The knowledge and attitudes of surgical staff towards the use of opioids in cancer pain management: can the Hospital Palliative Care Team make a difference?

The principles of cancer pain management are well established, but evidence suggests that these are not incorporated into daily practice and patients are still in pain. Deficiencies in knowledge and inappropriate attitudes towards the use of opioids may partially explain why the management of cancer pain is still such a widespread problem. This study assessed the knowledge and attitudes of 135 nursing and medical staff working in a surgical unit, before and after working with a newly established Hospital Palliative Care Team. The baseline survey highlighted the existence of a number of myths and misconceptions in relation to opioid use. Results of the follow-up survey indicated that the knowledge and attitudes of doctors and nurses had improved after working with the team, but that this probably occurred as a result of good working relationships and case discussions rather than through formal teaching. The study provided a useful method of identifying deficiencies in knowledge and attitude among staff, and helped to raise awareness of the problem of cancer pain management. Our challenge now is to work with staff to ensure that positive changes in knowledge and attitudes are translated into the everyday practice of hospital nurses and doctors caring for patients with cancer.

Model indicators for maternal and child health: an overview of process, product, and applications.

OBJECTIVES: Further improvements in the health of mothers and children depend, in part, on collecting, analyzing, and interpreting relevant data correctly. Despite consistent efforts to improve data capacity and use during the past two decades, the need persists for a model set of maternal and child health (MCH) indicators to guide decisions about health conditions to be monitored, elements to be included in data sets, and definitions of measures. This article describes development, key characteristics, and major applications of a set of MCH Model Indicators (MCH MI) created to address these needs. METHODS: A conceptual model with five domains was created to organize and guide development of the indicators. The development process included systematic specification of concepts, formulas, age/gender groups, and data sources, as well as recommendations for frequency of surveillance. Information sources included published reports and expert opinion. RESULTS: There are 217 indicators distributed across domains as follows: 75 health status, 9 contextual characteristics, 16 health systems capacity and adequacy, 49 risk/protective status, and 68 health and related services. Twenty of the indicators, all of them in the health status domain, are recommended for routine surveillance. CONCLUSIONS: The indicators can be used to identify and address MCH problems, to complement and expand other sets of MCH indicators, to serve as standards for consistent definitions, to provide guidance for creation and revision of MCH and related data bases, and to provide a foundation for the development of related sets of indicators. Some of the indicators require further development, but the total MCH MI package constitutes a solid foundation for subsequent work, as well as for ongoing modifications that are essential if the Model Indicators are to remain responsive to MCH needs.

Rural adolescent pregnancy: a view from the South.

An analysis of 1990 census and vital statistics data for eight Southeastern states revealed that the teenage birthrate generally was higher in rural than in metropolitan areas; the exception was among black women aged 15-17. The highest birthrate was 162 births per 1,000 among rural black women aged 18-19. Abortion rates were much lower for rural teenagers than for urban teenagers, regardless of race. For 15-17-year-olds, white women had an abortion rate of 12 abortions per 1,000 in rural counties and 18 per 1,000 in metropolitan counties; black women had rates of 13 per 1,000 and 30 per 1,000 in rural and metropolitan areas, respectively. Similarly, the abortion ratio was lower in rural than in urban areas; for example, 18% of rural white women aged 18-19 who became pregnant had an abortion, compared with 35% of their metropolitan counterparts. Black 15-17-year-olds in metropolitan areas had a higher pregnancy rate (106 per 1,000) than those in rural counties (87 per 1,000). The pregnancy rate of white women aged 15-17 was similar in rural [corrected] and metropolitan areas (about 46 per 1,000). Among rural women aged 18-19, 32% of births to whites and 45% of those to blacks resulted from a second or higher order pregnancy.

Prospects for childhood immunization registries in public health assessment and assurance: initial observations from the All Kids Count initiative projects.

This article offers an overview of selected evaluation findings from the initial implementation year of the Robert Wood Johnson Foundation's All Kids Count childhood immunization initiative in which demonstration projects were funded to develop community-based immunization registry and follow-up systems in 14 sites throughout the United States. The basic components of these systems, the process through which these registries were developed, efforts to secure the participation of private sector providers, the prospects for system success at the community level, and the potential for these immunization programs to influence other aspects of primary health care for children are addressed.

Problems in estimating the number of women in need of subsidized prenatal care.

For effective allocation of resources, public program planners need to know how many women require subsidized prenatal care and where they are located. Because sample surveys are expensive, indirect methods of estimation using secondary data sources are frequently used to arrive at quick annual estimates. Census data on poverty are often incorporated into such methods, but out study of the eight southeast States in Federal Region IV shows that available census data severely underestimate the proportion of pregnant women who are poor. Updated poverty data from the 1990 census will not solve this problem of underestimation. Alternative methods for estimating the number of women in need of subsidized prenatal care services, for measuring unmet need, and for doing estimates on the county level are presented and evaluated. Such considerations are especially important, given the new Title V block grant reporting requirements.

Goal-oriented evaluation as a program management tool.

Health promotion programs, like all human services activities, must be well managed in order to be effective. In an age of reduced financial resources to support new programs and sustain old ones, all program directors must be concerned with the efficiency with which available resources are used to meet program goals and objectives. In times such as these, competition is high for those resources that are available. Programs that can demonstrate both effectiveness in meeting their goals and operational efficiency in doing so are more likely to be successful in the competition for these scarce resources. In this article, practical suggestions for the use and presentation of evaluation data in the analysis of program effectiveness and efficiency are presented. The methodology is based on the contention that program evaluation should be useful to program directors as an integral part of their management of program resources in relation to program goals.

