Does service accessibility reduce socioeconomic differentials in maternity care seeking? Evidence from rural Bangladesh.

Maternal mortality is a serious public health concern in Bangladesh. However, most deaths could be prevented through proper and timely care seeking and adequate management. Unfortunately, fewer than half of pregnant women in Bangladesh seek antenatal care, and only one in eight receive delivery care from medically trained providers. The specific objectives of this research are to examine the socioeconomic differentials of maternity care seeking, and to determine whether accessibility of health services reduces the socioeconomic differentials in maternity care seeking. A multi-level logistic regression method is employed to analyse longitudinal data collected from a sample of 1019 women from all over Bangladesh. The study finds significant socioeconomic disparities in both antenatal and delivery care seeking. Service accessibility, however, significantly reduces the socioeconomic differentials in delivery care seeking. Services need to be made accessible to reduce the inequality in maternity care seeking between rich and poor, empowered and non-empowered.

Simultaneity in the use of maternal-child health care and contraceptives: evidence from developing countries.

This study examined the relationship between the use of maternal-child health (MCH) care and the use of contraceptives. The high correlation between the two may be due to the independent effect of one on the other or to an association of both with the same or similar background factors. We used structural equation models to examine the relationship between these two interventions. The data were derived from six Demographic and Health Surveys: Zimbabwe from Sub-Saharan Africa, Thailand from Asia, Egypt and Tunisia from North Africa, and Guatemala and Colombia from Latin America. The results show that in all six countries, the use of contraceptives and MCH care are significantly associated, independent of intervening factors; this finding suggests that families develop a joint demand for better-quality health and limited family size and translate these demands into action by using health services for mothers and for children and by voluntarily regulating fertility.

Focused medical surveillance: a search for subclinical movement disorders in a cohort of U.S. workers exposed to low levels of manganese dust.

Seventy-five workers with recent and/or historical exposure to manganese (Mn) at a metal producing plant in northern Mississippi were closely matched with 75 control workers who had no known history of occupational exposure to Mn. Both plants are OSHA STAR work sites and share common medical, safety, and industrial hygiene services. Airborne Mn levels were assessed for each of twelve job categories at the Mn facility by collecting 63 side-by-side full-shift personal samples of both total and respirable Mn dust. Exposures of workers currently working with Mn averaged 0.066 mg/3 respirable and 0.18 mg/3 total Mn. An assessment of major equipment and work practice changes over the past several years and estimates of the resultant relative impacts on exposure was made. Based on this information and individual employment information, each worker's cumulative exposure to respirable and total Mn was estimated for the preceding 30 days, preceding year, and for the worker's entire employment history. Both Mn and control workers were administered multiple neuropsychological tests including tests of hand-eye coordination, hand steadiness, complex reaction time, and rapidity of finger tapping. A questionnaire was used to evaluate a worker's neuropsychological status. Performance decreased significantly with increasing age in tests of hand-eye coordination, complex reaction time and finger tapping speed. No effect of Mn exposure was found on the results of the questionnaire or any neuropsychological test.

Population change, health planning and human resource development in the health sector.

As a result of the demographic and epidemiological transitions now occurring rapidly in many developed countries, a dramatic shift in the age structures of populations and the burden of disease towards the middle-aged and elderly is expected to take place over the next several decades. In the 1990s, however, there remains great diversity across countries in fertility levels and mortality patterns. The World Bank's 1993 World Development Report assessed the global burden of disease in order to define the minimum packages of public health measures and clinical interventions that would improve health conditions in low-income countries in a cost-effective and affordable way. Strategically implementing these programmes will require that government investments be directed toward a limited number of cost-effective health interventions, delivered equitably to the entire population. At the same time, steps must be taken to improve the efficiency and contain the costs of health care delivery in the public and private sectors. Such a population-based health strategy will require the development of a wide range of scientific, analytical and technical capacities, currently rare in most ministries of health. This will require the involvement of epidemiologists, demographers, sociologists, analysts, operations research specialists and environmental health scientists. Building up these capabilities in health ministries, universities or the private sector will be an essential ingredient of health system reform.

