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This study examines and explains the gender disparity in health despite rapid modernization in South Korea where the social structure is still based on traditional gender relations. A nationally representative sample of 2897 men and 3286 women aged 25-64 from the 2001 Korean National Health and Nutrition Examination Survey was analyzed. Health indicators included self rated health and chronic disease. Age-adjusted prevalence was computed according to a gender and odds ratios (OR) derived from logistic regression. Percentage changes in OR by inclusion of determinant variables (socio-structural, psychosocial, and behavioral) into the base logistic regression model were used to estimate the contributions to the gender gap in two morbidity measures. Results showed a substantial female excess in ill-health in both measures, revealing an increasing disparity in the older age group. Group-specific age-adjusted prevalence of ill-health showed an inverse relationship to socioeconomic position. When adjusting for each determinant, employment status, education, and depression contributed the greatest to the gender gap. After adjusting for all suggested determinants, 78% for self rated health and 86% for chronic disease in excess OR could be explained. After stratifying for age, the full model provided a complete explanation for the female excess in chronic illness, but for self rated health a female excess was still evident for the younger age group. Socio-structural factors played a crucial role in accounting for female excess in ill-health. This result calls for greater attention to gender-based health inequality stemming from socio-structural determinants in South Korea. Cross-cultural validation studies are suggested for further discussion of the link between changing gender relations and the gender health gap in morbidity in diverse settings. Keywords: Social determinants South Korea Health inequalities Gender differences Modernization Social change

Spatially aggregated data are frequently used for official statistics and by researchers investigating the contextual determinants of health. Results of reporting and analysis vary according to the choice of areal unit. This is the well-known Modifiable Areal Unit Problem or MAUP. Its implication for the monitoring and understanding of area inequalities in health has received little empirical attention in the public health literature. Health differences will likely be smallest across arbitrarily chosen areas whereas boundaries acknowledging the physical and social geography should indicate greater differences between areas. Here we use three methods to define area boundaries and compare the extent of health inequalities across each drawing on data from the London boroughs of Camden and Islington. Irrespective of the boundary definition used, between-area inequalities in obesity, alcohol intake, smoking, walking and self-rated health were small compared with inequalities between individuals. There was a tendency for slightly larger estimated inequalities across areas defined by socioeconomic homogeneity compared with other definitions, but differences between methods were very small in magnitude. Existing studies predominantly use area boundaries that are based on administrative boundaries. Although these have little theoretical basis for the study of neighbourhood inequalities in health, our findings indicate that alternative definitions of the neighbourhood boundaries have no substantive effect on the estimates of those inequalities. Based on these findings, we can have greater confidence in the results of numerous studies which have used administrative boundaries to define the neighbourhood. Keywords: UK Inequalities Health inequalities Neighbourhood Multilevel modeling Zone design Modifiable Areal Unit Problem

Quality of care research has reached some agreement on concepts like structure, process and outcome, and non-clinical versus clinical processes of care. These concepts are commonly explored through surveys measuring patient experiences, yet few surveys have focused on patient, or 'user', priorities across different quality dimensions. Population surveys on priorities can contribute to, although not replace participation in, policy decision making. Using 105,806 survey interview records from the World Health Organization's (WHO's) general population surveys in 41 countries, this paper describes the relative importance of eight domains in the non-clinical quality of care concept WHO calls 'health systems responsiveness'. Responsiveness domains are divided into interpersonal domains (dignity, autonomy, communication and confidentiality) and structural domains (quality of basic amenities, choice, access to social support networks and prompt attention). This paper explores variations in domain importance by country-level variables (country of residence, human development, health system expenditure, and 'geographic zones') and by subpopu-lations defined by sex, age, education, health status, and utilization. Most respondents selected prompt attention as the most important domain. Dignity was selected second, followed by communication. Access to social support networks was identified as the least important domain. In general, convergence in rankings was stronger across subpopulations within countries than across countries. Yet even across diverse countries, there was more convergence than divergence in views. These results provide a ranking of quality of care criteria for consideration during health reform processes further to the usual emphasis on clinical quality and supply-side efficiency. Keywords: Global surveys; Quality of care criteria; User-responsiveness; Population priorities; WHO; Comparative

We explored attitudes to and experiences of Child and Adolescent Mental Health Services (CAMHS) among families of South Asian origin who are underrepresented as service-users in an area of a Scottish city with a high concentration of people of South Asian origin. Six community focus groups were conducted, followed by semi-structured interviews with families who had used CAMHS and with CAMHS professionals involved in those families' cases. Lastly, parents of children who had problems usually referred to CAMHS but who had not used the service were interviewed. Qualitative analysis of transcripts and notes was undertaken using thematic and logical methods. Participants consisted of 35 adults who identified themselves as Asian and had children; 7 parents and/or the young service users him-herself; 7 health care professionals involved in the young person's care plus 5 carers of 6 young people who had not been referred to CAMHS, despite having suitable problems. Focus groups identified the stigma of mental illness and the fear of gossip as strong disincentives to use CAMHS. Families who had been in contact with CAMHS sought to minimise the stigma they suffered by emphasising that mental illness was not madness and could be cured. Families whose children had complex emotional and behavioural problems said that discrimination by health, education and social care professionals exacerbated their child's difficulties. Families of children with severe and enduring mental illness described tolerating culturally inappropriate services. Fear of gossip about children's 'madness' constituted a major barrier to service use for Asian families in this city. Given the widespread nature of the concern over the stigma of children's mental illness, it should be considered in designing culturally competent services for children's mental health. Keywords: UK; Mental health; Ethnicity; Access to services; Qualitative methods; Children; Adolescents

Encouraging self-management has been viewed as one means of reducing health service utilisation and contributing to improved demand management. However, the processes and imputed relationship between self-management education skills and health service contact are poorly understood. This paper reports on data from an embedded qualitative study which ran alongside a randomised controlled trial in England designed to test the clinical and cost effectiveness of a self-care support policy which found no statistically significant reductions in health service utilisation. Drawing on concepts from the sociology of chronic illness, analyses suggest that the biographical and social context relevant to individuals' experience of living with a long-term condition, history of health service utilisation, and relationships with health professionals are relevant to understanding the impact of self-management education and related policies aimed at bringing about changes in service use. Our study suggests that future health policy assumptions about utilisation in the context of chronic disease management and self-care support polices may benefit by acknowledging the complex, contextual and recursive nature of health service utilisation operating in the life worlds of patients' experience of living with a long-term condition. Keywords: UK; Self-care; Self-management; Health service utilisation; Chronic illness

