Association among income loss, financial strain and depressive symptoms during COVID-19: evidence from two longitudinal studies.

BACKGROUND: The COVID-19 pandemic has major ramifications for global health and the economy, with growing concerns about economic recession and implications for mental health. Here we investigated the associations between COVID-19 pandemic-related income loss with financial strain and mental health trajectories over a 1-month course. METHODS: Two independent studies were conducted in the U.S and in Israel at the beginning of the outbreak (March-April 2020, T1; N = 4 171) and at a 1-month follow-up (T2; N = 1 559). Mixed-effects models were applied to assess associations among COVID-19-related income loss, financial strain, and pandemic-related worries about health, with anxiety and depression, controlling for multiple covariates including pre-COVID-19 income. FINDINGS: In both studies, income loss and financial strain were associated with greater depressive symptoms at T1, above and beyond T1 anxiety, worries about health, and pre-COVID-19 income. Worsening of income loss was associated with exacerbation of depression at T2 in both studies. Worsening of subjective financial strain was associated with exacerbation of depression at T2 in one study (US). INTERPRETATION: Income loss and financial strain were uniquely associated with depressive symptoms and the exacerbation of symptoms over time, above and beyond pandemic-related anxiety. Considering the painful dilemma of lockdown versus reopening, with the tradeoff between public health and economic wellbeing, our findings provide evidence that the economic impact of COVID-19 has negative implications for mental health. FUNDING: This study was supported by grants from the National Institute of Mental Health, the US-Israel Binational Science Foundation, Foundation Dora and Kirsh Foundation.

Neurotomy of the rectus femoris nerve: Short-term effectiveness for spastic stiff knee gait: Clinical assessment and quantitative gait analysis.

BACKGROUND: Stiff knee gait is a troublesome gait disturbance related to spastic paresis, frequently associated with overactivity of the rectus femoris muscle in the swing phase of gait. OBJECTIVE: The aim of this study was to assess the short-term effects of rectus femoris neurotomy for the treatment of spastic stiff-knee gait in patients with hemiparesis. PATIENTS AND METHODS: An Intervention study (before-after trial) with an observational design was carried out in a university hospital. Seven ambulatory patients with hemiparesis of spinal or cerebral origin and spastic stiff-knee gait, which had previously been improved by botulinum toxin injections, were proposed a selective neurotomy of the rectus femoris muscle. A functional evaluation (Functional Ambulation Classification and maximal walking distance), clinical evaluation (spasticity - Ashworth scale and Duncan-Ely test, muscle strength - Medical Research Council scale), and quantitative gait analysis (spatiotemporal parameters, stiff knee gait-related kinematic and kinetic parameters, and dynamic electromyography of rectus femoris) were performed as outcome measures, before and 3 months after rectus femoris neurotomy. RESULTS: Compared with preoperative values, there was a significant increase in maximal walking distance, gait speed, and stride length at 3 months. All kinematic parameters improved, and the average early swing phase knee extension moment decreased. The duration of the rectus femoris burst decreased post-op. CONCLUSION: This study is the first to show that rectus femoris neurotomy helps to normalise muscle activity during gait, and results in improvements in kinetic, kinematic, and functional parameters in patients with spastic stiff knee gait.

Multimethod assessment of treatment process in chronic low back pain: comparison of reported pain-related anxiety with directly measured physical capacity.

Although cognitive behavioural treatments (CBT) have proven efficacy in improving symptom management, pain-related distress, physical performance and return to work. few studies have examined the relationship between changes in behavioural process variables during treatment and improvement in outcome variables following treatment. We designed a multimethod assessment strategy to test the relative contribution of changes in physical capacity and pain-related anxiety to treatment outcome variables. Low back pain patients (n = 59) were treated with an intensive programme of physical exercise and CBT. Comparisons from pre- to post-treatment showed significant improvement in pain severity, interference, affective distress, activity level, and depression. Improvements in pain-related anxiety were associated with improvements in all outcome variables except interference. Of three physical capacity composite scores, improvement in only one (lumbar extension and flexion capacity) was associated with improvements in all outcome variables except interference. Further analyses demonstrated that the relationship between changes in pain-related anxiety and treatment outcome were independent of changes in physical capacity performance. Changes during treatment in pain-related anxiety may be more important than changes during treatment in physical capacity when predicting the effect of treatment on behavioural outcome measures. These results are discussed in the context of how to improve assessment of the chronic pain patient and improve the effectiveness of multidisciplinary CBT.