PIP: In the 1990s, the demographic transition in the less developed countries is characterized by great variation in fertility, mortality, population age structure, age pattern, and cause of death. This heterogeneity is reviewed in selected demographic indicators from 7 major less developed regions of the world. At one extreme is Sub-Saharan Africa, with high fertility and high mortality, where 46% of the population is under age 15, and 60% of all deaths are found in this age group (the majority of deaths occur under the age of 5). At the other extreme is China, with low fertility and a high life expectancy, where only 27% of the population and 13% of all deaths are in the youngest age group. The 1993 World Development Report proposed a minimum package of public health measures and essential clinical interventions which would cost only $12 per capita a year in a low-income country, and would reduce diseases by 31%. Interventions are primarily directed toward preventing and treating diseases. The interventions for children include immunizations, micronutrient supplementation, and treatment of worm infections, while for adults they entail prenatal and delivery care, family planning, short-course chemotherapy for tuberculosis, and treatment of sexually transmitted diseases. The traditional Western-model, high-technology medical health care systems in developing countries have been institution-based, with hospitals and health personnel most concerned with one-on-one sickness care. The 1993 World Development Report puts priority on a population-based health development strategy that will require major reform of the health system in many countries. The medical education institutions are to be reoriented in developing and developed countries to curtail specialist training and promote primary care. The International Network of Community-Oriented Educational Institutions in the Health Sciences adopted one model of curriculum reforms that emphasize community-based and problem-based learning.

The challenge of world health.

PIP: 2 development specialists have expounded on the demands world health has placed on public health. Striking declines in infant and child mortality occurred with the advent of biomedical and technical interventions in developing countries after World War II. At the same time, these interventions promoted longer lives by curing and/or treating chronic diseases in developed countries. In the 1970s, however, it was apparent that the hospital based, curative approach could not meet health needs and was very costly. In developed countries, biomedical and social sciences showed that chronic diseases did not occur due to modernization but from unhealthy behaviors, diet, and lifestyle. In fact, in 1975, the US Centers for Disease Control announced that unhealthy lifestyles contributed to 50% of all deaths while the medical system was responsible for only 11%. The US and other developed countries then began to promote healthy lifestyles, and in the 1980s, considerable improvements in health occurred, especially among adults. Developing countries which depended on the Western medical model did not experience health gains in the 1970s. Yet developing countries where health systems concentrated on carrying essential services to all people and promoted basic hygiene and sound dietary practices continued to achieve considerable health gains. In 1978, WHO an UNICEF hosted the International Conference on Primary Health Care in Alma Ata, the Soviet Union to hold these developing countries with community based health systems as models of primary health care (PHC). The 1980s witnessed the spread of PHC especially in the form of child survival which focused on oral rehydration therapy and breast feeding. The biomedical and social sciences are needed to move this health policy and program strategy forward. Governments must see to policies that promote healthy people. Political will is needed to make human welfare a high priority.^ieng

Disease control priorities in developing countries: health policy responses to epidemiological change.

Health systems in developing countries are facing major challenges in the 1990s and beyond because of a growing epidemiological diversity as a consequence of rapid economic development and declining fertility. The infectious and parasitic diseases of childhood must remain a priority at the same time the chronic diseases among adults are emerging as a serious problem. Health policymakers must engage in undertaking an epidemiological and economic analysis of the major disease problems, evaluating the cost-effectiveness of alternative intervention strategies; designing health care delivery systems; and, choosing what governments can do through persuasion, taxation, regulation, and provision of services. The World Bank has commissioned studies of over two dozen diseases in developing countries which have confirmed the priority of child survival interventions and revealed that interventions for many neglected and emerging adult health problems have comparable cost-effectiveness. Most developing countries lack information about most major diseases among adults, reflecting lack of national capacities in epidemiological and economic analyses, health technology assessment, and environmental monitoring and control. There is a critical need for national and international investment in capacity building and essential national health research to build the base for health policies.