Primary health care (PHC) is a systems perspective for examining the provision of essential health care for all. A multidisciplinary collaborative approach to health care delivery is associated with effective delivery and care providers' enrichment. Yet data regarding multidisciplinary practice within PHC are limited. The purpose of this exploratory qualitative descriptive study was to better understand team-based PHC practice in the US. Aims included (a) describing nursing faculty involvement in PHC, (b) analyzing ways that multidisciplinary work was enacted, and (c) recommending strategies for multidisciplinary PHC practice. After institutional review board (IRB) protocol approval, data collection occurred by: (a) surveying faculty/staff in a Midwestern nursing college (N = 94) about their PHC practice, and (b) interviewing a purposive sample of nursing faculty/staff identified with PHC (n = 10) and their health professional collaborators (n = 10). Survey results (28% return rate) were summarized, interview notes were transcribed, and a systematic process of content analysis applied. Study findings show team practice is valued because health issues are complex, requiring different types of expertise: and because teams foster comprehensive care and improved resource use. Mission, membership attributes, and leadership influence teamwork. Though PHC is not a common term, nurses and their collaborators readily associated their practice with a PHC ethos. PHC practice requires understanding community complexity and engaging with community, family, and individual viewpoints. Though supports exist for PHC in the US, participants identified discord between their view of population needs and the health care system. The following interpretations arise from this study: PHC does not explicitly frame health care activity in the US, though some practitioners are committed to its ethics; and, teamwork within PHC is associated with better health care and rewarding professional experience. Nurses integrate PHC in multiple roles and are experts at aspects of PHC teamwork. Keywords: USA; Primary health care; Multidisciplinary; Teamwork; Nurses

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2006.04.027 Byline: Kate Wood, Elaine Chase, Peter Aggleton Keywords: Zimbabwe; Orphans; Grief; HIV/AIDS; Disclosure; Communication; Children Abstract: Zimbabwe is one of the countries most affected by HIV/AIDS, and as elsewhere in southern Africa, the impact on children and young people living in affected households is significant. Loss is highly complex and dependent on developmental stage, resilience, quality of care, and social support networks, and often includes a progression of experiences from the onset of a parent's or caregiver's illness, through to the aftermath of death. For several reasons, AIDS-related bereavement is likely to be especially complicated and difficult to accommodate. Understandings of bereavement and grief among African children, and adults' responses to orphans' psychological difficulties, remain under-developed. This paper focuses on the narratives of older children in their teens, who have experienced parental AIDS-related illness and death in six sites in Zimbabwe. A key finding is that, while many orphaned teenagers desire direct communication with adults about parental illness and death, adults themselves -- whether the sick parent, other relatives in the household or a caregiver following parental loss -- are often ill-equipped to identify and manage children's distress positively. While most existing psychosocial interventions focus on bereaved children, this paper suggests that, in order to create an enabling environment for orphans, building the capacity of key adults in orphans' lives, particularly surviving relatives, caregivers, and teachers to address emotional issues relating to parental loss constructively is an essential, but neglected, area of programming. Author Affiliation: Institute of Education, University of London, 27/28 Woburn Square, London WC1H 0AA, UK

This study measures socioeconomic inequalities in health across European Union Member States between 1994 and 2001. The analysis is based on the European Community Household Panel Users' Database (ECHP-UDB) and uses two binary indicators of health limitations for the full 8 waves of available data. Short- and long-run concentration indices together with mobility and health achievement indices are derived for indicators of severe health limitation and any health limitation. Results demonstrate the existence of socioeconomic inequality in health across Member States in both the short-term (1 year) and the long-term (up to 8 years), with health limitations concentrated among those with lower incomes. For all countries, the long-run indices show that income-related inequalities in health widen over time, in the sense that the longer the period over which an individual's health and income are measured the greater the measure of income-related health inequality. The ranking of countries according to their prevalence of illness differs from ranking by overall health achievement, which takes account of inequalities. This means that an equity-efficiency trade-off has to be faced in evaluating the performance of different countries and in comparing countries with diverse health and social welfare systems. Keywords: Europe; Health inequalities; Social mobility; Panel data

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2006.02.007 Byline: David P Lindstrom, Elisa MuA[+ or -]oz-Franco Keywords: Migration; Social networks; Maternal health care; Multi-level; Guatemala Abstract: This article examines the relationship between migration and the use of formal maternal health-care services among rural women in Guatemala. We identify assimilation, diffusion, and remittances as three potential pathways through which migration can affect health-care service utilization in rural areas. Using data from the 1995 Guatemalan Survey of Family Health and multi-level regression models, we estimate the impact of migration experience at the individual, household, and community level on the use of formal prenatal care and delivery assistance. We find that urban migration experience and having relatives abroad are associated with a greater likelihood of formal prenatal care utilization, after taking account of background characteristics and enabling resources. Migration experience at all levels is also strongly associated with formal delivery assistance; however, this association operates primarily through the positive association between migration and enabling resources. The differential effects of out-migration on maternal health-care service utilization reflect the different barriers to service use that exist for formal prenatal care and delivery assistance. Financial cost and geographic access are the most important barriers to formal delivery assistance, whereas awareness and acceptance remain as important barriers to the use of formal prenatal care in rural Guatemala. Urban migration experience and social ties to urban and international migrants lower the barriers to formal maternal health-care utilization through the acquisition and diffusion of new ideas and practices, and the return flow of financial resources. Author Affiliation: Brown University Providence, RI, USA

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2005.11.054 Byline: Francine M. Toye (a), Julie Barlow (b), Chris Wright (b), Sarah E. Lamb (c) Keywords: Osteoarthritis; Total knee replacement; Patient experience; UK; Gender Abstract: This study explores patients' personal meanings of knee osteoarthritis (OA) and total knee replacement (TKR). Personal meanings are important because decisions regarding the need for TKR do not seem to be explained by symptoms alone. A total of 18 semi-structured interviews were conducted with a purposive sample of respondents who were listed for TKR at one UK specialist orthopaedic hospital, and who had lower than average disease burden according to standard quantitative criteria. Data were analysed using interpretive phenomenological analysis. Several themes related to need for TKR emerged: adoption of the medical model, a person's social network, pain, functional loss, feelings of vulnerability, dependency, low mood and fatigue, ideas related to disease progression and expectations of TKR. Results suggest that the decision to undergo TKR is not related to symptoms alone, but to personal meanings. Some of these personal meanings may not be useful in accurately assessing the need for TKR, and may result in mis-targeting of treatment. It is important for health professionals to explore and tackle personal meanings when considering treatment. In particular, it may be important to consider gender differences that may influence when men and women are listed for TKR. For example: women may be less likely to discuss treatment options with their doctor; they may be more likely to have heard negative examples of TKR from friends or family; they may be more likely to discuss pain and mobility issues than activities requiring higher function; and they may be more likely to discuss the effect on their mood and the emotional impact of OA. Author Affiliation: (a) Department of Physiotherapy, Nuffield Orthopaedic Centre, Windmill Road, Oxford OX3 7LD, UK (b) Interdisciplinary Research Centre in Health, Coventry University, UK (c) Warwick Medical School, University of Warwick, UK

In many countries health policy has been guided by a focus on the supply side factors of access to health care, a lot of attention being directed at the availability of services. This paper concentrates on the demand side of access and investigates relational factors that may limit people's subjective choice sets or their freedom to utilise health services, emphasising that relations between service providers and individuals are based on an interchange of information. It develops an argument for health communication strategies based on an interactive exchange of information as a means of improving access and is intended as a conceptual basis for further debate. Trust assumes a key position within this transactional process of information exchange or communicative interaction. Information may enlarge individual choice sets and increase the freedom to use health care; it serves as a stimulus for access. The paper argues that trust plays a role in the utilisation of provided information. Trust emerges as a prerequisite of the effectiveness of information with regard to access. A discussion of the origins of trust shows that, while trust enhances communicative interaction, it is the process of communicative interaction that generates trust in the first place. Culturally diverse societies are often low-trust environments. The paper analyses the driving forces of trust and distrust in health care within these societies and delineates barriers for the individual and the community to the transfer of information. Specific characteristics of health communication turn out to be key determinants of access. In conclusion, principles for health policy on equity and information are derived which are rooted in a distinctive notion of democratic societal structure. Keywords: Access; Health communication; Information; Trust