Self-rated health status and health care utilization among immigrant and non-immigrant Israeli Jewish women.

INTRODUCTION: Since 1989, Israel has absorbed over 700,000 Jewish immigrants from the former Soviet Union, among them about 375,000 women. Immigrants are known to have greater and/or different health needs than non-immigrant residents, and to face unique barriers to receiving care. However, research addressing the specific health problems of these immigrant women has been scarce. OBJECTIVES: To compare self-reported health status and health care utilization patterns among immigrant and non-immigrant Israeli Jewish women; and to explore ways to overcome existing barriers to their care. METHODS: A telephone survey was conducted in September and October 1998 among a random national sample of women age 22 and over, using a standard questionnaire. In all, 849 interviews were completed, with a response rate of 84%. In this article we present comparative data from a sub-set that included 760 immigrant respondents from the former Soviet Union and non-immigrant Jewish respondents. RESULTS: A greater proportion of immigrant versus non-immigrant women reported poor perceived health status (17% vs. 4%), chronic disease (61% vs. 38%), disability (31% vs. 18%) and depressive mood symptoms (52% vs. 38%). Lower rates of immigrant women visited a gynecologist regularly (57% vs. 83%) and were satisfied with their primary care physician. Lower rates of immigrants reported discussing health promotion issues such as smoking, diet, physical activity, HRT, and calcium intake with their physician. The article concludes with a discussion of the implications of the findings for designing services that will effectively promote immigrant women's health, both in Israel and elsewhere.

Impact of a hospital-based antimicrobial management program on clinical and economic outcomes.

Inappropriate use of antimicrobial agents results in unnecessary exposure to medication, persistent or progressive infection, emergence of resistance, and increased costs. We implemented a program to control use of restricted agents while improving care. This study compared 2 major mechanisms for improving use of antimicrobial agents: (1) recommendations made by the Antimicrobial Management Team (AMT), which included a clinical pharmacist backed up by a physician from the Division of Infectious Diseases (ID), and (2) recommendations made by ID fellows. Outcome measures included appropriateness of recommendations, cure rate, number of treatment failures, and cost of care, which were assessed for 180 patients. The AMT outperformed the ID fellows in all outcomes examined by the study (including appropriateness [87% vs. 47%; P<.001], cure rate [64% vs. 42%; P=.007], and treatment failures [15% vs. 28%; P=.03]), although the differences in economic outcomes between cases managed by the AMT and those managed by the ID fellows were not statistically significant. In an academic setting with a restricted formulary, the AMT demonstrated better antimicrobial prescribing than ID fellows.

How Israeli primary care physicians perceive their role in the health care system.

In some Western European countries, primary care physicians (PCPs) play a major role in the health care system, but in Israel the health care system is in the process of being reformed and the role of PCPs has not yet been established. The purpose of the study described in this article was to determine the attitude of PCPs toward the role that they should play in the health care system in Israel and the formal training they need to fill this role. PCPs cited 12 primary functions that they should carry out, including coordinating patient care and counseling patients. Also, 60% of PCPs have undergone specialty training, and 94% think that this training is essential. Among the conclusions of the study are that a higher percentage of PCPs should undergo specialty training in order to enhance their professional status and that continued medical education should emphasize specific issues, such as the consideration of economic factors in patient management decisions, responsibility for patients' administrative issues, 24-hour responsibility for patients, and house calls.

Implementing managed competition in Israel.

