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The purpose of this paper was to trace the development of the Neighborhood Health Center Program supported under section 314(e) of the Public Health Service Act, as amended, and to extract from this project grant experience some implications for the best future use of federal health services project grant funds. These implications were drawn in the context of emerging federal and private sector initiatives in the areas of financing, organization, and delivery of health services, such as health maintenance organizations and national health insurance. Although the paper was presented 2 years ago, the authors feel the conclusions in the paper remain germane today. [ABSTRACT FROM AUTHOR]

The threshold of the new millennium offers an opportunity to celebrate remarkable past achievements and to reflect on promising new directions for the field of public health. Despite historic achievements, much will always remain to be done (this is the intrinsic nature of public health). While every epoch has its own distinct health challenges, those confronting us today are unlike those plaguing public health a century ago. The perspectives and methods developed during the infectious and chronic disease eras have limited utility in the face of newly emerging challenges to public health. In this paper, we take stock of the state of public health in the United States by (1) describing limitations of conventional US public health, (2) identifying different social philosophies and conceptions of health that produce divergent approaches to public health, (3) discussing institutional resistance to change and the subordination of public health to the authority of medicine, (4) urging a move from risk factorology to multilevel explanations that offer different types of intervention, (5) noting the rise of the new "right state" with its laissez-faire attitude and antipathy toward public interventions, (6) arguing for a more ecumenical approach to research methods, and (7) challenging the myth of a value-free public health. (Am J Public Health. 201)0;90:25-33) [ABSTRACT FROM AUTHOR]

Abstract: Under the rubries of preventive and social medicine, public health, and family arid community medicine, medical educators in Latin America have developed programs to train physicians for community-oriented health care (COPC). The historical background for such programs in Latin America is reviewed. Three relevant examples of programs in Mexico. Nicaragua, and Costa Rica are highlighted, drawing on the author's direct experience with and in these faculties. The paper addresses the relation between these programs, and national and regional trends in education and services. (Am J Public Health 1987:77:485-490.) [ABSTRACT FROM AUTHOR]

Abstract: One of the 1990 Health Objectives established by the U.S. Department of Health and Human Services is for 60 per ¢ of adults 18-65 years of age to be participating regularly in vigorous physical exercise. Unfortunately, no valid and practical measurement system is available that will allow assessment of leisure lime physical activity participation of large populations. Consequently, not only is it difficult to assess progress toward the 1990 goal, an accurate baseline from which to measure potential progress does not exist. This paper presents a time diary technique for measuring aggregate population physical activity participation and utilizes actual time diaries collected from adults by the Institute for Social Research in 1981 to arrive at a possible baseline. The results indicated that time diaries are a viable method for assessing aggregate physical activity behavior of large populations. American Adults were quite sedentary in 1981. Over a period of one week, 31% undertook no leisure time physical activity. Only 14 per ¢ expended more than 1600 kcals/week in leisure time physical activity, and 10 per ¢ met the DHHS physical activity requirements. (Am J Public Health 1987:77:455-460.) [ABSTRACT FROM AUTHOR]

Abstract: This paper reports the home-facility and level of care changes, discharges, and deaths over a five-year period for 1,653 clients newly admitted in 1978 to a long-term care program in British Columbia, Canada. Five years after admission, of clients initially admitted to care at home (N = 1241), 34,3 per ¢ were still in the program (14.5 per ¢ unchanged; 6.7 per ¢ at home but at a higher level of care, and 11.7 per ¢ in facilities). Of the remainder, 38.9 per ¢ had died and 26.8 per ¢ had been discharged. Findings for those initially admitted to care in facilities (N = 412) are remarkably similar. After five years, 28.4 per ¢ of these clients were still in the program; 39.3 per ¢ had died. Moves from facility to home care were few (2.4 per ¢). Despite their advanced age at admission (X = 74.7, S.D. 14.6), one-third were still in the program five years later, some with status virtually unchanged. INSET: Health Implications of Smokeless Tobacco Use. [ABSTRACT FROM AUTHOR]