Choosing an evaluation strategy.

Most people making their first attempt at program evaluation will ask the same general kinds of questions at the outset of their endeavor: Why evaluate? How much will it cost? Can I do it myself, or will consultants be required? How scientifically rigorous must it be? Should I have a control group? How big should the sample be? etc. All of these questions can be answered, but only after a set of important assumptions about the program being evaluated has been carefully specified. In most cases, all of these questions can be answered quite adequately by the person(s) asking them. Very little technical expertise is required. In this article we present an approach to the formulation of a general evaluation strategy, including a method for answering some of the questions that need to be answered first.

From activated patient to pacified activist: a study of the self-care movement in the United States.

Self-care education programs in operation in the United States during the mid-1980s are surveyed by mailed questionnaire to determine the nature and content of the curricula of these programs, their organizational sponsorship, the level and types of staff working in them, and their principal prevention emphases. Results indicate that over 75% of these programs offer instruction or sponsored activities intended to help individuals or their families to: (1) increase wellness or health status through lifestyle change; (2) reduce an established risk factor; and/or (3) prevent the onset of illness or injury. Fifty-five percent of the organizations offering these services classified themselves as health services delivery organizations. A surprising finding, given the American popular media treatment of self-care as a 'movement', is that relatively few laypersons function as instructors in these programs. The paper describes the way in which self-care has been absorbed into the mainstream of American health care, even though the concept of self-care has tended to drop from scholarly attention in the socio-medical sciences in the United States.

The management and use of data on maternal and child health and crippled children: a survey.

With the advent of the Maternal and Child Health Services Block Grant, both maternal and child health programs and crippled children's (CC) programs at the State level have assumed greater responsibility for identifying populations in need, planning appropriate services for them, and monitoring progress toward program objectives. To determine the capabilities of eight Southeastern States to produce and apply the data necessary to accomplish those tasks, a survey of data systems available to, and used by, perinatal and CC programs in the Southeast was undertaken. Findings of the survey suggested that the data available to perinatal programs were more useful for planning and evaluation than those available to CC programs, primarily due to the vital statistics data systems in each State. The major data management needs of the region include (a) measuring the health status of populations served by public perinatal programs, (b) measuring services received by population groups considered in need of public perinatal care, (c) estimating the incidence and prevalence of handicapping conditions among children, and (d) measuring the outcomes of CC programs. If these shortcomings are addressed, the programs will be in better positions for effective planning and evaluation. To improve data management and utilization capabilities, the programs may need to engage technical assistance and consultation from sources outside their service-oriented agencies.

Controlled evaluation of rural regional perinatal care: developmental and neurologic outcomes at 1 year.

The effectiveness of a rural regionalized perinatal care (RPC) program was evaluated by a controlled, population-based design. The RPC program, begun in a carefully selected study region in July 1975, evolved into a system of care which included the following major components: identification of high-risk pregnancies and high-risk newborn infants; obstetric and newborn consultation and referral services between Level I, II, and III centers; professional education for physicians, nurses, and other health professionals; and nutrition and social work consultation. Substantial resources were made available from 1975 to 1980 to implement this "total package" of RPC. A matched, control region was identified which, except for the RPC program, was as comparable as possible to the study region. It was hypothesized that the RPC intervention would have the following effects when the study region was compared with the control region: reduction in fetal and neonatal mortality, no increase in postneonatal mortality, and reduction in obstetric and newborn morbidity. These findings were reported previously. This paper presents results of hypothesized reductions in adverse developmental, neurologic, maternal-infant attachment, and selected physical health outcomes. A sample of 447 infants was assessed by an extensive battery of instruments at 1 year, adjusted for gestational age. The most notable findings were mothers' reports of receptive language development and observations of maternal attachment behaviors that significantly favored the study region. No significant differences between study and control regions were observed for Bayley Mental and Motor Scores, abnormal neurologic signs, and the physical health measures.(ABSTRACT TRUNCATED AT 250 WORDS)

A controlled evaluation of rural regional perinatal care: impact on mortality and morbidity.

The impact of a rural regional perinatal care (RPC) program was assessed by a quasi-experimental, controlled, population-based design. Outcome measures included changes in five-year average fetal and neonatal mortality rates as well as short-term obstetric and newborn morbidity. Declines in fetal and neonatal as well as birthweight specific mortality rates were observed for both pilot and control regions, for both races, and especially for 1501-2500 g infants. However, comparisons of preprogram (1966-74) and postprogram (1975-80) average yearly changes showed no statistically significant differences between regions. While the incidence of prenatal morbidity was the same for both regions, intrapartum and newborn morbidity significantly favored the pilot region. These results were difficult to interpret. Program relevant implications of the findings in relation to rural RPC in North Carolina are discussed. Specific benefits appeared to be associated with the development of two high-risk maternity clinics and a Level II center capability in the pilot region. The importance of community support and public/private sector cooperation in relation to RPC is noted.

An evaluation of subsidized rural primary care programs: III. Stress and survival, 1981-82.

Surveys of a national sample of 193 subsidized rural primary care programs were conducted in 1981 and 1982 to determine what adaptations the programs might anticipate making given a reduction in their subsidy and what actual changes they made after the implementation of new federal policies and in the face of severe economic recession. During the period between the two surveys, nine of the 193 programs closed. The remaining programs changed elements of their operation, finances, and staffing, but these changes do not, in all cases, appear to be a direct response to subsidy reductions or increases. The programs exhibited adaptiveness and strength in the face of a potentially hostile environment.

An evaluation of subsidized rural primary care programs: I. A typology of practice organizations.

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