As of January 1, 1995, Israel's National Health Insurance (NHI) Law laid the foundations for regulating competition among the country's four private, not-for-profit sick funds. Prior to NHI the sick funds (SFs) had competed without governmental control. Extensive research on NHI implementation and the behavior of the sick funds (SFs) after passage of NHI reveals a paradoxical development: The NHI bill drew on the rhetoric of managed competition and did indeed establish a legal and structural framework for regulating competition among the SFs. Nevertheless, in practice, SF autonomy was constrained and competition over provision of statutory care was limited. Rather than fostering competition, the main thrust of the NHI reforms was to enhance central government's control over SF expenses in order to constrain government expenditures. The NHI reforms did encourage the SFs to cut costs and make visible service improvements. However, the reforms did not lead the SFs to reorganize, expand the scope of their services, or improve clinical quality, as the reformers had hoped. Nor did the reforms help eliminate the SF's operating deficits or insure financial stability for the whole health system. Furthermore, the reforms had unanticipated and undesired outcomes, including aggressive and illegal marketing by SFs and collaboration among SFs to restrict the extent of care provided under compulsory insurance. The Israeli case suggests that the theory of managed competition contains unrealistic assumptions about the types of competitive behavior that result from exposure to managed competition and the capacity of government and health providers to monitor quality. In addition to stemming from universal limitations to the managed competition model, the implementation pattern in Israel reflects local, historical forces and the interplay of Israel's powerful health system actors.

Reforming the Israeli health system: findings of a 3-year evaluation.

Israel, like many other European countries, has recently reformed its health care system. The regulated market created by the National Health Insurance (NHI) law embodies many of the principles of managed competition. The purpose of this paper is to present initial findings from an evaluation of the first 3 years of the reform (1995-1997) regarding the implementation of the reform and the extent to which it has achieved its main goals. The evaluation was conducted using multiple quantitative and qualitative research tools: interviews with key informants; analysis of documents and sick fund financial statements; analysis of trends in sick fund membership; and population surveys conducted in 1995 and 1997 to assess the impact of the reform on outcome measures related to level of services to the public. Data from the evaluation show that the NHI law achieved a considerable number of its goals: to provide insurance coverage for the entire population, to ensure freedom of movement among sick funds, and to standardize the way resources are allocated to sick funds. The incentives that are embodied in the law have encouraged the sick funds to improve the level of services provided to the average insuree, and to develop services in the periphery and for some of the weaker populations. From the financial perspective, concerns that NHI would lead to a rise in the national health expenditure were not realized as of 1997. In the wake of NHI, there has been a decline in the age adjusted per capita expenditure in three sick funds, with no reports by insurees, at least through 1997, on a decline in satisfaction or level of service. However, the Israeli experience shows that regulating competition does not necessarily lead to economic stability and equality. Regulating the competition also did not solve some of the major policy issues in the Israeli health system including level of resources allocated to health, organizational structure of the hospital system, manpower planning and the extent of government involvement in system. Additional policy changes may be needed to resolve these issues. Up-to-date information is essential in helping policymakers track the process of reform implementation and results, and identify problems which need to be addressed in the future.

The reform of the Israeli health care system: a comparison between older and younger consumers, one year and three years after its implementation.

OBJECTIVE: One of the main objectives of the National Health Insurance Law, which was implemented in Israel in January 1995, was to increase equity among different population groups and improve services for weaker populations, such as older people. It is not clear, however, whether the law's goals are being achieved. This study aimed to examine changes in the satisfaction and perceived quality of healthcare services among older people one year and three years after enactment of the law, and to compare the satisfaction and perceptions of older people with those of young adults. DESIGN: Two cross-sectional telephone surveys conducted by the JDC-Brookdale Institute. SETTING: Israel. PARTICIPANTS: Two random samples of the adult residents of Israel at the end of 1995 and at the end of 1997. Two hundred and eighteen older people (of 1,116 respondents) were included in the first survey, and 198 older people (of 1,205 respondents) were included in the second survey. Sixty-seven percent of older respondents in both surveys were 65 to 74 years old and the remaining 33% were 75 years old and over. Forty-three percent were men. Sixty-four percent reported having had at least one chronic illness. There were no differences between the two samples, with the exception of a higher percentage of new immigrants in the second survey. MEASUREMENTS: Perception of changes in the level of services, satisfaction with services, and perceived quality of care (availability, accessibility, early detection procedures). RESULTS: Older people felt there had been an improvement in the level of sick fund (who operate as health maintenance organizations [HMOs] in the United States) services since implementation of the law. The proportion reporting improvement increased from 13% in 1995 to 28% in 1997. At the same time, the proportion of older people who sensed a decline in the level of services also increased, albeit at a much lower rate (4% in 1995 and 8% in 1997). The percentage of younger adults reporting an improvement in services and the percentage reporting a decline were greater than the percentages of older people, in both surveys. Regarding access to services, 69% waited up to 15 minutes to see their physician and 56% received an appointment to see a specialist within one week; this was an improvement. While a higher proportion of younger adults received an appointment within a shorter time span in 1995, the gap had diminished by 1997. Most of the older people felt that the office hours of their family physicians, specialists, administrative services, and laboratories were convenient. The proportion of elderly reporting so increased between 1995 and 1997, and in both surveys was higher than among younger adults. CONCLUSION: The study's findings show that older people perceived an improvement in a number of areas during the first three years of the law's implementation. Their experience was similar to that of younger adults and was even better in some areas. It is necessary to continue monitoring the impact of the law on the need for health services of vulnerable groups such as the chronically ill and disabled older people.