The World Health Organization's goal of Health for All by the Year 2000 (HFA) has become a major force in national and international health policies. This paper deals with some of the historical roots of HFA and describes ways in which the major components of the health sector--health services, manpower, and universities--have evolved and should evolve in the future if they are to support the idea of HFA. One conclusion is that the changes called for in relation to HFA are not simply incremental extensions of previous values, structures, and functions. Rather a radical break with the past is often required. To expect otherwise is to misunderstand how fundamentally the concepts of HFA differ from values that have governed the health sector in the past. A second conclusion is that recent decades have seen a remarkable progression of new ideas and changes in the health sector, so much so that the changes called for by HFA are not so improbable as one might otherwise think. (Am J Public Health 1984: 74:714-719.) [ABSTRACT FROM AUTHOR]

This paper describes the place and level of care of an urban and a semi-rural health unit for which 1,653 clients began their experience in British Columbia's Long-Term Care (LTC) program and where they were one and three years later. Three years after admission, 54 per cent of 759 clients initially admitted at home to the lowest level of care were still active clients: 25.8 per cent unchanged. 11.3 per cent at home but at a higher level of care, 16.9 per cent had moved to facilities. 25.4 per cent had died: the remainder of this group had been discharged from LTC. A similar proportion of the 184 clients admitted to the lowest level of care in facilities were still in the program at the end of three years. In contrast, 25 per cent of those admitted to the highest level of care at home (N=60) and 14.1 per cent of those admitted to the highest level in facilities (N-64) remained in the program after three years. The potential of the study data for planning purposes is suggested. [ABSTRACT FROM AUTHOR]

Abstract: This paper concerns care of refugees from Southeast Asia who speak little English and are relatively unfamiliar with the formal health care system in the United States. It aims to demystify the behaviors of refugee patients and to support health practitioners who are attempting to care for them. Western medicine is discussed in terms of the expectations that refugees tend to hold of it, and of the conflicts with Southeast Asian beliefs and practices which it presents. Despite language differences, health care agents can increase the effectiveness of their communication with persons from Southeast Asia, primarily by allowing for their viewpoints. Topics discussed are: the first encounter with a refugee patient: use of interpreters; obtaining informed consent: "the passive obedient" patient: the "non-compliant" patient: body image: sources of social support for healing; use of medications; traditional self-care practices; and death and depression. (Am J Public Health 1983: 73:431-438.) [ABSTRACT FROM AUTHOR]

Abstract: This paper' explores the relationships among physician supply, workload (output per physician), and utilization (physician services per capita) in rural Manitoba. Surgery taking place within a patient's home area and that taking place outside this area arc discussed. Longitudinal and cross-sectional analyses are compared, Although the average surgeon does more surgical procedures than docs the average general practitioner, the number of procedures performed varies greatly within each specialty. Individual physician workloads remained fairly stable over time when a surgically active physician moved into an area, while population utilization increased 17 per ¢. When such physicians left an area, the surgical workloads of the physicians increased significantly (18.7 per ¢) while population utilization stayed essentially the same. Both physician workload and surgical utilization in control areas increased gradually (between 6 and 7 per ¢) over' the period studied. Several models of physician behavior were investigated using data on individual procedures as well as overall figures. A model emphasizing the importance of physician discretion appeared to provide the best fit with the data. (Am J Public Health 1983: 73:414421.) [ABSTRACT FROM AUTHOR]

The design of a comprehensive evaluation of subsidized rural primary care programs on a large national scale is described. Its major purpose is to derive data whose analysis will answer major policy questions about the factors influencing the outcome of the major types of such programs in different communities. This first paper also delineates a typology which was developed of five principal organizational forms of these programs. This classification appears to provide suitable operational definitions of forms of rural practice as a basis for evaluating the differential impact of alternative types of primary care programs. [ABSTRACT FROM AUTHOR]

Abstract: This paper examines the experience of the Robert Wood Johnson Foundation's Rural Practice Project (RPP), a major non-governmental effort in the last decade concentrating on the direct delivery of rural health services. The nine RPP sites started prior to 1977 showed a slow but steady increase in their utilization levels and improvement in their financial status during their initial operational years. The tempo of their development was remarkably similar to that of federally sponsored practices in underserved rural areas. After four years of operation, all of the practices had completed their period of grant support: the practices survived in all cases, with almost all of the practices still retaining community sponsorship, salaried physicians, and a commitment to comprehensive care. Practices in sparsely populated rural areas and in areas with fewer hospital beds grew more slowly than those set in rural areas with higher population density and more ancillary resources. We conclude that the use of time-limited initial subsidies is an effective strategy in starting new rural practices in underserved areas anti that those practices have a good chance of surviving their start-up phase. (Am J Public Health 1982: 72: 1380-1385). [ABSTRACT FROM AUTHOR]

