What is the future for equity within health policy? (1/1047)

In spite of differences in meaning, equity is generally accepted as an important social and economic policy goal. However, recent policy debates suggest that this consensus is under challenge. This paper explores the current debate between the 'New Right' and its opponents, and how different approaches affect health policy. It is strongly argued that if equity is not to remain a misunderstood concept, it is essential to clarify the arguments in its favour, as well as the steps required to protect its position within policy. The paper then goes on to justify the concern with equity, the broad goals equity seeks to achieve, and the practical translation of these goals into health policy. In the final section essentially practical issues are raised, by considering planning strategies and what research is necessary to support and develop pragmatic planning based on equity goals.  (+info)

Threats to global health and survival: the growing crises of tropical infectious diseases--our "unfinished agenda". (2/1047)

Health, one of our most unassailable human values, transcends all geographic, political, and cultural boundaries. The health problems of the rapidly growing 80% of the world's population that live in the tropical developing countries of Asia, Africa, and Latin America pose major threats to industrialized as well as developing regions. These threats can be divided into three areas, or three "E"s: (1) emerging, reemerging, and antimicrobial-resistant infections; (2) exploding populations without improved health; and (3) erosion of our humanity or leadership if we ignore the growing health problems of the poor. Our assessment of current trends in global population distribution and resource consumption; DALY calculations, causes, and distribution of global mortality and morbidity; and the misperceptions about and maldistribution of resources for health point to the critical importance of addressing tropical infectious diseases and global health for preservation of democracy and civilization as we know it.  (+info)

Goal attainment scaling as a measure of clinically important change in nursing-home patients. (3/1047)

OBJECTIVES: To assess the feasibility, validity and responsiveness of an individualized measure--goal attainment scaling-in long-term care. DESIGN: Prospective descriptive study. SETTING: One academic and three community-based long-term care facilities. SUBJECTS: 53 nursing-home patients seen in consultation between July 1996 and June 1997. INTERVENTION: Specialized geriatric medicine consultation. MAIN OUTCOME MEASURES: Effect size and relative efficiency of the Barthel index, hierarchical assessment of balance and mobility, global deterioration scale, axis 8 (behaviour) of the brief cognitive rating scale, cumulative illness rating scale and the goal attainment scale. RESULTS: Mean goal attainment scale at follow-up was 46+/-7. The goal attainment scale was the most responsive measure, with an effect size of 1.29 and a relative efficiency of 53.7. The goal attainment scale did not correlate well with the other measures (-0.22 to 0.17). CONCLUSION: Goal attainment scaling is a feasible and responsive measure in long-term care. Although fewer problems in nursing-home patients than elderly inpatients are susceptible to intervention, clinically important goals can be achieved in this population.  (+info)

Delay activity of orbital and lateral prefrontal neurons of the monkey varying with different rewards. (4/1047)

We examined neuronal activity in the orbitofrontal cortex (OFC) in relation to reward expectancy and compared findings with those of the lateral prefrontal cortex (LPFC) in the monkey. Activity of OFC neurons was examined in a delayed reaction time task where every four trials constituted one block within which three kinds of rewards and no reward were delivered in a fixed order. More than half of OFC delay neurons were related to the expectancy of delivery or nodelivery of a reward as the response outcome, while some neurons showed nature-of-reward-specific anticipatory activity changes. These delay-related activities reflected the preference of the animal for each kind of reward and were modulated by the motivational state of the animal. LPFC neurons are reported to show nature-ofreward-specific anticipatory activity changes in a delayed response task when several different kinds of rewards are used. Such rewarddependent activity is observed in LPFC delay neurons both with and without spatially differential delay (working memory-related) activity. Although reward expectancy-related activity is commonly observed in both OFC and LPFC, it is suggested that the OFC is more concerned with motivational aspects, while the LPFC is related to both the cognitive and motivational aspects of the expectancy of response outcome.  (+info)

Reward processing in primate orbitofrontal cortex and basal ganglia. (5/1047)

This article reviews and interprets neuronal activities related to the expectation and delivery of reward in the primate orbitofrontal cortex, in comparison with slowly discharging neurons in the striatum (caudate, putamen and ventral striatum, including nucleus accumbens) and midbrain dopamine neurons. Orbitofrontal neurons showed three principal forms of reward-related activity during the performance of delayed response tasks, namely responses to reward-predicting instructions, activations during the expectation period immediately preceding reward and responses following reward. These activations discriminated between different rewards, often on the basis of the animals' preferences. Neurons in the striatum were also activated in relation to the expectation and detection of reward but in addition showed activities related to the preparation, initiation and execution of movements which reflected the expected reward. Dopamine neurons responded to rewards and reward-predicting stimuli, and coded an error in the prediction of reward. Thus, the investigated cortical and basal ganglia structures showed multiple, heterogeneous, partly simultaneous activations which were related to specific aspects of rewards. These activations may represent the neuronal substrates of rewards during learning and established behavioral performance. The processing of reward expectations suggests an access to central representations of rewards which may be used for the neuronal control of goaldirected behavior.  (+info)

