Changes in empowerment: effects of participation in a lay health promotion program.

The Camp Health Aide Program is a lay health promotion program for migrant and seasonal farmworkers. The program increases access to health care while facilitating leadership development and empowerment of individual farmworkers through training and experience as lay health promoters (camp health aides [CHAs]). This article describes a study which documents impacts on the CHAs of working as lay health promoters in terms of changes in personal empowerment. The authors developed a working definition of personal empowerment and interviewed 27 CHAs at three program sites (Arizona, New Jersey, and Florida) at three different times. CHAs are grouped in five descriptive categories reflecting varying degrees of change in empowerment over this period. Of the total group of 27 CHAs, 24 exhibited some increase in personal empowerment during the study period. These changes are described in detail, and implications are discussed.

An analysis of the cost of incomplete abortion to the public health sector in South Africa--1994.

OBJECTIVE: To analyse the medical costs incurred in treating women for incomplete abortion. This study was performed in conjunction with a nationwide survey of women who presented to public hospitals with incomplete abortion in 1994. DESIGN: Cost analysis with two modified Delphi panels used to develop models of resource use reflecting three severity categories of symptoms and three hospital treatment settings. SETTING: Public hospitals in South Africa. PARTICIPANTS: A panel of 15 senior level obstetrician/ gynaecologists and a second panel of 11 patient care managers representing district, regional and tertiary level hospitals in 7 provinces. MAIN RESULTS: A conservative estimate of the total cost of treating women is R18.7 million +/- R3.5 million for 1994. An estimated R9.74 million +/- R1.3 million of this was spent treating women with 'unsafe' incomplete abortions. CONCLUSIONS: The management of incomplete abortion requires significant public sector expenditure. The long-term indirect costs to women, their families and communities are discussed and treatment costs estimated so that unmet needs for medical care resulting from unsafe abortions can be addressed.

The effect of sub-lethal doses of bromadiolone on the breeding performance of house mice (Mus domesticus).

Both laboratory and field strains of Mus were exposed to wheat containing 0.0001% bromadiolone under laboratory and outdoor conditions, respectively. While both strains readily consumed the poisoned wheat, ad libitum sub-lethal doses of this anticoagulant equating to between 20% and 70% of the acute LD50 per feed had little apparent effect on the breeding performance of these mice. The implications of these findings are discussed with respect to the use of anticoagulants as pesticides.

Process, costs, and outcomes of community-based prenatal care for adolescents.

An evaluation of a community-based prenatal care program for teens compared 180 adolescent clients with a sample of adolescents matched on age and year of delivery who received care through a traditional prenatal care program at a university medical center. Evaluation criteria describing the process of receiving care were the mean number of prenatal visits, nonscheduled outpatient visits, nonstress tests, ultrasounds, and inpatient days during pregnancy. The two programs were significantly different as measured by these criteria. Outcome criteria included gestational age, birthweight, the percentage of infants requiring neonatal intensive care, and the percentage of clients with maternal complications. A multivariate analysis showed no statistically significant differences in these outcomes. The average cost of resources consumed during prenatal care for the study group was 41% that of controls.

Self-certification in lay midwives' organizations: a vehicle for professional autonomy.

The recent resurgence of lay midwifery in the United States has been intimately connected with the establishment of grassroots organizations which address women's health issues and make the reappearance of the lay midwife a different kind of phenomenon than was the case earlier in this century. This paper describes the organizational structure of 32 lay midwives' organizations and compares them to a model of alternative women's health groups as well as more traditional health professional organizations. Are lay midwives' groups the beginnings of new professional organizations which eventually will become part of the dominant system or do they model themselves more closely after alternative women's health groups? Voluntary self-certification in five lay midwives' groups is described in detail as a means of determining how a group handles the question of integration with or separation from the existing medical care system. Certification plays a critical role in promoting acceptance and credibility of midwifery practice and is seen increasingly as a mechanism to preempt regulation by another body.

State laws and the practice of lay midwifery.

A national survey was conducted to assess the current status and characteristics of state legislation regulating the practice of lay midwives. As of July 1987, 10 states have prohibitory laws, five states have grandmother clauses authorizing practicing midwives under repealed statutes, five states have enabling laws which are not used, and 10 states explicitly permit lay midwives to practice. In the 21 remaining states, the legal status of midwives is unclear. Much of the enabling legislation restricts midwifery practice often resulting in situations similar to those in states with prohibitory laws. Given the growth of an extensive grassroots movement of lay midwives committed to quality of care, this outcome suggests that 21 states with no legislation may provide better opportunities for midwifery practice than states with enabling laws.

Women's health and social change: the case of lay midwives.

