Technology assessment. Old, new, and needs-based.

Recent health reports, including the 1993 World Development Report, have emphasized the importance of integrating the needs of the population into technology assessment. This paper reviews previous approaches to technology assessment and identifies the missing link between technology and its impact on the physical, emotional, and social needs of the community, namely needs-based technology assessment. It stresses the key role played by issues of equity and community values in making technology decisions. A number of models for needs-based technology assessment are described.

Investing in health wisely. The role of needs-based technology assessment.

Countries worldwide spend huge sums on health--about $1,700 billion a year, or roughly 8% of global income. But the World Development Report 1993: Investing in Health shows that these monies could be spent much more wisely, in the process doing a great deal to help the world's 1 billion poor. Essential national public health and clinical packages are proposed based on assessment of the burden of disease (measured in disability adjusted life years) and the cost-effectiveness of interventions. Governments can play a central role in improving the health of their citizens: they can foster an environment that enables households to improve health and they can also improve their own spending on health, targeting it to support universal access to essential national public health and clinical packages based on the above methods. This is a good example of the concept of needs-based technology assessment, combining the disciplines of epidemiology, economics, and policy formulation. When applied, it should lead to improved effectiveness, efficiency, and equity.

The role of academic health sciences centres in international health.

For many years, Canadian academic health science centres have been active in international health. This brief review describes the activities of the Canadian Society for International Health, the Canadian University Consortium for Health in Development, and McGill, McMaster and Ottawa universities. Three principles are derived from these examples. Health must be placed in the broader context of development, and international health initiatives must be intersectoral. Canadian universities can make a distinctive and important contribution to health and development internationally, but this requires a clear commitment to scientific excellence and social responsibility. Finally, Canadian institutions, as representatives of the North, have much to learn through collaboration and partnerships with institutions in the South.

AIDS-related knowledge, attitudes, beliefs, and practices in Haiti.

AIDS constitutes an important public health problem in Haiti, where it appears to be spread mainly through heterosexual encounters. The study reported here employed in-depth interviews, focus group discussions, and a national cross-sectional survey of 1,300 men and 1,300 women 15 to 49 years old to assess AIDS-related knowledge, attitudes, beliefs, and practices in Haiti. According to criteria established for the study, 38.1% of the 1,118 sexually active male survey respondents were found to engage in high-risk behavior. In general, the women were found to have better knowledge of AIDS than the men. Significant obstacles to condom use included the inability of women to choose whether condoms would be used and a belief that condom lubricant could cause health problems. The study also found a tendency to ostracize people with AIDS, especially in areas outside Port-au-Prince, and a belief that AIDS was imposed on people by fate--which could partially explain the tendency to persist in high-risk behavior.

PIP: AIDS constitutes a major health problem in Haiti which continues to grow through what seems to be mainly heterosexual relations. Over 1989-90, 8.9% of 1720 pregnant women attending a prenatal clinic in a suburban slum were identified as HIV-seropositive. Among initial blood donors in 1990, 5.8% of 1199 males and 1.9% of 15 female donors were seropositive for HIV. In-depth interviews, focus groups, and a national cross-sectional survey of 1300 men and 1300 women aged 15-49 years were conducted in an effort to assess participants' AIDS-related knowledge, attitudes, beliefs, and practices. 38.1% of the 1118 sexually active male survey respondents engaged in high-risk behavior. Men were considered to be at high risk for infection/transmission if they had ever visited a prostitute or had more than 1 sex partner in the month preceding the interview. Most in Haiti have heard of AIDS, but many misconceptions remain about how HIV is transmitted. Women did, however, tend to better informed than men. Even though the women may be comparatively better informed about HIV transmission, their lack of ability to negotiate condom use still impedes the more widespread use of condoms. The belief that condom lubricant may cause health problems also impedes condom use. Finally, the study found a tendency to ostracize people with AIDS, especially outside of Port-au-Prince, and the belief that individuals acquire AIDS deterministically according to fate. A coordinated national effort is needed to correct these misconceptions and increase the prevalence of condom usage.

Respiratory problems among cotton textile mill workers in Ethiopia.

This study was conducted to investigate the prevalence of respiratory problems, in particular byssinosis, and to explore factors associated with their occurrence among a group of 595 randomly selected workers representing 40.5% of those exposed to dusty operations in a typical Ethiopian cotton textile mill. A standard questionnaire on respiration was administered and pre and postshift forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) were determined for each worker; workers found to have byssinosis and other respiratory diseases were compared with workers having no respiratory diseases in terms of the level and duration of exposure to cotton dust and other variables. Multiple area air samples from different sections were analysed for elutriated cotton dust concentrations (0.86-3.52 mg/m3). The prevalence of byssinosis was 43.2% among blowers and 37.5% in carders in comparison with four to 24% among workers in other sections. Prevalence of chronic bronchitis ranged from 17.6 to 47.7% and bronchial asthma from 8.5 to 20.5% across all sections. Significant across shift decrements in FEV1 and FVC were seen in those workers with respiratory tract diseases compared with those workers without such diseases. A significant dose response relation for pulmonary function and respiratory illnesses was also found by regression analysis. Preventive measures are proposed. Further research including a nationwide survey of textile mills is suggested. This is the first epidemiological study of the textile industry in Ethiopia.

Do infant formula samples shorten the duration of breast-feeding?

To determine whether advertising by infant formula companies shortens the duration of breast-feeding, we randomly assigned 448 breast-feeding new mothers to either receive or not receive a formula sample packet upon discharge from a maternity ward. These mother, unaware of the study, were then telephoned 3 months post partum by a research assistant blind to the randomisation status. "Sample" mothers were less likely to still be breast-feeding at 1 month (78% vs 84%, p = 0.07) and more likely to have introduced solid foods by 2 months (18% vs 10%, p = 0.01). These trends became more significant in three vulnerable subgroups: less educated mothers, primiparas, and mothers who had been ill post partum. Our results suggest that infant formula samples may shorten the duration of breast-feeding and hasten the age at which solids are introduced.