In Colombia, dengue has been a target for public health interventions since the 1950s, with inadequate results. Furthermore, during the last few years in Colombia, the reported cases of dengue have increased. The social and cultural realities of the disease has been shown to be important and has not been considered when creating and implementing prevention and control programs. The paper draws on qualitative research of low- and high-income communities in the vicinity of Villaviecencio, South East Colombia to describe changing practices and direction of dengue prevention and control. It can be clearly observed from individuals' therapeutic itineraries and their perception of disease that public policies advertised in booklets and flyers and on television differ radically from people's everyday reality. This difference influences the success or failure of these policies. Keywords: Disease perception; Politics of health control and prevention; Dengue; Colombia

This paper investigates the socio-economic inequities in healthcare seeking in the treatment of common communicable endemic diseases, with an emphasis on the use of primary health care (PHC) centres, where most endemic disease control activities take place. A questionnaire was used to collect information on occurrence of diseases and healthcare seeking from randomly selected households in four local government areas in Southeast Nigeria. Principal components analysis was used to create a socio-economic status (SES) index, which was divided into quartiles. The ratio of the values for the poorest quartile to that of the least poor quartile (bottom/top quartile) together with concentration indices for the variables under consideration was used as the measures of inequity. Logistic analysis was used to examine the determinants of use of PHC centres. The poorest quartile was more likely to use low-level providers (patent medicine dealers, shops, herbalists) and least likely to use the PHC centres. The concentration indices were -0.10, -0.06, -0.37, 0.11 and 0.04 for the use of herbalists, patent medicine dealers, community-health workers, PHC centres and hospitals, respectively. Also, the poorest quartile was more likely to lose person-days when ill. Logistic analysis showed that SES, availability of good services, proximity of the centres to the homes and polite health workers increased the use of the PHC centres. As such, improvement of quality of PHC services and improved geographic access could increase the overall use of PHC centres. Furthermore, in the long-term, a decrease in the amount of user fees, enhanced physical access and improved quality of services could decrease inequity in use of PHC centres and hospitals in the treatment of endemic diseases. The bottom/top quartile ratios and concentration indices produced similar results and hence both methods hence complement each other. Keywords: Inequity; Equity; Tropical diseases; Socioeconomic status; SES; Help-seeking; Nigeria

The current structure of the health care system in Chad, which is characterized by a weak public health system and a nascent and largely unaffordable private sector, raises questions about how low-income households manage illnesses. These questions are also compelling because of claims about the potential of oil-related investments to restructure the current landscape of care over the next 25-30 years. This paper focuses on household strategies for treating episodes of malaria reported in an on-going, longitudinal study of household health and access to care in Chad. Treatment of malaria outside the health care system is widespread in endemic areas, therefore it is not surprising that low-income households in this study rely heavily on unregulated drug markets for care. However, the paper shows how self-medication and the use of these drug markets are shaped by the current organization and delivery of care, and are not simply the outcome of a lack of information about the dangers associated with such practices. The paper also shows the consequences of this particular constellation of services for health in low-income households. We see, for example, the emergence of regimes for managing illness that consist of keeping debilitating symptoms at bay through the use of intermittent, sub-optimal therapies that provide a temporary reprieve but not a 'cure.' We also see that households ignore health problems--absorbing them into the experience of everyday life--that might elsewhere demand attention. When illnesses appear as crises it is often because cash-strapped households are unable to sustain this type of management regime, and easily treatable problems spiral out of control. Whether and how the experiences of the low-income households described in this paper will be impacted by the public investment of oil revenues in the health sector is the question our longitudinal study is designed to address. Keywords: Chad; Malaria; Pharmaceutical markets; Self-medication; Health sector reform; State

This study used US state-level data from 1985 to 1995 to examine the relationship of primary care resources and income inequality with all-cause mortality within the entire population, and in black and white populations. The study is a pooled ecological design with repeated measures using 11 years of state-level data (n = 549). Analyses controlled for socioeconomic and demographic characteristics. Contemporaneous and time-lagged covariates were modeled, and all analyses were stratified by race/ethnicity. In all models, primary care was associated with lower mortality. An increase of one primary care doctor per 10,000 population was associated with a reduction of 14.4 deaths per 100,000. The magnitude of primary care coefficients was higher for black mortality than for white mortality. Income inequality was not associated with mortality after controlling for state-level sociodemographic covariates. The study provides evidence that primary care resources are associated with population health and could aid in reducing socioeconomic disparities in health. Keywords: USA; Primary care resources; Mortality; Ethnicity

Fundamental health care reforms in Estonia started in 1991 with the introduction of a social health insurance system. While increasing the efficiency of the health care system was one of the targets of the health care reforms, equity issues have received relatively less attention. The objective of this study is to provide an overview of social inequalities in health care utilisation in Estonia in 1999, after 8 years of large-scale reforms. Data were obtained from a nationally representative household interview survey including 3990 respondents aged 25-74 years. Health care utilisation was measured by the telephone consultations, visits to the general practitioner, visits to the specialist, visits to the dentist, and hospitalisation. These utilisation measures were related to variables on ethnicity, place of residence, education, income and employment, by means of direct standardisation and logistic regression models. Three different regression models were applied in order to (a) describe social differences in health care utilisation, (b) to assess whether these differences can be explained by differences in health needs, and (c) to assess the independent effect of each social variable net of all other social variables. Substantial inequalities were observed for all types of health care services and according to most social dimensions. Residents of rural areas were more likely to visit a general practitioner or to use telephone consultation, but less often used outpatient specialist care or dentist care. Ethnic differences were generally smaller, with no consistently higher use by either Russians or ethnic Estonians. Large differences were observed in relation to socio-economic status (education, income, or employment), with a more favourable socio-economic status being associated with higher probability to use health care services, especially after controlling for health needs. In case of hospitalisation, however, no notable social inequalities were found. These findings suggest that important geographic, financial and information barriers to health care utilisation exist after almost one decade of health care reforms in Estonia. Further health care reforms should aim to lessen or even remove these barriers. Keywords: Health care utilisation; Equity; Health care reform; Estonia; Socio-economic factors; Place of residence

Substantial debate on the appropriate foundations of economic evaluation in health-care has been conducted between welfarists and non-welfarists in the health economics literature. This has focussed on defining and measuring appropriate outcomes. However, there has been little discussion of the importance of procedures. This paper examines six dimensions of procedure in relation to health-care rationing which are drawn from existing literature and previous empirical investigation. A survey of the general public was used to test for preferences for each dimension of procedure. Results show that for each dimension the importance differed according to the level of decision-making (we tested decision-making at the level of the individual doctor, health authority and government). We identified three distinct clusters of respondents who can be broadly described as 'proceduralists' (47%), ''pluralists' (15%) and 'anticonsequentialists' (38%). The paper concludes that consequentialism is insufficient to provide the conceptual framework that public decision-making in health requires, although this does not mean that consequences are unimportant. Keywords: Health-care rationing; Empirical social choice: Procedural fairness