Abstract: Emergency Medical Service (EMS) evaluation is usually conducted on an aggregated, system-wide basis, despite the fact that there is substantial geographical variation in EMS performance. This paper suggests a method for the identification and analysis of geographically disaggregated EMS performance, using Seattle's Medic I program as an example. (Am J Public Health 1981; 71:841-844.) [ABSTRACT FROM AUTHOR]

There is a challenging need to identify the relationships between environmental quality and health status. It may be especially important to be able to isolate key variables which can be consolidated into a few indices of environmental conditions as they are related to health. Such indices might be used to identifying associations among groups of variables, such as specific geographic area. The indices may also provide insights into environmental health relationships which are worthy of further epidemiological investigation. Canonical correlation analysis is a multivariate statistical technique which provides a means of identifying associations among groups of variables, such as health and environmental measures. The technique can produce weighted indices of environmental conditions as they are related to health within a city or region. This paper describes what canonical correlation is, and outlines how it might be used for these purposes. An illustrative application based on data collected for Philadelphia, Pennsylvania is also presented. (Am. J. Public Health 69:353-359, 1979.) [ABSTRACT FROM AUTHOR]

This paper examines the uses of some health status indices in measuring equity of access to medical care. Empirical examples are provided using data from national surveys of the U.S. population conducted from 1964 through 1976. A simple indicator, mean number of physician visits, suggests that between 1963 and 1976 the poor improved their position relative to the rest of the population and, indeed, currently enjoy the highest level of access. However, a second measure, the use-disability ratio indicates that the poor may still receive less care relative to their need. A third measure, the symptoms-response ratio suggests how norms of appropriate behavior might be incorporated into an access measure. [ABSTRACT FROM AUTHOR]

During the past two years we have studied the characteristics of state and territorial public health laboratories in an attempt to develop guidelines for considering reorganization of laboratory services in Massachusetts. Only a few recent monographs have dealt with this topic and, to our knowledge, the functional and organizational characteristics of these laboratories have not been reviewed. The state public health laboratory system affords an excellent example of applied laboratory science or technology organized to provide basic public health services. In this paper the programs and organization of the state public health laboratory are reviewed, and a functional basis more responsive to society's current needs is suggested. INSET: Cheap Bubble Fountains. [ABSTRACT FROM AUTHOR]

The article comments on the public health promotion policy in the U.S. proposed by J. B. Richmond and M. Kotelchuck in their paper titled "Coordination and Development of Strategies and Policy for Public Health Promotion in the United States," that was published in the book "Oxford Textbook of Public Health." According to the authors, the health policy model devised by Richmond and Kotelchuck posits that there are three necessary ingredients that make preventive action happen, namely, the knowledge base; the political will to support change; and a social strategy to accomplish change.

This paper models the prevailing political attack on government as a heuristic, a judgmental strategy that simplifies complex phenomena by applying simple tests to a limited set of relevant data. The heuristic of market individualism offers three tools for analyzing the problems of governing: the supremacy of the free market as a regulatory device, a belief in individual freedom of choice and personal responsibility, and the elevation of individual satisfaction as the chief goal of society. Because public health is inherently concerned with the health of the population rather than individual health, because the market itself is a major source of ill health, and because individual choice is socially mediated, use of the heuristic precludes the recognition of the value of public health work. Although some degree of accommodation to current political realities is a practical necessity, public health advocates must not neglect the task of fashioning radically different alternative visions over the long term. [ABSTRACT FROM AUTHOR]

