State laws on youth access to tobacco in the United States: measuring their extensiveness with a new rating system.
OBJECTIVE: To develop and implement a rating system evaluating the extensiveness of state laws restricting youth access to tobacco. DESIGN: State laws on youth access to tobacco were analysed and assigned ratings on nine items. Six items addressed specific tobacco-control provisions, and three related to enforcement provisions. For each item, a target was specified reflecting public health objectives. Achieving the target resulted in a rating of +4 points; for three items, a rating of +5 was possible if the target was exceeded. Criteria for lower ratings were established for situations when the target was not met. SETTING: United States. RESULTS: State scores (sum of the ratings across all nine items) ranged from 0-18 in 1993, 2-21 in 1994, and 1-21 in 1995 and 1996, out of a possible total of 39. The average score across states was 7.2 in 1993, 7.9 in 1994, 8.2 in 1995, and 9.0 in 1996. The overall mean rating (per item) was 0.80 in 1993, 0.88 in 1994, 0.91 in 1995, and 1.00 in 1996, on a scale where 4.0 indicates that the target goals (per item) were met. From 1993 to 1996, scores increased for 20 states, decreased for one state, and remained unchanged for the others. The number of states for which state preemption of local tobacco regulation was a factor doubled from 10 states in 1993 to 20 states in 1996. CONCLUSIONS: Although all states have laws addressing youth access to tobacco, this analysis reveals that, as of the end of 1996, the progress towards meeting health policy targets is slow, and state legislation that preempts local tobacco regulation is becoming more common. (+info)
Gender and ethnic differences in young adolescents' sources of cigarettes.
OBJECTIVE: To identify the sources used by young adolescents to obtain cigarettes. DESIGN: In early 1994 a survey assessing usual sources of cigarettes and characteristics of the respondents was administered in homeroom classes. SETTING: A large urban, predominantly African American school system. SUBJECTS: A population-based sample of 6967 seventh graders averaging 13 years of age. MAIN OUTCOME MEASURE: Reports of usual sources of cigarettes. RESULTS: At this age level, young smokers were more likely to get cigarettes from friends (31.2%) than buy them in stores (14.3%). However, the odds of purchasing varied for different groups of children. Regular smokers were much more likely (48.3%) to have purchased cigarettes than experimental smokers (9.6%), p < 0.001. Girls were less likely to have bought their cigarettes than boys (p < 0.001), and black smokers were less likely to have purchased cigarettes than white children (p < 0.001). Results suggested that family members who smoke may constitute a more important source of tobacco products than previously recognised, particularly for young girls. CONCLUSIONS: In this middle-school sample, peers provided the major point of cigarette distribution. However, even at this age, direct purchase was not uncommon. Sources of cigarettes varied significantly with gender, ethnicity, and smoking rate. (+info)
Managing the health care market in developing countries: prospects and problems.
There is increasing interest in the prospects for managed market reforms in developing countries, stimulated by current reforms and policy debates in developed countries, and by perceptions of widespread public sector inefficiency in many countries. This review examines the prospects for such reforms in a developing country context, primarily by drawing on the arguments and evidence emerging from developed countries, with a specific focus on the provision of hospital services. The paper begins with a discussion of the current policy context of these reforms, and their main features. It argues that while current and proposed reforms vary in detail, most have in common the introduction of competition in the provision of health care, with the retention of a public monopoly of financing, and that this structure emerges from the dual goals of addressing current public sector inefficiencies while retaining the known equity and efficiency advantages of public health systems. The paper then explores the theoretical arguments and empirical evidence for and against these reforms, and examines their relevance for developing countries. Managed markets are argued to enhance both efficiency and equity. These arguments are analysed in terms of three distinct claims made by their proponents: that managed markets will promote increased provider competition, and hence, provider efficiency; that contractual relationships are more efficient than direct management; and that the benefits of managed markets will outweigh their costs. The analysis suggests that on all three issues, the theoretical arguments and empirical evidence remain ambiguous, and that this ambiguity is attributable in part to poor understanding of the behaviour of health sector agents within the market, and to the limited experience with these reforms. In the context of developing countries, the paper argues that most of the conditions required for successful implementation of these reforms are absent in all but a few, richer developing countries, and that the costs of these reforms, particularly in equity terms, are likely to pose substantial problems. Extensive managed market reforms are therefore unlikely to succeed, although limited introduction of particular elements of these reforms may be more successful. Developed country experience is useful in defining the conditions under which such limited reforms may succeed. There is an urgent need to evaluate the existing experience of different forms of contracting in developing countries, as well as to interpret emerging evidence from developed country reforms in the light of conditions in developing countries. (+info)
Childcare needs of female street vendors in Mexico City.
This article reports on strategies developed by female street vendors (vendedoras ambulantes) in Mexico City to ensure the care of their young children in the absence of a specific and operational government policy to fulfil this need. The information concerning child care and health was gathered by a survey of 426 street traders selected by multi-stage random cluster sampling in four of the administrative districts (delegaciones politicas) of Mexico City during 1990. It was found that, as mothers of young children, street vendors most frequently looked after their children personally on the street or left them with other members of the family. Related factors were availability of alternative child care providers in the family, the age of the children and working conditions of the mother. Children who remained on the streets with their mothers suffered more frequently from gastro-intestinal diseases and accidents than the national average. The incidence of acute respiratory diseases, however, was similar in the cases of maternal care in the street and care by family members in another environment. Existing public health measures show a greater concern for the health of food consumers than that of workers in this area. Current public policy seeks to regulate street vending activities and to concentrate traders in ad hoc areas and facilities. Our research results document the need for actions that can contribute to an improvement in the care and health conditions of these young children. (+info)
Sales practices of patent medicine sellers in Nigeria.