One reaction to the medicalization of birth has been the comeback of lay midwives in the past 10 years. While many practice alone as did midwives 80 years ago, now midwives are networking and organizing in regional and statewide groups, an important new distinction in the light of increasing regulatory policy formation by many states. Are these groups the beginnings of traditional bureaucratic health professional organizations or are they better described as alternative women's health groups that espouse nonhierarchical philosophies of women's health? In this article, we describe an empirical study of one such group, the Michigan Midwives' Association, and explore the philosophies and practices of individual members as well as the internal organization of the group and its influence on members. Data were collected using individual telephone interviews with 48 of 50 members, group newsletters and documents, and two spokespersons who developed an oral history of the Association since its origin in 1978. Results suggest that the group plays an important role in reinforcing individually held philosophies about women-controlled birth and in providing social support to health workers practicing outside the traditional system.

PIP: An empirical study of the Michigan Midwives Association (MMA), a lay midwife group, was undertaken, and a oral history was developed; interviews were conducted with 48 of the 50 members. Their ages cluster in the 30s. 27 (56%) of these women considered themselves full-time midwives. They usually meet their clients by word-of-mouth. Their practice patterns are characterized by client-centered care and continuity of care. The midwives' socioeconomic backgrounds are similar; but their political attitudes include many views. The words "natural" or "normal" were used by the midwives to describe birth. The MMAs origin was informal. Originally there were 8 members, but the group grew rapidly. Currently there are 50 members. Authority is shared equally among members. Work is done through committees. MMA members share common views about birth and women's right to make decisions about it. Members are spread out geographically all over Michigan, so frequent meetings are impossible. Many members have changed their practice ways since they started midwifery. About 75% of the midwives thought that client relationships had changed since they began practicing. Several felt that their attitudes toward their profession had changed. The MMA holds peer review sessions whenever a midwife requests it. An internal certification process has been developed.

A study of costs and behavioral outcomes of menstrual regulation services in Bangladesh.

This paper reports the results of a program evaluation of menstrual regulation (MR) services provided by the Bangladesh Women's Health Coalition, a nongovernmental organization formed in response to a concern about the availability of quality MR services to Bangladeshi women. The program emphasizes individual counseling which stresses informed choice in reproductive health care. The evaluation examines the cost of this process as a function of behavioral outcomes which include the percentage of clients who are post-MR contraceptive acceptors and the percentage which return for follow-up care and consultation 2 weeks after the procedure. The average cost per post MR contracepting client is $3.75; the average cost per returning client is $5.68, figures which appear to be well within the range of costs reported by family planning programs in developing countries.

Gender hierarchies in the health labor force.

Rapid growth and increasing diversity characterize trends of the U.S. health labor force in recent decades. While these trends have promoted change on many different fronts of the health system, hierarchical organization of the health work force remains intact. Workers continue to be stratified by class and race. Superimposed on both strata is a structure that segregates jobs by gender, between and within health occupations. While female health workers outnumber males by three to one, they remain clustered in jobs and occupations lower in pay, less prestigious, and less autonomous than those of their male counterparts. What has prevented women from improving their economic and leadership status as health workers? Is work performed by men of higher prestige because men perform it? Would curative and technical fields have less status if dominated by women? Would health promotion be funded more generously if most health educators were men? In this article, two analytical constructs are presented to take a closer look at occupational categories, selected structural characteristics, differential rewards, and their relationship to gender segregation. Taken together, they demonstrate how women always cluster at the bottom and men at the top, no matter which dimension is chosen.

Describing health service areas: a methodological note on a summary indicator.

This paper describes the development of an indicator of use in the analysis of regional travel patterns for health care services. The indicator is derived using two different models which describe the relationship between utilization and travel distance. Results from both models are compared in terms of their validity, sensitivity and usefulness in describing health service areas and to population-based policy analysis concerned with access-to-care for rural populations.

Women's health groups: alternatives to the health care system.

This article describes an empirical study of 28 alternative women's health organizations. These organizations were formed by women who rejected the existing institutions of health care, especially the nature and quality of reproductive health services. The study examined their philosophy of health care, the range of services provided and the characteristics of women who use them, their internal organization in terms of the distribution of power and authority, and the problems and challenges involved in their existence. Implications and impacts resulting from their continuing existence into the 1980s on the delivery of health care for women are addressed.

'Barefoot doctors' in rural Georgia: the effect of peer selection on the performance of trained volunteers.