This paper traces the development of the US federal government's program to provide personal and public health services to American Indians and Alaska Natives since the 1940s. Minimal services had been provided since the mid 19th century through the Bureau of Indian Affairs of the Department of the Interior. As a result of attempts by western congressmen to weaken and destroy the bureau during the 1940s, responsibility for health services was placed with the US Public Health Service. The transfer thus created the only US national health program for civilians. providing virtually the full range of personal and public health services to a defined population at relatively low cost. Policy changes since the 1970s have led to an emphasis on self-determination that did not exist during the 1950s and 1960s. Programs administered by tribal governments tend to be more expensive than those provided by the Indian Health Service, but appropriations have not risen to meet the rising costs, nor are the appropriated funds distributed equitably among Indian Health Service regions. The result is likely to be an unequal deterioration in accessibility and quality of care. [ABSTRACT FROM AUTHOR]

Objectives. This paper analyzes the impact of seven chronic conditions (three nonfatal: arthritis, visual impairment, hearing impairment; four fatal: ischemic heart disease, chronic obstructive pulmonary disease, diabetes mellitus, malignant neoplasms) on US adults aged 18 and older. Impact refers to how readily a condition prompts activity limitations, physician visits, and hospital stays. Methods. Data come from three national health surveys and vital statistics. For comparability, a single disease classification scheme was applied, and new rates were estimated. Frequency, impact, and prominence of the target conditions are studied via rates, ratios of rates, and ranks, respectively. Results. In young adulthood, the nonfatal conditions prompt limitations less readily than do the fatal ones, but by older ages, arthritis and visual impairment have a limiting impact equivalent to that of fatal conditions. Despite high prevalence and limitations, nonfatal conditions stand well below fatal conditions for health services use. Conclusions. Although statistics on frequency, impact, and prominence all indicate conditions' "importance," they give only weak clues about specific service needs of affected persons. The persistent finding that nonfatal conditions do not receive health services care commensurate with their prevalence and impact reflects long-standing imbalanced attention on fatal conditions in research and medical care. [ABSTRACT FROM AUTHOR]

Ecological studies have been evaluated in epidemiological contexts in terms of the "ecological fallacy." Although the empirical evidence for a lack of comparability between correlations derived from ecological- and individual-level analyses is compelling, the conceptual meaning of the ecological fallacy remains problematic. This paper argues that issues in cross-level inference can be usefully conceptualized as validity problems, problems not peculiar to ecological-level analyses. Such an approach increases the recognition of both potential inference problems in individual-level studies and the unique contributions of ecological variables. This, in turn, expands the terrain for the location of causes for disease and interventions to improve the public's health. [ABSTRACT FROM AUTHOR]

Adults, defined here as people between 15 and 59 years of age, in developing countries have a high risk of premature death and suffer from frequent morbidity and high rates of chronic impairment. Their ill health imposes a major burden on health services and large negative consequences on families, communities, and societies. This paper describes the level and impact of adult mortality and morbidity, and highlights some of its characteristics and causes, which in some cases contradict commonly held beliefs. It concludes that "adult health" is a legitimate public health concern for developing countries that is not being addressed. An agenda for remedial research and action is proposed. [ABSTRACT FROM AUTHOR]

Background: This paper describes utilization of mental health services by poor Puerto Ricans living on the island. It examines the utilization rates, within health sectors, and settings for the provision of mental health services. Methods. Data are based on an islandwide probability sample of 18- to 64-year old respondents living in low socioeconomic areas. We assessed need with the Psychiatric Symptom and Dysfunction Scales. Results: Approximately one-third of our study population (31.5%) met criteria for need. Of these, only 32% had received any mental health care in the past year. Need was significantly associated with use of physical or mental health services for mental health problems. We found those who needed services to be five times more likely than those who did not need services to have used one or both sectors of care at least once in the past year. Among the first group 21.8% used the physical health sector to deal with mental health problems in contrast with 17.9% who sought care in the mental health sector. In the physical health sector, subjects used the public and private settings equally. In the mental health sector, 70% of subjects used the public setting. Conclusions: This suggests the nonpsychiatric physician as a main provider for mental health treatment. [ABSTRACT FROM AUTHOR]

The Harvard resource-based relative value scale (RBRVS) for physician services has assumed a critical role in physician payment reform. We have demonstrated that the relative resource costs of providing physician services can be defined and measured in a rational and systematic way and that the results are reliable and valid. Consequently, the RBRVS is a viable basis for national payment policy and could be used for establishing a national fee schedule for physician services or to identify "mispriced" physician procedures, Since the release of the final report of the first phase of the Harvard RBRVS study in September of 1988, there has been extensive review, discussion, and criticism of the RBRVS, Dr. Laurence F. McMahon, Jr., in the accompanying article, provides a further critique of our research. In this paper, we review the RBRVS study and results and respond to the major criticisms that have been raised by Dr. McMahon and others. We then describe the tasks we are currently undertaking to expand and validate our research and address the important criticisms and limitations. [ABSTRACT FROM AUTHOR]