A survey was carried out among patent medicine dealers to evaluate their practices that militate against laws governing prescriptions-only medicines in Nigeria. Questionnaires were distributed to 46 patent medicine dealers and later collected from them on appointment. Analysis of the results showed that all the patent medicine dealers were aware of the law governing the sale of prescription drugs in Nigeria. Seventy-five per cent of them stock such drugs. Patent medicine dealers obtain their drugs largely from sales representative of pharmaceutical companies as well as from industries. Inappropriate use of sales boys and girls in patent medicine stores and defective government policies were all investigated. (+info)
Using condom data to assess the impact of HIV/AIDS preventive interventions.
The effective evaluation of preventive activities depends on the identification of indicators and the selection of appropriate outcome measures which reflect the goals of the intervention. An increase in condom use has been seen as a positive sign of the impact of HIV/AIDS public education. This paper examines possible sources of data relating to condom use in the context of assessing public response to the AIDS epidemic, with particular reference to methodological challenges presented by each; issues relating to the validity of data, problems of interpretation and the scope for improvement. A multiple indicator approach, using several types of data in unison, is advocated. Conclusions drawn from the multiple indicator approach are likely to be firmer and sounder than those drawn from the single indicator approach, and are more likely to offer insight into the mechanisms which influence particular outcomes. (+info)
Factors affecting bargaining outcomes between pharmacies and insurers.
OBJECTIVE: To model the bargaining power of pharmacies and insurers in price negotiations and test whether it varies with characteristics of the pharmacy, insurer, and pharmacy market. DATA SOURCES/STUDY SETTING: Data from four sources. Pharmacy/insurer transactions were taken from Medstat's universe of 6.8 million pharmacy claims in their 1994 Marketscan database. Sources Informatics, Inc. supplied a three-digit zip code-level summary database containing pharmacy payments and self-reported costs for retail (cash-paying) customers for the top 200 pharmaceutical products by prescription size in 1994. The National Council of Prescription Drug Programs supplied their 1994 pharmacy database. Zip code-level socioeconomic and commercial information was taken from Bureau of the Census' 1990 Summary Tape File 3B and 1994 Zip Code Business Patterns database. STUDY DESIGN: The provider/insurer bargaining model first employed in Brooks, Dor, and Wong (1997, 1998) was adapted to the circumstances surrounding pharmacy and insurer bargaining. DATA COLLECTION/EXTRACTION METHODS: The units of observation in this study were single Medstat claims for each unique insurer/pharmacy combination in the database for selected pharmaceutical products. The four products selected varied in the conditions they treat, whether they are used to treat chronic or acute conditions, and by their sales volume. Used in the analysis were 9,758 Zantac, 2,681 Humulin, 3,437 Mevacor, and 1,860 Dilantin observations. PRINCIPAL FINDINGS: We find statistically significant variation in pharmacy bargaining power. Pharmacy bargaining power varies significantly across markets, insurers, and pharmacy types. With respect to market structure, pharmacy bargaining power is negatively related to pharmacies per capita and pharmacies per employer and positively related to pharmacy concentration at higher concentration levels. In addition, the higher the percentage of independent pharmacies in an area, the lower the pharmacy bargaining power. With respect to socioeconomic conditions, pharmacy bargaining power is higher in areas with lower per capita income and higher rates of public assistance. CONCLUSIONS: The bargaining power of pharmacies in contract negotiations with insurers varies considerably with exogenous factors. Local area pharmacy ownership concentration enhances pharmacy bargaining. As a result, anti-trust law prohibiting the collective bargaining of independent pharmacies with insurers leaves independents at a disadvantage with respect to chains. (+info)
An outbreak of hepatitis A associated with an infected foodhandler.
OBJECTIVE: The recommended criteria for public notification of a hepatitis A virus (HAV)-infected foodhandler include assessment of the foodhandler's hygiene and symptoms. In October 1994, a Kentucky health department received a report of a catering company foodhandler with hepatitis A. Patrons were not offered immune globulin because the foodhandler's hygiene was assessed to be good and he denied having diarrhea. During early November, 29 cases of hepatitis A were reported among people who had attended an event catered by this company. Two local health departments and the Centers for Disease Control and Prevention, in collaboration with two state health departments, undertook an investigation to determine the extent of the outbreak, to identify the foods and event characteristics associated with illness, and to investigate the apparent failure of the criteria for determining when immune globulin (IG) should be offered to exposed members of the public. METHODS: Cases were IgM anti-HAV-positive people with onset of symptoms during October or November who had eaten foods prepared by the catering company. To determine the outbreak's extent and factors associated with illness, the authors interviewed all case patients and the infected foodhandler and collected information on menus and other event characteristics. To investigate characteristics of events associated with transmission, the authors conducted a retrospective analysis comparing the risk of illness by selected event characteristics. To evaluate what foods were associated with illness, they conducted a retrospective cohort study of attendees of four events with high attack rates. RESULTS: A total of 91 cases were identified. At least one case was reported from 21 (51%) of the 41 catered events. The overall attack rate was 7% among the 1318 people who attended these events (range 0 to 75% per event). Attending an event at which there was no on-site sink (relative risk [RR] = 2.3, 95% confidence interval [CI] 1.4, 3.8) or no on-site kitchen (RR = 1.9, 95% Cl 1.1, 2.9) was associated with illness. For three events with high attack rates, eating at least one of several uncooked foods was associated with illness, with RRs ranging from 8 to undefined. CONCLUSION: A large hepatitis A outbreak resulted from an infected foodhandler with apparent good hygiene and no reported diarrhea who prepared many uncooked foods served at catered events. Assessing hygiene and symptoms s subjective, and may be difficult to accomplish. The effectiveness of the recommended criteria for determining when IG should be provided to exposed members of the public needs to be evaluated. (+info)