Reward-related neuronal activity during go-nogo task performance in primate orbitofrontal cortex. (6/1047)

The orbitofrontal cortex appears to be involved in the control of voluntary, goal-directed behavior by motivational outcomes. This study investigated how orbitofrontal neurons process information about rewards in a task that depends on intact orbitofrontal functions. In a delayed go-nogo task, animals executed or withheld a reaching movement and obtained liquid or a conditioned sound as reinforcement. An initial instruction picture indicated the behavioral reaction to be performed (movement vs. nonmovement) and the reinforcer to be obtained (liquid vs. sound) after a subsequent trigger stimulus. We found task-related activations in 188 of 505 neurons in rostral orbitofrontal area 13, entire area 11, and lateral area 14. The principal task-related activations consisted of responses to instructions, activations preceding reinforcers, or responses to reinforcers. Most activations reflected the reinforcing event rather than other task components. Instruction responses occurred either in liquid- or sound-reinforced trials but rarely distinguished between movement and nonmovement reactions. These instruction responses reflected the predicted motivational outcome rather than the behavioral reaction necessary for obtaining that outcome. Activations preceding the reinforcer began slowly and terminated immediately after the reinforcer, even when the reinforcer occurred earlier or later than usually. These activations preceded usually the liquid reward but rarely the conditioned auditory reinforcer. The activations also preceded expected drops of liquid delivered outside the task, suggesting a primary appetitive rather than a task-reinforcing relationship that apparently was related to the expectation of reward. Responses after the reinforcer occurred in liquid- but rarely in sound-reinforced trials. Reward-preceding activations and reward responses were unrelated temporally to licking movements. Several neurons showed reward responses outside the task but instruction responses during the task, indicating a response transfer from primary reward to the reward-predicting instruction, possibly reflecting the temporal unpredictability of reward. In conclusion, orbitofrontal neurons report stimuli associated with reinforcers are concerned with the expectation of reward and detect reward delivery at trial end. These activities may contribute to the processing of reward information for the motivational control of goal-directed behavior.  (+info)

Effects of reversible inactivation of the primate mesencephalic reticular formation. I. Hypermetric goal-directed saccades. (7/1047)

Single-neuron recording and electrical microstimulation suggest three roles for the mesencephalic reticular formation (MRF) in oculomotor control: 1) saccade triggering, 2) computation of the horizontal component of saccade amplitude (a feed-forward function), and 3) feedback of an eye velocity signal from the paramedian zone of the pontine reticular formation (PPRF) to higher structures. These ideas were tested using reversible inactivation of the MRF with pressure microinjection of muscimol, a GABA(A) agonist, in four rhesus monkeys prepared for chronic single-neuron and eye movement recording. Reversible inactivation revealed two subregions of the MRF: ventral-caudal and rostral. The ventral-caudal region, which corresponds to the central MRF, the cMRF, or nucleus subcuneiformis, is the focus of this paper and is located lateral to the oculomotor nucleus and caudal to the posterior commissure (PC). Inactivation of the cMRF produced contraversive, upward saccade hypermetria. In three of eight injections, the velocity of hypermetric saccades was too fast for a given saccade amplitude, and saccade duration was shorter. The latency for initiation of most contraversive saccades was markedly reduced. Fixation was also destabilized with the development of macrosaccadic square-wave jerks that were directed toward a contraversive goal in the hypermetric direction. Spontaneous saccades collected in total darkness were also directed toward the same orbital goal, up and to the contraversive side. Three of eight muscimol injections were associated with a shift in the initial position of the eyes. A contralateral head tilt was also observed in 5 out of 8 caudal injections. All ventral-caudal injections with head tilt showed no evidence of vertical postsaccadic drift. This suggested that the observed changes in head movement and posture resulted from inactivation of the caudal MRF and not spread of the muscimol to the interstitial nucleus of Cajal (INC). Evidence of hypermetria strongly supports the idea that the ventral-caudal MRF participates in the feedback control of saccade accuracy. However, development of goal-directed eye movements, as well as a shift in the initial position following some of the cMRF injections, suggest that this region also contributes to the generation of an estimate of target or eye position coded in craniotopic coordinates. Last, the observed reduction in contraversive saccade latency and development of macrosaccadic square-wave jerks supports a role of the MRF in saccade triggering.  (+info)

Evidence for the transient nature of a neural system supporting goal-directed action. (8/1047)

Disruption of a neural system supporting goal-directed action gives rise to lapses of intention in healthy individuals and disorganized behavior in patients with prefrontal lesions. Evidence from behavioral studies indicates that the occurrence of lapses in selective attention, working memory and prospective memory tasks is transient in nature. In the current study, we used event-related brain potentials to demonstrate that lapses are associated with a slow wave over the frontal region that begins well before stimulus onset and lasts for several hundred milliseconds. The magnitude of this slow wave was modulated by task demands, indicating that attentional processes can be flexibly allocated in the service of goal-directed action. Together the findings of these experiments indicate that lapses result from a transient inability to bring to bear the goals of the individual upon the action selection system.  (+info)