Salud: de la investigación a la acción / Health: from the research to the action

"Actividad fundamental en el desarrollo de la civilización, la investigación científica tiene por objeto conseguir información pertinente y fidedigna de fenómenos concretos y, llegado el caso, aplicar soluciones específicas a problemas definidos. Este paso -el de la investigación a la acción en materia de salud- es el que un grupo de especialistas internacionales aborda en esta obra. Jaime Martuscelli, Héctor Brust y Gladys Faba nos refieren cómo la investigación básica y la investigación orientada han contribuido a las políticas de salud en México. Avedis Donabedian trata de lo alcanzado en uno de los más recientes campos de la investigación en salud: el estudio científico de la organización de sistemas de salud. Julio Frenk examina la investigación en el sector público, centrándose en el dilema básico entre pertinencia y excelencia. La cooperación internacional, aspecto insustituible para el desarrollo de la investigación aplicada, es el tema que aborda Robin Badgley. Harvey Fineberg analiza la difusión de los resultados de la investigación clínica en la atención médica. La aplicación del conocimiento a la práctica no siempre es la apropiada, José Luis Bobadilla ilustra la situación con un estudio de la operación cesárea en México. Rodrigo Guerrero expone los resultados de un estudio sobre la regionalización de la atención quirúrgica. Los grandes logros de la investigación en salud han tenido significativas repercusiones demográficas, Henry Mosley aborda este punto medular de la sociedad contemporánea. Otro problema actual es el crecimiento explosivo de las grandes urbes; Roberto Castañón, en el último capítulo del libro, ilustra el caso con un estudio de los accidentes en la ciudad de México." (ED). Los temas de los capítulos que conforman el contenido de la obra son: I) La investigación como insumo de las políticas de salud en México. II) Cándido en el país de la investigación en servicios de salud. III) De la pertinencia a la excelencia: dilemas de la investigación. IV) Asistencia internacional para la investigación de los servicios de salud. V) De la investigación a la práctica clínica. VI) Los excesos tecnológicos: el caso de la operación cesárea en México. VII) Regionalización de la atención qirúrgica: un ejemplo de la investigación aplicada. VIII) El impacto demográfico de los programas de sobrevivencia en la infancia: propuesta para la estrategia de los programas. IX) Problemas de salud en las megalópolis

Arginine vasotocin binding to isolated branchial cells of the eel: effect of salinity.

Binding of 125I-labelled arginine vasotocin (AVT) was studied in isolated intact gill cells obtained from eels (Anguilla anguilla) adapted to fresh water (FW) or to sea water (SW). Experiments carried out at 20 degrees C showed maximum and stable binding beyond 10 min of incubation. Specific binding, determined by using labelled peptide in the presence or absence of an excess of unlabelled hormone, represented 30-50% of total and was reversible, with a half-time of less than 5 min. Scatchard plot analysis revealed the presence of a single population of saturable, high-affinity sites. Maximum binding capacity (Bmax: fmol AVT/10(6) cells) and dissociation constant (Kd: nM) were respectively 5.16 and 3.21 in FW and 24.25 and 1.05 in SW. Analysis of chloride cell number and size in gills and of binding characteristics of AVT revealed parallel changes with external salinity. These results are taken as evidence for the direct intervention of neurohypophysial peptides on the gill epithelium of teleost fishes.

[Biological and socioeconomic determinants of child survival]. / Determinantes biológicos y socioeconómicos de la sobrevivencia en la infancia.

PIP: This document describes advances in a conceptual framework under development since 1984 for research on child survival in developing countries. The framework links variables explaining biologically determined disease processes to social determinants in the family and community. The major addition is the extension of previous models of proximate determinants to include fertility-child survival interactions, as well as the interaction between child growth and child survival. The role of health policies within the framework of proximate determinants is also explored. A strategy oriented toward specific diseases will not prove successful in developing countries, where most infant and child deaths are not due to a single cause but rather are the final product of a series of episodes of infection combined with malnutrition. Health policies must therefore identify the risk factors that reduce probabilities of survival as well as the pathologies that actually cause death. Risk factors can be classified as proximate determinants, the basic biological mechanisms that directly influence risks of morbidity and mortality, and underlying determinants, all the other social and environmental determinants that operate indirectly through the proximate determinants to influence infant survival. The 1st step in applying the focus on proximate determinants is to achieve a clear understanding of some measurable biological indicators of health and child survival or of their opposites, illness and death. Abnormal growth has been found to be a sensitive and nonspecific indicator of morbidity in children. Measurement of height and weight could serve as the social science counterpart of mortality measurement for a demographer. Mortality and permanent growth stunting are both indicators reflecting different points of chronic and irreversible physical deterioration on the continuum that ranges from good health to death. The proposed conceptual framework integrates Bongaarts' proximate fertility determinants with the proximate child survival determinants proposed in an earlier work by Mosley and Chen. 9 specific determinants are divided into 4 categories of factors that influence both child survival and fertility: factors regulating exposure to conception (sexual union, coital frequency), lactation, ecological risk (dietary deficiency, environmental contamination, accidents), and direct interventions (personal preventive measures, curative measures, and intentionally inflicted lesions). 5 groups of underlying determinants operate through the proximate determinants: individual factors, family factors, cultural factors, institutional factors, and environmental factors.^ieng