Although the English NHS has been described as a world leader in pioneering methods of distributing expenditure in relation to population needs, concerns about the legitimacy of using the current utilisation-based model to allocate health service resources are mounting. In this paper, we present a critical review of NHS resource allocation in England and demonstrate the feasibility and impact of using direct health estimates as a basis for setting health care capitations. Comparing target allocations for the inpatient treatment of coronary heart disease in a sample of 34 primary care trusts in contrasting locations in England, we find that a morbidity-based model would result in a significant shift in hospital resources away from deprived areas, towards areas with older demographic profiles and towards rural areas. Discussing the findings in relation to a wider policy context that is generally concerned to direct more health care resources towards the poor, the paper concludes by calling for greater clarity between the goals of health care equity and health equity. Whilst the former demands that the legitimate needs of demographically older populations for more health care resources are acknowledged, the goal of health equity requires real political commitment to resource broader social policy initiatives. Keywords: NHS resource allocation; Health and equity; Urban and rural health needs; Morbidity-based capitation; England

Most countries of the Former Soviet Union (FSU) have either initiated or are contemplating reform of the health sector. With negative real income growth and falling government revenues, a key concern of many governments is to secure additional finance through non-budgetary sources such as hypothecated payroll taxes, voluntary insurance, and increased private finance through patient cost-sharing. However, before such reforms can be considered, information is needed both on the current levels and distribution of household expenditures on health care, and the extent to which increased charges may affect access to health services, especially amongst the poor. This paper uses the Tajikistan Livings Standard Survey to investigate the level and distribution of out-of-pocket payments for health care in Tajikistan and to examine the extent to which such payments act as barriers to health-care access. The data show that there are significant differences in health-care utilisation rates across socio-economic groups and that these differences are related to ability to pay. Official and informal payments are acting both to deter people from seeking medical assistance and once advice has been sought, from receiving the most appropriate treatment. Despite informal exemptions, out-of-pocket payments for health care are exacting a high toll on household welfare with households being forced to sell assets or go into debt to meet the costs of care. Urgent action is needed to ensure equity in access to health care. Keywords: Health financing; Informal payments: Poverty; Tajikistan

The unification of Germany in 1990 brought about substantial social and economic changes in its eastern part, with new uncertainties and, despite increasing overall income, rising inequality. This paper explores the potential impact on health of these changes during the 1990s, looking specifically at income-related health inequalities in east and west Germany and its modulation by psychosocial factors. We used data from the German Socio-Economic Panel (GSOEP) for the years 1992 and 1997, including individuals aged 25 +. We investigated changes in self-perceived health in the two parts of Germany and its socio-economic and psychosocial determinants. Analyses estimated odds ratios of less than good health using logistic regression. In 1992, 47% of east Germans rated their health worse than good compared with 54% in the west. By 1997, the east-west gap in self-rated health had disappeared, with the prevalence of poor health increasing to 56% in both parts. Income and education were important determinants of health in east and west, with, in the age-sex-adjusted model, those having available less than 60% of median equivalent income being at increased risk of poor health in 1992 (O[R.sub.east] 2.39, 1.45-3.94; O[R.sub.west] 2.04, 1.65-2.52). Addition of education reduced the strength of this relationship only slightly. In the west, income-related health inequalities widened between 1992 and 1997 yet the initially stronger gradient declined in the east, despite an overall increase in income inequality (O[R.sub.east] 1.63, 1.04-2.56; O[R.sub.west] 2.65, 2.19-3.21). The impact of education remained stable. Psychosocial variables were important determinants, mediating the effects of income, with leisure-cultural social involvement exerting the strongest effect in both east and west. The results show that, unlike in the west, the overall increase in income inequality in east Germany between 1992 and 1997 was not accompanied by a simultaneous increase in income-related health inequalities. This suggests that mechanisms involved in the association of socio-economic factors and health possibly behave differently in east and west. Keywords. East and west Germany; Self-perceived health; Health inequalities; Psychosocial factors

There is a growing literature which demonstrates that (a) conditions throughout the life-course are important for health outcomes in older people and (b) 'contextual' conditions in the place of residence, as well as individual characteristics influence health variations. This paper contributes to this debate by presenting results of an analysis of data from the Office for National Statistics Longitudinal Study (LS) for England and Wales. The analysis makes use of a new set of variables, which have been added to the LS, describing the social and economic conditions in the 1930s in residential areas where members of the LS sample were registered as living in 1939. The analysis focuses on people who were aged 0-16 in 1939. The health outcomes considered are death between 1981 and 1991, and for those still living, whether long-term illness was reported in the 1991 census. Regression analysis is used to examine the effects of residence in 1981, and data on the registered place of residence in 1939. The analysis shows that individual characteristics and type of area of residence in 1981 were associated with health outcomes. In addition, some variables describing socioeconomic conditions in the 1930s contribute independently to the regression models (notably measures of economic deprivation and unemployment). The results suggest that conditions in residential area in early life may help to explain relatively poor health experience of populations in some parts of Britain today. Keywords: Mortality; Morbidity; Longitudinal effects; Place effects; Health inequality; England and Wales

This paper describes and critiques the income inequality approach to health inequalities. It then presents an alternative class-based model through a focus on the causes and not only the consequences of income inequalities. In this model, the relationship between income inequality and health appears as a special case within a broader causal chain. It is argued that global and national socio-political-economic trends have increased the power of business classes and lowered that of working classes. The neo-liberal policies accompanying these trends led to increased income inequality but also poverty and unequal access to many other health-relevant resources. But international pressures towards neo-liberal doctrines and policies are differentially resisted by various nations because of historically embedded variation in class and institutional structures. Data presented indicates that neo-liberalism is associated with greater poverty and income inequalities, and greater health inequalities within nations. Furthermore, countries with Social Democratic forms of welfare regimes (i.e., those that are less neo-liberal) have better health than do those that are more neo-liberal. The paper concludes with discussion of what further steps are needed to 'go beyond' the income inequality hypothesis towards consideration of a broader set of the social determinants of health. Keywords: Income inequality; Class; Globalization; Welfare state; Infant mortality

This paper analyses the relationship between social capital and population health. The analysis is carried out within an econometric model of population health in 19 countries in the Organisation for Economic Co-operation and Development countries using panel data coveting three different time periods. Social capital is measured by the proportion of people who say that that they generally trust other people and by membership in voluntary associations. The model performs well in explaining health outcomes. We find very little statistically significant evidence that the standard indicators of social capital have a positive effect on population health. By contrast, per capita income and the proportion of health expenditure financed by the government are both significantly and positively associated with better health outcomes. The paper casts doubt upon the widely accepted hypothesis that social capital has a positive effect on health and illustrates the importance of testing this kind of hypothesis in an extended model. Keywords: Population health; Social capital; Income inequality; Econometric model; Per-capita GDP; Public health expenditure