Primary care physicians in Israel: self-perception of their role in the healthcare system and policy makers' and patients' perception of them as gatekeepers.

BACKGROUND: The rapidly increasing costs of healthcare pose a major challenge to many governments, particularly in developed countries. Health policy makers in some Western European countries have adopted the policy of a strong primary healthcare system, partly due to their recognition of the value of primary care medicine as a means to restrain costs while maintaining the quality and equity of healthcare services. In these countries there is a growing comprehension that the role of the family physician should be central, with responsibility for assessing the overall health needs of the individual, for coordination of medical care and, as the primary caregiver, for most of the individual's medical problems in the framework of the family and the community. OBJECTIVES: To describe primary care physicians in Israel from their own perception, health policy makers' opinion on the role PCPs should play, and patients' view on their role as gatekeepers. METHODS: The study was based on three research tools: a) a questionnaire mailed to a representative sample of all PCPs employed by the four sick funds in Israel in 1997, b) in-depth semi-structured interviews with key professionals and policy makers in the healthcare system, and c) a national telephone survey of a random representative sample of patients conducted in 1997. RESULTS: PCPs were asked to rank the importance of 12 primary functions. A total of 95% considered coordination of all patient care to be a very important function, but only 43% thought that weighing economic considerations in patient management is important, and 30.6% thought that 24 hour responsibility for patients is important. Also, 60% of PCPs have undergone specialty training and 94% thought that this training is essential. With regard to the policy makers, most preferred highly trained PCPs (board-certified family physicians, pediatricians and internists) and believed they should play a central role in the healthcare system, acting as coordinators, highly accessible and able to weigh cost considerations. Yet, half opposed a full gatekeeper model. They also felt that the general population has lost faith in PCPs, and that most have a low status and do not have adequate training. Regarding the patients' viewpoint, 40% preferred that the PCP function as their "personal physician" coordinating all aspects of their care and fully in charge of their referrals; 30% preferred self-referral to sub-specialists, and 19% preferred their PCP to coordinate their care but wanted to be able to refer themselves to specialists. CONCLUSIONS: In order to maintain high quality primary care, it is important that all PCPs have board certification. In addition, PCP training systems should emphasize preventive medicine, health promotion, health economy, and cost-effectiveness issues. Efforts should be made to render PCPs a central role in the healthcare system by gradually implementing the elements of the gatekeeper model through incentives rather than regulations.

[What do primary care physicians think of Israel's health policy reform?].

Opinions of the National Health Insurance (NHI) Law held by primary care physicians were surveyed. A questionnaire was submitted (April-July 1997) to 930 primary care physicians employed by sick funds, including general practitioners, family physicians, pediatricians and internists. Response rate was 86%. They supported the main components of the NHI law. It was considered desirable "to a great" or "very great extent" to allocate funds to sick funds based on age and number of members (76%), to require them to accept all applicants (72%), to designate a uniform basket of services (65%), to allow members to transfer freely between funds (63%), and to allow sick funds to sell supplemental insurance (59%). However, only 41% were satisfied with the implementation of the law. Multivariate analysis showed that employment by Maccabi, Meuhedet, or Leumit sick funds had an independent effect on low satisfaction with the law as implemented, and on negative opinions about the uniform basket of services, the accepting of all applicants, and allocation of funding based on age and number of members. Those employed by the Maccabi and Meuhedet funds were in favor of allowing sick funds to sell supplemental insurance. The findings of the study have implications for policy-makers interested in increasing support for national health reform by physicians. It is important to examine possibilities of developing direct channels of communication between national policy-makers and physicians, as well as institutionalizing mechanisms that involve physicians directly in formulation of national policy.