Does volunteer selection by peers have a measurable effect on volunteer performance? This paper examines this question in the context of a field experiment which used community organizations as a means to select people to serve as Emergency Medical Coordinators (EMCs). Field sites were 36 rural Georgia communities with populations ranging from 150 to 1850. EMCs were trained in a 40 hour program as first responders to emergency incidents and as organizers of an emergency response system within their communities. Their performance in each of these roles was assessed by composite measures (a first aid performance index and an activity index) developed as part of the study. Each sponsor organization conducted the selection of EMCs for their respective communities. The process was monitored and assessed as either comprehensive, including the evaluation and elimination of candidates, or as unstructured where interested individual self-volunteered. Performance scores were regressed on the selection process variable as well as a set of structural, predisposing and enabling variables. Peer selection was a statistically significant predictor of EMC performance as a first responder but not as a response system organizer. Implications of this result as well as the influence of other independent variables are discussed.

Acceptance of a volunteer first-responder system in rural communities: a field experiment.

This article describes a randomized control field experiment that was used to evaluate the impact of an organized volunteer-based emergency first-responder system in 36 rural, medically underserved communities in central Georgia. The system created an information network within communities, which allowed rapid contact with trained resident volunteers when emergencies occurred. The evaluation examined selected environmental variables related to creating an information network and their effect on the general public's willingness to use a first responder for medical emergencies. Measurements of community awareness and attitudes were made using a household telephone survey conducted immediately before project initiation, 3 months and 13 months after implementation. Willingness to use the system was greatest for individual respondents living in communities with less than 800 population and who were participants in the social network of the community. Implications for administrating this type of project through statewide EMS systems are discussed.

An evaluation of program implementation strategies for a rural first-responder system.

An experimental emergency first-responder system was introduced in 36 small rural Georgia communities as a means for addressing inadequate access to emergency medical services for these communities. A prospective evaluation was designed to address the most efficient and effective means to organize, implement, and administrate such a program on a regional basis. Key to the program were community-selected residents who served as Emergency Medical Coordinators (EMCs) and performed as first responders, information sources on emergency care, and system organizers. The evaluation examined the process of organizing the program through local government versus voluntary group sponsors in terms of response and participation by communities and their ability to select effective EMCs. It assessed the effectiveness of a set of criteria for selecting residents as EMCs against three sets of performance measures encompassing first-responder skills and activities which maintained public awareness and program visibility. Critical to program success was the degree of sponsor involvement in selecting EMCs.

An economic interpretation of the distribution and organization of abortion services.

PIP: Compared with other medical services, elective abortion is a special case where economic factors affecting delivery remain essentially constant. The consumer purchases it infrequently and the provider provides relatively frequently; the patient is not seeking information or interpretation of symptoms, only therapeutic service for which the technique is almost universal. In this area of medicine the consumer assesses the symptoms and decides on treatment before selecting a provider. U.S. women are not using abortion as a means of contraception in general and if they do, it is only once or twice. Prices charged for 1st trimester abortions are relatively stable ($171 in 1978, $174 in 1980). Since the liberalization of abortion legislation in 1973 there has been a yearly increase in elective 1st trimester abortions (85%), but a decreasing rate for each subsequent year (21% for 1973-74, 4% for 1977-78). Unmet need decreased from 58% in 1973 to 26% in 1978, concentrated in rural areas. The supply of abortions is subjected to constraints such as the aura of illegality, negative professional peer pressure, and distribution of providers. In 1977 13% of all providers performed 71% of all abortions, freestanding clinics had an average case load of more than 1600 year, hospitals provided 3% of abortions and office-based physicians performed 4%. In contrast to other medical services, abortion is a cash-on-delivery transaction with only 10% of patients submitting insurance forms. Information is provided to consumers regarding cost and quality of services through advertising and professional referral and is relatively widely available due to efforts of women's organizations, evaluative information is also disseminated. In Atlanta, 7 clinics performed 20,337 procedures in 1977, an increase of 1859 from 1976, prices ranging from $125-$165 in 1978 with a coefficient of variation of 0.09, the same since 1972-73. In a survey of 75 university students who had had abortions (16.8% of those who returned a questionnaire distributed at the university), it was found that newspaper and word of mouth are initial information sources about providers. Most important factors in choosing a provider were medical reputation, time required, absence of need for parental consent, and staff attitude. If present trends in delivery of services continue as demand levels off, large freestanding clinics will grow and choices will decrease. Statewide dissemination of information about facilities, particularly to people with access problems, would assist the consumer to increase competition between large and small clinics. 1 option for further research is the comparison of abortion services in different locations with varying market structure and degree of unmet need.^ieng

Engineering-based interdisciplinary education for health systems problem solving.

This paper examines the educational challenges created by the existence of complex health care delivery systems and the need to train analysts and problem solvers to work effectively within these systems. An undergraduate, interdisciplinary curriculum, based in the College of Engineering at the Georgia Institute of Technology, is described which addresses these challenges. One particular course is used to illustrate how cognitive and experiential learning approaches are combined to provide the student with a bridge between acquiring technical skills and applying them sensitively in a real world context.