The nature and effects of stigma have been widely discussed in the context of mental illness, and references to stigma are commonly used to explain a wide array of social processes. For example, it is often claimed that stigmatisation affects aspects of personal identity, that it underpins unjust and discriminatory behaviour, and that it is responsible for a reluctance among members of the lay public to disclose the presence of treatable psychiatric symptoms and problems to health professionals. A widespread reluctance to disclose symptoms of `emotional problems' to health professionals is in fact well documented. Yet the reasons for such patterns of behaviour are far from clear. However, in this paper, on the basis of qualitative data collected from primary care attendees in Wales (N = 127), the authors suggest that appeals to stigma are inadequate to explain the phenomenon. More likely, it seems, is that members of the lay public have markedly different images from health professionals of what constitutes a mild to moderate psychiatric problem. Consequently, it is argued that the phenomenon of non-disclosure could be viewed more accurately as a problem of alternative taxonomic systems than of fear of stigma. The implications of the argument for health practice and theory are outlined. Keywords: Culture; Depression; Stigma; Primary care; Wales

There is an epidemic rise in diabetes in the developing world, with ensuing concern about the management and control of the disease. This study investigates the use of complementary therapies to manage Type 2 diabetes in an urban population in Kerala, a state in Southern India. Using ethnographic methods, it shows that the subjects' experiences of the disease and their health management decisions are closely linked to their cultural background and the environmental resources of the region. Participants in the study relied on biomedicine for treating diabetes, but frequently used Ayurvedic medicine and folk herbal remedies as supplements. They named 24 local plants and plant products that were employed to lower blood glucose levels. Knowledge of tried and tested local or regional remedies and their incorporation into individual and community health care practices are evidence of medical knowledge as cultural capital. Greater attention needs to be paid to the broader systems of the environment and culture and their interconnections to understand the use of complementary therapies by persons with chronic illnesses such as diabetes. Keywords: Complementary therapy; Diabetes; Phytotherapy; Cultural capital; Culture region; Kerala; India

Older people now constitute the majority of those with health problems in developed countries so an understanding of health variations in later life is increasingly important. In this paper, we use data from three rounds of the Health Survey for England, a large nationally representative sample, to analyse variations in the health of adults aged 65-84 by indicators of attributes acquired in childhood and young adulthood, termed personal capital; and by current social resources and current socio-economic circumstances, while controlling for smoking behaviour and age. We used six indicators of health status in the analysis, four based on self-reports and two based on nurse collected data, which we hypothesised would identify different dimensions of health. Results showed that socio-economic indicators, particularly receipt of income support (a marker of poverty) were most consistently associated with raised odds of poor health outcomes. Associations between marital status and health were in some cases not in the expected direction. This may reflect bias arising from exclusion of the institutional population (although among those under 85 the proportion in institutions is very low) but merits further investigation, especially as the marital status composition of the older population is changing. Analysis of deviance showed that social resources (marital status and social support) had the greatest effect on the indicator of psychological health (GHQ) and also contributed significantly to variation in self-rated health, but among women not to variation in taking three or more medicines and among men not to self-reported long-standing illnesses. Smoking, in contrast, was much more strongly associated with these indicators than with self-rated health. These results are consistent with the view that self-rated health may provide a holistic indicator of health in the sense of well-being, whereas measures such as taking prescribed medications may be more indicative of specific morbidities. The results emphasise again the need to consider both socio-economic and socio-psychological influences on later life health. Keywords: Older people; Health status; Social support; Marital status; Inequalities in health

In keeping with the neo-liberal emphasis on privatization, international aid has been increasingly channeled through non-governmental organizations (NGOs) and their expatriate technical experts to support primary health care (PHC) in the developing world. Relationships between international aid workers and their local counterparts have thus become critical aspects of PHC and its effectiveness. However, these important social dynamics of PHC remain understudied by social scientists. Based on three years of participant-observation in Mozambique, this paper presents an ethnographic case study, of these relationships in one central province. The Mozambique experience reveals that the deluge of NGOs and their expatriate workers over the last decade has fragmented the local health system, undermined local control of health programs, and contributed to growing local social inequality. Since national health system salaries plummeted over the same period as a result of structural adjustment, health workers became vulnerable to financial favors offered by NGOs seeking to promote their projects in turf struggles with other agencies. It is argued that new aid management strategies, while necessary, will not be sufficient to remedy the fragmentation of the health sector. A new model for collaboration between expatriate aid workers and their local counterparts in the developing world is urgently needed that centers on the building of long-term equitable professional relationships in a sustainable adequately funded public sector. The case study presented here illustrates how the NGO model undermines the establishment of these relationships that are so vital to successful development assistance. Keywords: NGOs; Mozambique; International aid; Primary health care; Social inequality

In the context of current concerns about health inequalities among minority ethnic groups in the UK, this paper addresses perceptions of mental health services among members of an African-Caribbean community in a South England town. Efforts to reduce health inequalities must take account of the views of local community members on the sources of those inequalities and on local health services. The statistical existence of inequalities in diagnosis and treatment of African-Caribbeans in the UK is well-established, supported by sociological explanations of these inequalities which centre on social exclusion in a variety of forms: institutional, cultural and socio-economic. However, detailed studies of the perspectives of local communities on mental health issues and services have received less attention. In this case study of community perceptions of mental health services, we find that social exclusion comprises an explanatory framework which is repeatedly invoked by community members in describing their interaction with mental health services. Interviewees assert that experience and expectation of racist mis-treatment by mental health services are key factors discouraging early accessing of mental health services, and thereby perpetuating mental health inequalities. We conclude that participation and partnership are vital means by which to generate both the objective and subjective inclusion that are requirements for an accessible and appropriate health service. Keywords: African-Caribbean; Social exclusion; Health inequalities; Ethnic minorities; Mental health services; UK

Central to the success of many recent health system reforms is the implementation of new primary health care delivery models. The central characteristic common to these new models usually emphasises interdisciplinary collaboration. Using empirical research, this paper studies interdisciplinary collaboration among various groups of professionals within an original Canadian primary health care delivery model, the Quebec Community Health Care Centres (CCHCs). The entire population of more than 150 CHCCs have been surveyed. The goals of this study are (1) to measure the achieved intensity of inter-professional collaboration among Quebec CHCCs, and (2) to identify the organisational and professional factors fostering or limiting interdisciplinary collaboration. The results show that Quebec CHCCs have reached modest results in achieving interdisciplinary collaboration especially since interdisciplinary collaboration is a central objective that has been pursued for more than 25 years. This study demonstrates that the main factors associated with interdisciplinary collaboration are closely linked to work group internal dynamics. Interdisciplinary collaboration is linked to the simultaneous and antagonistic effect of some central intragroup process factors. Conflicting values and beliefs are present that both enhance and limit interdisciplinary collaboration. The presence of conflicting stimuli seriously undermines the strength of the CHCC work group's shared beliefs and strongly limits interdisciplinary collaboration. The results also stress the importance of administrative formalisation initiatives to enhance collaboration among different professions. The efficacy of formalisation in this context is based on its capacity to offer an articulated and operative interdisciplinary framework that can generate a counteractive effect to the traditional professional framework. It offers concrete rules that help align the work group beliefs with interdisciplinary values. The formalisation of functions and processes appears thus to be an interesting means to further interdisciplinary collaboration. Keywords: Interdisciplinary collaboration; Primary health care delivery models; Self-managed work teams; System of professions