The Saradidi, Kenya, rural health development programme: retrospective demographic analysis.

A census was done in Saradidi, Kenya from 1980 to 1982 as part of a community-based health development programme. The population was 42,755 (excluding 39 persons of unknown age or sex); 17.1% were less than five years old, 46.9% were below age 15, 4.7% were age 65 years or older and 19.7% were women in the reproductive years (age 15 to 44 years). The sex ratio was 86 males per 100 females due principally to migration of adult males for work. The mean number of persons per household was 4.0 and the mean village population was 764. The singulate mean age of marriage for men was 27.0 years and for women 19.9 years; 0.8% of adult men had never married. Only 0.1% of women by age 50 had never been married. Men were significantly more likely than women to be married to more than one spouse, divorce and separation was higher among men, and by age 50 about one-third of women were widows. Men had more years of formal education than women and young people of both sexes more than older people; 73.1% of men and 96.1% of women 60 years and more had never attended school. Infant mortality rates estimated indirectly ranged between 139 and 155 by area. A strong association was found between increasing education of the mother and decreased reported mortality of children. The total fertility of 6.2 was high but lower than the national average possibly because of the high rates of polygamy and primary infertility and the long periods of amenorrhoea and breast feeding which occurred after delivery. This area continues to have one of the highest levels of infant and child mortality in Kenya as well as relatively high fertility and a population with a very young age structure. This implies a continued very rapid rate of population growth which will make more difficult in the future the problems of delivering effective health services and overcoming poverty. A vigorous programme directed toward improving health is indicated which must include family planning.

Impact on mortality and fertility of a community-based malaria control programme in Saradidi, Kenya.

Mortality and fertility rates were measured from 1981 to 1983 by prospective registration of vital events as part of a community-based malaria control and health development programme in Saradidi, Kenya. There was no obvious effect of providing chloroquine phosphate for treatment of malaria in each village on mortality or fertility rates. Crude death rates were 13.1 in the year before intervention (1 May 1981 to 30 April 1982) and 12.3 after intervention (1 September 1982 to 31 August 1983). Neonatal mortality increased from 36.8 per 1000 live births pre-intervention to 49.1 during intervention. There was a slight decline in post-neonatal (one to 12 months) mortality (72.8 to 67.0) and a significant drop in early childhood mortality (25.2 to 18.2). The change in mortality rates in these two age groups were fully explained by a high rate of measles mortality in the pre-intervention period. Measles accounted for 35.7% of 284 reported deaths in infants one to 12 months of age and for 40.9% of 230 deaths in children one to four years old. There was little change in reported malaria-specific mortality rates in infants and young children most likely because of a high level of chloroquine use for treatment of presumptive illness. Perinatal mortality by area ranged between 60.4 and 81.3 pre-intervention to 79.5 to 97.2 after the control programme was instituted. Crude birth rates by area remained stable at about 40 and general fertility rates were about 200. Both pre-intervention and during intervention infants were significantly more likely to have died without medical consultation than children one to four years. However, 79.2% of 284 infants and 90.7% of 193 children died in spite of having consulted a health worker prior to death. The data suggest that a measles vaccine programme would significantly reduce mortality rates in infants and young children. The fact that the majority of infants and young children died in spite of receiving medical attention indicates both the inadequacy of curative medical services in this high mortality setting as well as the necessity for promoting preventive health measures.