Employee flexible spending accounts for health care represent one component of the current health care financing system that merits serious reform. These accounts create a system of undesirable incentives, force employees and employers to take complicated gambles, reduce tax revenues, and fail to meet their purported policy objectives. This paper describes shortcomings in these accounts from both a theoretical and an empirical perspective. Some proposed alternatives, including medical spending accounts and zero balance accounts, resolve many of these concerns but not all of them. [ABSTRACT FROM AUTHOR]

This paper documents oral health and public health expenditures for fiscal years 1984, 1986, 1988, and 1989, as reported by state health agencies. During this period, reported national expenditures for public and oral health increased 68% and 46%, respectively; between successive fiscal years, fewer states (73%, 67%, 57%) reported increased oral health expenditures, while increasingly more states reported no categorical oral health expenditures. Block grant expenditures for oral health increased overall but decreased as a percentage of total oral health expenditures; 16 stages reported no block grant expenditures for oral health in fiscal year 1989, perhaps reflecting either substantial state support, or marginal to nonexistent oral health programs in these states. [ABSTRACT FROM AUTHOR]

The article reports on the announcement of Vision Care Section of the American Public Health Association in the U.S. of its awards program for 1987. The association solicits nominations in the three categories of awards including distinguished achievement, outstanding student and outstanding paper or project. The distinguished achievement award is the highest honor bestowed by the Vision Care Section, designed to recognize the leaders in vision care and public health. The outstanding student award provides recognition to a student who has demonstrated the ability in the promotion of vision care in the public health field. The paper or project award is designed to recognize an individual, institution, or group that have significantly contributed to the advancement of vision care.

The article presents a position paper from the American Public Health Association relative to the improvement of health care in prisons, jails, and youth detention centers in the U.S. The association backs the recommendation for a federal strategy to help improve health care these centers as structured by the report of General Accounting Office to U.S. Congress. It also supports the Health Services Administration's Prison Health Initiative aimed to assign National Health Service Corps staff to prisons and jails. In addition, the group urges the development of periodic and independent medical audit reviews to check that standards are being met and quality care provided. Other significant decisions of the group are presented.

The article discusses various reports published within the March 1993 issue of the "American Journal of Public Health." It introduces two papers that describe the results of experiments testing the efficacy of health promotion programs in the workplace. Moreover, a study that aims to determine the efficacy of a smoking cessation program is mentioned. It addresses the potential of the workplace as a site for delivery of effective health programs and medical services. Furthermore, medical centers should take part in the initiation of a dialogue by inquiring about the issues that are of concern in the workplace.

This paper describes changes in the population for which General Motors provides health benefits using data from domestic personnel records. Total population size grew from 2.01 million in 1983 to 2.14 million in 1987, twice as fast as the US populations. Dependents, particularly spouses, fueled the population growth. Trends suggest that nonworker eligibility for employer-provided health benefits may receive more attention in health care cost containment efforts. [ABSTRACT FROM AUTHOR]

The author talks about the results of the National Preventive Dentistry Demonstration Program(NPDDP). He states that his paper on school-based preventive dental care was directed at providing an alternative way of interpreting the results of the NPDDP. He asserts that any interpretation still leaves many questions regarding school-based preventive programs unanswered considering either sample size or design. He suggests that it is incumbent upon all public health researchers to foster a healthy climate of free and open discourse on preventive health discourse.

The article presents a position paper from the American Public Health Association relative to the availability of nutrition status data to local health agencies in the U.S. The association encourages that there be adequate personnel and funding to make surveillance data collected by the Center for Disease Control available to all the states and territories of the U.S. It also encourages that there be enough funding and manpower to enable the administrators of the Health and Nutrition Examination Survey of the National Center for Health Statistics to formulate a method to make data available and more useful to local communities and develop future surveys to accomplish the purpose.