This study used the Canadian version of the World Health Organization-Health Behaviour in School-Aged Children (WHO-HBSC) Survey to examine the role of multiple risk behaviours and other social factors in the etiology of medically attended youth injury. 11,329 Canadians aged 11-15 years completed the 1997-1998 WHO-HBSC, of which 4152 (36.7%) reported at least one medically attended injury. Multiple logistic regression analyses failed to identify an expected association between lower socio-economic status and risk for injury. Strong gradients in risk for injury were observed according to the numbers of multiple risk behaviours reported. Youth reporting the largest number (7) of risk behaviours experienced injury rates that were 4.11 times (95% CI: 3.04-5.55) higher than those reporting no high risk behaviours (adjusted odds ratios for 0-7 reported behaviours: 1.00, 1.13, 1.49, 1.79, 2.28, 2,54, 2.62, 4.11; [p.sub.trend] < 0.001). Similar gradients in risk were observed within subgroups of young people defined by grade, sex, and socio-economic level, and within restricted analyses of various injury types (recreational, sports, home, school injuries). The gradients were especially pronounced for severe injury types and among those reporting multiple injuries. The analyses suggest that multiple risk behaviours may play an important role in the social etiology of youth injury, but these same analyses provide little evidence for a socio-economic risk gradient. The findings in turn have implications for preventive interventions. Keywords: Adolescent; Etiology; Multiple risk behaviours; Trauma; Wounds and injuries; Youth; Canada; Socioeconomic status (SES)

It is clear that regulatory strategies can be effective in reducing tobacco use. Because legislators ultimately determine whether many of these policies are enacted, they are a key focus for tobacco policy research. This study identifies political and personal predictors of Canadian legislators' support for tobacco control policies. Data are from a 1996-97 survey of federal, provincial and territorial legislators. Multivariate regression analysis was used to assess relationships between five groups of variables (political factors including political ideology, personal characteristics, tobacco experiences, tobacco knowledge, interest group saliency) and support for tobacco control based on an 11-item scale. Support for tobacco control varied by political party. Support was higher among legislators who thought government had a duty to promote healthy lifestyles, knew second-hand smoke could cause lung cancer, knew tobacco caused more deaths than alcohol, and said they wanted more contact with medical associations about tobacco issues. Support was lower among current smokers and those with tobacco industry jobs in their ridings. The findings indicate that political party membership cannot be ignored in enlisting legislator support for tobacco control. It also appears that legislators who oppose tobacco control measures may not be opposed to tobacco control per se, but are more generally opposed to a government role in health promotion. Thus, public health professionals and tobacco control advocates need to be more attentive to the way tobacco control issues are framed for particular legislators. Further, meetings with health groups about tobacco issues would be welcomed by many legislators; non-governmental organizations and other health advocates could work to increase tobacco knowledge among legislators. Keywords: Legislators; Tobacco control; Policy; Support; Canada

Gender differences in health and health behavior are well established in Western societies, but little is known about gender health inequalities in rural China. We examine patterns of age-sex differences in health and health behavior of men and women in rural HeBei, People's Republic of China, and consider the extent to which these patterns resemble gender health inequalities observed in North America and Western Europe. The data analyzed were collected from 14,895 individuals residing in 288 villages in the HeBei Province. The results show that gender differences emerged at a later age than generally reported in Western societies. Poorer health among women, as compared with men, becomes observable during young adulthood (25-44) rather than at adolescence, and reached its peak among older adults (45-59) rather than during the productive and reproductive stage of the life course. Among the elderly, the differences between the health and the health behavior of men and women narrowed, similar to many reports in North America and Western Europe. Most importantly, no gender differences in mental health were observed. These findings suggest that the older adult age group (45-59) may be appropriate for interdisciplinary efforts to advance the understanding regarding the relative contributions of nature and nurture to gender differences in health. Keywords: China; Gender; Rural health

This paper defines high-risk areas of cholera based on environmental risk factors of the disease in an endemic area of Bangladesh. The risk factors include proximity to surface water, high population density, and low educational status, which were identified in an earlier study by the authors. Cholera data were analyzed by spatially referenced extended household units for two time periods, 1983-1987 and 1992-1996. These periods were chosen because they had different dominant cholera agents. From 1983-1987 classical cholera was dominant and from 1992-1996 El Tor was dominant. By defining high-risk areas based on risk factors, this study builds a spatial risk model for cholera. The model is then evaluated based on the locations of observed cholera cases. The study also identifies the determinants of death due to cholera for the two different time periods dominated by the different cholera agents. The modeled risk areas that were based on the risk factors were found to correspond with actual distributions of cholera morbidity and mortality. The high-risk areas of the dominant cholera agents are relatively stable over time. However, from 1983-1987 El Tor cholera, which was not the dominant agent during that period, was not associated with high-risk areas, suggesting that the El Tor habitat may have changed over time. The case fatality rate for cholera was related to proximity to a diarrhea treatment hospital in the study area. Keywords: Cholera; Disease risk; Spatial analysis; Bangladesh

This study examines the possible health impact of marginal employment, including both temporary and part-time employment schemes. It addresses three research questions: (1) Are employed people with a fixed-term contract or no contract more likely to report poor health than those who hold jobs with permanent contracts? (2) Are part-time employed respondents (even when they hold jobs with permanent contracts) more likely to report poor health than full-time workers? (3) Does change in employment stability (i.e., from employment with permanent contract to fixed-term or no contract employment and vice-versa) have an impact on health status? Logistic regression models were used to analyze panel data from Britain and Germany (1991-1993), available in the Household Panel Comparability Project data base. We included 10,104 respondents from Germany and 7988 from Britain. A single measure of perceived health status was used as the dependent variable. Controlling for background characteristics, the health status of part-time workers with permanent contracts is not significantly different from those who are employed full-time. In contrast, full-time employed people with fixed-term contracts in Germany are about 42 per cent more likely to report poor health than those who have permanent work contracts. In Britain, only part-time work with no contract is associated with poor health, but the difference is not statistically significant. We conclude that monitoring the possible health effects of the increasing number of marginal employment arrangements should be given priority on the social welfare research agenda. Keywords: Marginal employment; Part-time employment; Britain and Germany

African-Americans have typically registered lower rates of suicide than other ethnic groups. In the last 20 years this pattern has changed, particularly among young African-Americans between the ages of 15 and 19 (National Center for Injury Prevention and Control, Mortality Statistics, 1998, Atlanta, GA). Today, young African-American males are as likely to commit suicide as their White counterparts. To date, the research conducted regarding this phenomenon has been inconclusive and existing suicide interventions appear to have no effect on reducing this behavior among young African-Americans. This paper synthesizes classical (Durkheim, Suicide, 1979, Free Press, New York) and postmodern (Beck, Risk Society: Towards a New Modernity, 1992, Sage, London; Bauman, Modernity and Ambivalence, Cornell University Press, Ithaca, 1991) social theories in order to provide a more complete theoretical explanation for the increase in the suicide rate among adolescent African-American males. Postmodern society is typified by: (1) institutional deconstruction; (2) decreased collectivism; (3) increased normlessness and helplessness; and (4) exacerbated personal risk for stress. It is therefore possible to hypothesize that postmodernity characteristically loosens the bonds between the individual and society, thereby increasing vulnerability to depression, related pathologies (such as substance abuse), and suicide. African-Americans tend to be more affected/vulnerable because they are concentrated in resource-poor, low income areas, and institutions that provided social support (family, religious, community) and protected individuals from societal risk factors, have gradually been dissolving in postmodern societies. We argue that young African-American males of today are more exposed to stressors which increase psychological distress thus increasing depression and related pathological behaviors such as suicide. The main reason behind this increase is found in the inability of institutions to offer protection from psychological distress. Overall, this paper presents a postmodern, macro-level framework to explain the increase in suicide among African-American male adolescents. Keywords: Suicide; African-Americans; Adolescence; Postmodernity

