.

This paper discusses the contributions of public health to compliance in five areas: clinical trials, smoking cessation, dietary compliance, breast cancer screening and hypertension control. Public health programs have been based on a number of theoretical foundations, most notably, social learning theory and the health belief model. Social marketing, community organization, and, more recently, consumer information processing models also are important. The strongest public health programs embody an ecological approach, with interventions directed not only at individuals, but also at groups, communities and changing institutional norms. Among the most important contributions of public health interventions are: multiple levels of intervention and evaluation, tailoring to target audiences, use of social support and community organization for behavior change. Together, community health and clinical compliance-enhancing strategies can exert a synergistic impact on health behavior change.

This paper describes the development of consultancy groups in behavioral science, epidemiology and biostatistics, and information science in a required community medicine rotation with a twenty year history. The addition of consultants to individual student tutors and field preceptors has led to a structure which promotes student-project flexibility, development of critical assessment skills and independent learning while maximizing faculty expertise and effectiveness.

The objectives of the paper were to identify barriers to community participation in road safety activities and to recommend strategies to reduce those barriers. Information was obtained from: a review of relevant literature, from the authors' extensive community-based experiences, from undertaking community-based research, and from interviews with key stakeholders in road safety in Western Australia. Ten significant barriers to community participation were identified. These are classified into two groups: personnel and planning issues. The former includes: reasons why people are often reluctant to become involved in projects in their communities, a lack of leadership, and a lack of skills. The latter includes: inappropriate program foci, inappropriate program evaluation, lack of resources, and a lack of sustainability. It was concluded that the barriers to community involvement in road safety initiatives are similar in many parts of Australia and overseas and apply to a wide range of health promotion interventions besides road safety. Awareness of the barriers and knowledge of their solutions can ensure that appropriate steps are taken to maximise the likelihood of community participation. KEY WORDS: community participation; community mobilization; health promotion; capacity building; road safety.

Health reform is an important movement in countries throughout the region of the Americas, which could profoundly influence how basic health services are provided and who receives them. Goals of health sector reform include to improve quality, correct inefficiencies, and reduce inequities in current systems. The latter may be especially important in countries with indigenous populations, which are thought to suffer from excess mortality and morbidity related to poverty. The purpose of this paper is to report the results of a community health assessment conducted in 26 indigenous communities in the Province of Cotopaxi in rural Ecuador. It is hoped that this information will inform the health reform movement by adding to the current understanding of the health and socioeconomic situation of indigenous populations in the region while emphasizing a participatory approach toward understanding the social forces impacting upon health. This approach may serve as a model for empowering people through collective action. Recommended health reform strategies include: 1) Develop a comprehensive plan for health improvement in conjunction with stakeholders in the general population, including representatives of minority groups; 2) Conduct research on the appropriate mix between traditional medicine, primary health care strategies, and high technology medical services in relation to the needs of the general population; 3) Train local health personnel and traditional healers in primary health care techniques; 4) Improve access to secondary and tertiary health services for indigenous populations in times of emergency; and 5) Advocate for intersectoral collaboration among government institutions as well as non-governmental organizations and the private sector. KEY WORDS: health care reform; indigenous peoples; participatory assessment.