Maternal age and birth rank of women with breast cancer.

Data from a large international case-control study of breast cancer suggested that women born to young mothers had a 25% lower risk of breast cancer. The association was not secondary to a tendency for these women themselves to have had children at early ages. The data provided no indication of a meaningful association between breast cancer risk and birth rank. Confounding was controlled by stratification according to a summary confounder score.

Hospitalizations in a southern rural community: an application of the 'ecology model'.

The purpose of this study is to re-examine the concepts of health services utilization presented by White and his colleagues in 'The Ecology of Medical Care'. We re-test their model in a rural population in the southern United States using longitudinal instead of cross-sectional data and find that the general principles of the 'Ecology' model do, indeed, apply to rural populations like Rougemont/Bahama. Use of this model has implications for modifying and improving the organization of the health care delivery system and for a fundamental change of emphasis in medical education.

Utilization of services for preventable disease: a case study of dental care in a southern rural area of the United States.

The use made of dental services, both preventive and symptomatic, was explored in a small rural southern community in North Carolina as part of a case study illustrative of southern rural patterns of utilization of elective health services. The target population of 1689 persons in 545 households was interviewed in a household survey and in each of four follow-up panel visits over a period of one year--1974--75. Though overall utilization of dental services was low and preventive dental services even lower in both blacks and whites, blacks were at a considerable disadvantage. Unlike whites, increasing education did not increase use of services in blacks; also, unlike whites, black mothers' preventive behaviour was not associated with increased dental preventive behaviour in their children. In addition to barriers to care suffered by the poor, blacks in the south still have additional barriers to overcome: Established patterns of practice are slow to change even when legal and financial barriers are lowered.

Demand for medical care in a rural setting: racial comparisons.

Household data from a southern rural community are used to examine racial differences in the utilization of medical care services, and both monetary and nonmonetary determinants of demand are considered. Regression analysis results indicate that office waiting time (for black households) and travel time to the provider (for both black and white households) have a greater impact on demand than price. Racial differences exist in the effects of health insurance coverage and household income on household medical visit expenditures, and both need and household size are found to be consequential determinants of demand.

Where does primary care begin? The health facilitator as a central figure in primary care.

The role of lay advisors (health facilitators) in primary care is described. Health facilitators are people to whom others naturally turn for advice, counsel and support. The majority of illnesses reported by patients are never presented to a doctor. Because primary care is center in the family or other close social support system within the community social structure, all professional care is in fact external to that natural structure and may be considered secondary in function. In the United States, the recent trend toward self-care shows that professional care does not meet the needs of even the middle class and that people actively seek and receive support from peer groups. A pilot program in North Carolina is described, in which 39 health facilitators were identified and given training in the recognition of common illnesses, disease prevention, health promotion, and community resources. The implications of such programs and their effects on primary health care are discussed.

Racial differences in medical care expenditures.

Out of pocket medical expenditures made by families for physician services, dental visits, medications, hospitalizations and insurance premiums are examined in a southern rural community using household survey interview data. White families paid an average out of pocket amount for total medical services of $709 as compared with $383 for black families over a 12-month period, 1974-75. Correlates of expenditure differences between blacks and whites are explored with respect to family characteristics (race, education of household head, family income, family size and family composition), illness levels (number of family members with perceived fair or poor health status and number of family members reporting chronic conditions), and use of services (number of doctor visits and type of usual source of care). We find that whites consistently report greater expenditures than blacks, regardless of the variables controlled for. We consider that expenditure differences are in part due to a mix of three factors: variations in the cost of doctor visits to whites and blacks; a lower level of use of services by blacks; and the differential availability and use of third party payors.

The health interview survey and minority health.

This article emphasizes the advantages and disadvantages of the National Center for Health Statistics Health Interview Surveys (HIS) when applied to the needs of ethnic minorities at the local level. While HIS gives information on health status of minorities and their use of services at the national level, this information is of limited help to providers in local communities. In any national survey, the numbers of minority persons sampled will be very small and heterogeneous populations sharing a common language (for example, Spanish) may be aggregated though their characteristics may differ widely. Certain groups may be missed or their numbers greatly underestimated if they do not live in settled households, which form the unit of HIS. Pertinent examples are migrant farm workers and young adult black urban males. Other possible problems arise in the use of proxy respondents, in the HIS definition of acute illness, and in the rather infrequent use of linkage studies. While there are a number of important ways by which HIS surveys may be made more effective, special national surveys of specific minority groups and in-depth local surveys are needed to fill gaps in meeting minority needs.

Pro Bono Publico--a century later.

From the introduction of Pro Bono Publico smoking tobacco in Durham, NC a century ago, the production of tobacco products has become a vital part of the state's economy. How this may relate to the smoking behavior, and consequently to the health of its residents is assessed from smoking patterns of adult residents of a rural area of Durham County. Male smoking rates are considerably higher than U.S. estimates whereas female rates are lower. The national trend of increasing incidence of lung cancer can be expected to continue in North Carolina and may be even greater due to the high rate of smoking.

The role of the health facilitator in community health education.

A community health education program has been established by the Department of Community Health Sciences of Duke University Medical Center in two target areas of Durham County, North Carolina. The program trains unpaid lay people, "health facilitators", to whom others already turn for help, to increase their competency for advising and referring community residents to appropriate community resources. Several methods for identifying potential health facilitators have been developed. Evaluation of the role of health facilitators hinges upon designing measures to demonstrate their existence in the community and the impact that they make. To be successful, the training of health facilitators should result in improving the quality of the advice they give their fellows. It is also important to assess the cultural acceptability of the facilitators' advice and to ensure that their helping role in the community is not disturbed by the possible professionalization of their role due to the training program.

Health care decision making in Southern County.

We combine two standard approaches to analyze power and influence in health policy formulation within a moderately large county in the south. Intrinsic methodologic weaknesses are discussed and several conclusions are drawn regarding power in the health care sector of that community. The most significant finding is the shift in power over time, away from the individuals to committees and health care organizations. The ignorance of most physicians about the broader health care issues that affect the community was reflected in their lack of recognition by others in the community as influential decision makers. The insular relationship of the university to the rest of the community was also noted. Past racial politics had a continuing effect on later health policy formulation. These findings are discussed in light of current and past issues. Because we had promised confidentiality to the persons we interviewed, fictitious names were given to the county, the institutions, and the interviewees.