The current study was concerned with factors associated with the use of complementary medicine (CM). The reasons for CM use were examined by dividing complementary medicine clients into two groups based on the frequency and length of their use of complementary therapies, and comparing them with conventional medicine clients as well as to each other. New/infrequent CM clients (n = 70), established CM clients (n = 71), and orthodox medicine clients (n = 58) were distinguished on the basis of health beliefs, socio-demographic, medical, and personality variables. Different patterns of predictors of CM use emerged depending on which client groups were compared. In general, health-aware behaviors and dissatisfaction with conventional medicine were the best predictors of overall and initial/ infrequent CM use, and more frequent health-aware behaviors were associated with continued CM use. Medical need also influenced the choice to use CM, and was the best predictor of committed CM use, with the established CM clients reporting more health problems than the new/infrequent CM group. Overall, income was a significant discriminator, but did not predict initial or continued CM use. Openness to new experience was associated with CM use in general, but was most notable in the decision to initially try or explore using CM. The findings support the utility of the three components (predisposing, enabling, and need factors) of the socio-behavioral model for explaining why some people choose CM. Overall, the results of the current study suggest that CM clients need to be looked at in more sophisticated ways, rather than being treated simply as a homogenous group with similar beliefs, motivations and needs. Keywords: Complementary medicine; Motivation; Beliefs; Health awareness; Canada

In this article it is argued that the current emphasis on third generation reforms to health systems places at risk the empowering comprehensive agenda of second generation reforms. Using the HIV/AIDS epidemic in South Africa as an exemplar, the authors demonstrate the importance of retaining this agenda. They suggest that the emphasis on `packaged' priority programmes with measurable outcomes, which characterizes third generation reforms, needs to be accompanied by the reorientation of primary health care providers towards an empowering comprehensive approach to care. In addition, using psychodynamic principles, they also show how certain aspects of the health care system need restructuring to provide containment and support for such care. Keywords: HIV/AIDS; South Africa; Primary health care; Psychodynamic

A new reimbursement system for general hospitals in Israel was introduced in July 1990. the new system specified that for 15 selected procedures, hospitals would be paid by the insurers prospectively, rather than by the traditional per-diem arrangement. The rates were determined by the Ministry of Health. Henceforth, the number of selected procedures has increased and by now 40 procedures are included. In line with the ever-lasting interest in the effect of financial incentives on suppliers of medical care, the purpose of this paper is to examine the first-year effect of this change on the volume of activity, length of stay, quality of care, and hospitals' real income. We focused on five selected procedures (cholecystectomy, hysterectomy, hip replacement, operations on lens and heart surgeries) performed in the four largest Israeli medical centers (Sheba, Sorasky, Rambam, and Hadassah). The analysis includes more than 17,000 hospitalizations occurring during two years prior to the change (July 1988-June 1990) and the first year after its implementation (July 1990-June 1991). We, therefore, examined, the short-term effects, wherein changes in the hospitals' behavior are reflected mainly in the above-mentioned hospitalization characteristics. Further analysis will be required to examine the long-run implications of the change as well as its effect on the rest of the general inpatient sector in Israel. Keywords: Per-diem; Prospective payments; General inpatient care; Israel

This paper explores the utility of concepts drawn from psychosocial theory as predictors of the proneness to mental distress among the residential population of a large suburban council estate (Wythenshawe, South Manchester). In this respect, items are selected and tested to form composite variables measuring individual ratings with regard to notions of structural risk, personal vulnerability, goal-setting behaviour, quality of life, and the frequency of life events and restricted opportunities. Mental distress is enumerated on the standard GHQ12-point scale. The design makes the distinction between composite variables that record persistent states and those which count events and aspirations immediate to the individual's present experience. To examine the consequences of this difference between indicators of prevalence and incidence, our analysis adopts a two-stage multiple regression format. The first examines these state-event interactions among the composite variables, while the second tests the separate significance of these types as predictors of GHQ12. The findings reveal significant proportions of the variation in GHQ 12 are be explained either by associations with the ageing process or by those linked to subjective indicators of the quality of life. In contrast, structural deprivation correlates less significantly with the reporting of psychiatric distress in this socially homogeneous population. The discussion considers the methodological implications of these relationships for understanding common mental health problems together with their connotations for health policy. Keywords: Mental distress; Quality of life; Risk indicators; Ageing; Suburban council estates; Health policy; UK

Previous studies have demonstrated associations between fetal insults and psychological and developmental outcomes in children and adolescents. It is not clear whether psychosomatic problems in adults also have early origins. This study involved full-term live-born singletons free of congenital anomaly in the 1970 British Birth Cohort Study. Birthweight, gestational age, maternal smoking, parental social class and birth order were recorded around the time of birth. Psychological and somatic distresses were measured by the Malaise Inventory at age 26. A number of socio-behavioural covariates were also measured at this time. Multiple (least square) regression analysis showed that birthweight standardised for gestational age had a 'reverse J' relation with psychological distress (p < 0.05); gestational age was inversely related to psychological distress (each p Keywords: UK; Fetal growth; Child health; Maternal health; Smoking; Psychological distress

We examine the determinants of patients' accounts of their own mental illness. In particular, we examine the factors that affect the likelihood of attributing one's own mental illness to controllable factors rather than non-controllable factors. Our quantitative measure of attributional control is derived from the coding of in-depth interviews with people with severe mental illness seeking treatment for the first time (N = 144). We find that those who occupy positions of social disadvantage (particularly African-American males and those who receive public assistance) are less likely to attribute their illness to controllable sources, suggesting that personal mental illness attributions are systematically related to a person's social location. We outline the significance of these findings for research on the psychological consequences of mental illness attributions. Keywords: Mental health; Attributions; Control; Social status; USA

Modern hospitals are complex multi-product organisations. The analysis of a hospital's production and/or cost structure should therefore use the appropriate techniques. Flexible functional forms based on the neo-classical theory of the firm seem to be most suitable. Using neo-classical cost functions implicitly assumes minimisation of (variable) costs given that input prices and outputs are exogenous. Local and global properties of flexible functional forms and short-run versus long-run equilibrium are further issues that require thorough investigation. In order to put the results based on econometric estimations of cost functions in the right perspective, it is important to keep these considerations in mind when using flexible functional forms. The more recent studies seem to agree that hospitals generally do not operate in their long-run equilibrium (they tend to over-invest in capital (capacity and equipment)) and that it is therefore appropriate to estimate a short-run variable cost function. However, few studies explicitly take into account the implicit assumptions and restrictions embedded in the models they use. An alternative method to explain differences in costs uses management accounting techniques to identify the cost drivers of overhead costs. Related issues such as cost-shifting and cost-adjusting behaviour of hospitals and the influence of market structure on competition, prices and costs are also discussed shortly. Keywords: Hospital cost analysis; Methodological aspects of multi-product cost functions; Economies of scale and scope

This qualitative study examines how individuals in an advanced stage of multiple sclerosis (MS) who live at home, accommodate to their illness. The downward phase in the illness trajectory of MS often consists of a lengthy period of gradual decline. According to Corbin and Strauss's framework, accommodation is conceptualized as biographical work that refers to the actions taken to retain control over the life course and to give life meaning again. For our purpose semi-structured interviews with 22 people with MS were conducted and compared with 21 interviews with their family caregivers. The analysis consisted of fragmenting and connecting the data and involved close reading and constant comparison. The continuity of biography is at risk since body and performance failures lead to the loss of salient aspects of self. Participants interpret MS as an all-encompassing illness and emphasize the process of having to give up everything. Four case stories are described to demonstrate the complex intertwining of the biographical processes and to show the range in biographical accommodation. Some patients are capable of putting their lives back together again, while others retreat or do not consider MS a part of their lives. The unpredictable course of MS makes it impossible to give new direction to the life course. Keywords: Multiple sclerosis; Chronic illness; Biography; Illness trajectory; The Netherlands; Belgium

Participatory approaches are becoming increasingly important in the field of health, and many organizations, governments and donors have recognized the need to increase stakeholder involvement to ensure sustainable and real change. However, commitment to participation is often lacking and participatory processes, if applied, tend to be short-term and discrete, especially in institutional settings. Rarely, for example, are stakeholders involved in long-term monitoring and evaluation activities, due the time-consuming nature of participation, and to perceptions on the part of donors and other decision-makers that participation lacks the rigor and objectivity of external evaluation. This paper describes the strategies used by an international reproductive health organization to collaborate with local stakeholders in a long-term participatory approach to quality improvement, focusing on defining quality of care, identifying problems in health facilities, setting goals and seeking solutions to those problems, tracking changes in quality over time, and feeding this monitoring and evaluation information back into the quality improvement process. The paper also illustrates how greater participation was achieved over time as local stakeholders moved away from traditional models and relationships and started working together to meet their quality improvement goals. The paper argues that participatory techniques are essential if the real needs of clients are to be met through sustained change and continuous quality improvement at the site level. Keywords: Participation; Evaluation; Quality; Reproductive health; Supervision; Tanzania

In this paper we argue that a gender analysis is fundamental to health and health planning. We begin with a definition of gender and related concepts including equity and equality. We discuss why gender is key to understanding all dimensions of health including health care, health seeking behaviour and health status, and how a gender analysis can contribute to improved health policies and programming. Despite the many reasons for incorporating gender issues in health policies and programmes many obstacles remain, including the lack of attention to gender in the training of health professionals and the lack of awareness and sensitivity to gender concerns and disparities in the biomedical community. We argue that the key to placing gender values firmly in place in Health for All renewal is a change in philosophy at all levels of the health sector and suggest ways in which such a change can be implemented in the areas of policy, research, training and practical programmes and interventions. Keywords: Gender; Health for all; Health policy; Health seeking behaviour; Health care; Health status; Health programming

This paper reviews changing patterns of mortality worldwide, paying particular attention to differences between developed and developing countries and the consequences of demographic and epidemiological transitions. These involve gains in life expectancy and a shift from infectious to degenerative conditions as causes of death. Reversals to these transitions in certain Eastern European and African countries, due respectively to the social disorganisation accompanying the collapse of communism and to AIDS is described. The implications of changing population structures for the experience of old age and dying are explored and gender and socio-economic differences within countries is highlighted. The current state of knowledge about differences in the dying trajectories of different causes of death is summarised and gaps in this knowledge identified. The availability of lay health care in the community at different points in the demographic transition is described, and the problems and dilemmas of formal health care provision for dying people in both developed and developing countries outlined, including an analysis of the reasons for public support for euthanasia in some Western countries. In particular, the appropriateness of models of specialist palliative care outside the cultures in which such care originally developed is questioned. Finally, there is discussion of the extent to which medical and scientific measures erode traditional religious consolations for the problems involved in dying and bereavement. Keywords: Dying; Mortality; Demographic transition; Old age; Palliative care services

Over the last decade, western countries have reduced their intake of refugees, even though a substantial number of persons continue to be displaced by war and persecution. At the same time, there has been a substantial increase in the number of asylum seekers who apply for refugee status after entering western countries without resettlement documents. Evidence is accruing that asylum seekers are at high risk to trauma-related psychiatric and physical disorders. Increasing concerns have been raised, therefore, about the difficulties that asylum seekers face in accessing health and welfare services. The present Australian-based volunteer study compared Tamil asylum seekers (n = 62) from Sri Lanka with compatriots (30 refugees; 62 immigrants) on a number of indices relating to difficulties accessing medical, counselling and welfare services. The majority of asylum seekers ([greater than]60%) reported serious difficulties accessing medical and dental services and a sizeable minority reported problems obtaining assistance with welfare (40%), counselling (34%), and charity (23%). Difficulties accessing medical and dental services consistently exceeded those reported by refugees and immigrants. In spite of the inevitable sampling limitations, the data support past research as well as clinical impressions in suggesting that asylum seekers are particularly disadvantaged in accessing health care services. Keywords: Asylum seekers; Health access; Refugees; Tamils

This study examines the effect of socio-economic inequalities on the tumour size at diagnosis and the choice of surgical treatment in Danish women with breast cancer. The Danish Breast Cancer Cooperative Group (DBCG) registers all women with breast cancer in Denmark and provides clinical register data on tumour size and surgical treatment for 1594 women < 75 yr diagnosed with breast cancer between 1991 and 1996. A questionnaire including questions on social class was sent to the women. The tumour size at diagnosis (an indicator of access to treatment) and the surgical procedure (lumpectomy or mastectomy) for patients who were potential candidates for lumpectomy were the main outcome measures examined. Social class was not associated with tumour size at diagnosis. The tumour size was associated with age and the existence of a mammographic screening program in the county. However, treatment was strongly related to social class. Among women considered candidates for lumpectomy 77% underwent lumpectomy in the highest social class, compared to 50% in the lowest social class. Treatment was associated with age, tumour size and hospital status. It was concluded that the study showed no socio-economic inequalities related to access to health services as measured by tumour size, though significant social differences were found regarding treatment. Key words - Equity, Access, Socio-economic status, Breast cancer, Denmark

Qualitative data from two studies in Puerto Rico and New England are used to show how cultural values, standards and beliefs in different health care contexts affect (1) health care professionals' responses to patients' problems, (2) the relationships between providers and patients, and (3) the patients' responses to chronic pain and illness. Influencing elements in the care setting include the world view of the relationship of mind and body in illness processes, the dominant values and standards regarding pain and illness behaviors and the degree of cooperation between the providers and other agencies the patient depends on for compensation, rehabilitation and health insurance. In the New England study, the biomedical world view of mind-body dualism was shared by providers and most patients, but this shared belief often contributed to substantial patient stress and alienation. In contrast, in the Puerto Rican study providers and patients often shared a view of mind-body integration in illness and valued treatments which addressed chronic pain as a biopsychosocial experience. In this setting, shared views and values contributed to more supportive patient-provider relationships, and patients thus experienced less treatment-related stress. Key words - chronic pain, cultural context, ethnomedical systems, variation