Who needs a gatekeeper? Patients' views of the role of the primary care physician.

BACKGROUND: The primary care physician serving as a 'gatekeeper' can make judicious decisions about the appropriate use of medical services, and thereby contribute to containing costs while improving the quality of care. However, in Israel, sick funds competing for members have not adopted this model for fear of endangering their competitive stance. The purpose of this study was to examine, for the first time, the stated preferences and actual behaviour of a national sample of members of the four Israeli sick funds regarding self-referral to specialists, and to identify the characteristics of patients who prefer the gatekeeper model. METHODS: Data were derived from a national telephone survey carried out in 1997. A random representative sample of 1084 of all adult sick fund members were interviewed, with a response rate of 81%. Bivariate analysis was conducted using over all chi-square tests, and multivariate analysis was performed using logistic regression models. RESULTS: A third of all respondents prefer self-referral to a specialist, 40% prefer their family physician to act as gatekeeper and 19% prefer the physician to co-ordinate care but to refer themselves to a specialist. Independent variables predicting preference for the gatekeeper model are: living in the periphery, sick fund membership, low level of education, being male, fair or poor health status, having a permanent family physician and being satisfied with the professional level of the family physician. A significant correlation was found between practising self-referral and preference for self-referral. CONCLUSIONS.: The findings indicate the importance of surveying patients' attitudes as an input in policy formulation. The study identified specific population groups which prefer the gatekeeper model, and explored the advantages of a flexible model of gatekeeping.

The role of the primary care physician in the Israeli health care system as a 'gatekeeper'--the viewpoint of health care policy makers.

The aim of the study was to determine the attitudes of policy makers in the health care system in Israel to a change in the role of primary care physicians (PCP) and to ascertain the conditions under which they would be ready to adopt the model of PCP as gatekeeper. The study design was qualitative, with analyses of in-depth structured interviews of 20 policy makers from the Ministry of Health, the Sick Funds' central administrations and the Israel Medical Association (IMA) central office. The majority of the respondents claim that they want highly trained PCPs (family physicians, pediatricians and internals) to play a central role in the health care system. They should be co-ordinators, highly accessible and should be able to weigh cost considerations. However, only about half of the respondents support a full gatekeeper model and most of them think that the gatekeeper concept has a negative connotation. They also feel that it would be difficult to implement regulations regarding primary care. The barriers to implementation of the gatekeeper model, as cited by the respondents include loss of faith in PCPs by the general population, dearth of PCPs with adequate training, low stature, lack of availability on a 24-h basis, resistance by specialists, strong competition between the sick funds including promises of direct access to specialists, the medical care habits of the general population many of whom do not settle for only one opinion, and a declared anti-gatekeeper policy by one of the sick funds. Ways to overcome these obstacles include implementation of fundholding clinics, patient education on the importance of having a personal physician, appropriate marketing by family medicine and primary care advocates, and continued training in primary care. Israeli health care policy makers have an ambivalent attitude to strengthening the role of primary care. In theory, they profess support for placing primary care physicians in a central role in the health care system. However, in practice almost half oppose the full gatekeeper model. Therefore, introduction of a gatekeeper model into the Israeli health care system should be implemented gradually, based on incentives rather than regulations. Furthermore, the idea should be marketed by the primary care physicians' professional organizations, the Ministry of Health and the sick funds to physicians as well as to patients, in order to garner their support. In light of the broad consensus that competent primary care physicians are the basis for implementation of the gatekeeper model, board certification should be gradually required by employers of primary care physicians. The process of training physicians currently working in the system should be encouraged and supported by the Ministry of Health. Given the existing opposition of policy makers to giving primary care physicians exclusive referral rights to specialists, the current policy of direct access to a limited number of specialties should be continued but not extended to other specialties.

Correlates of a perceived need for mental health assistance and differences between those who do and do not seek help.

BACKGROUND: This study examined prevalence of perceived need for mental health assistance, characteristics of people with a perceived need, and how persons with a need who sought help were different from those who did not. METHODS: A national random phone survey (n = 1,394) was conducted in Israel, which included questions about (1) perceived need for mental health assistance and (2) help seeking. RESULTS: Prevalence of life-time and recent perceived need for males was 21% and 10.7%, and for females 31% and 15.1%. Of those with a perceived need, 31.4% of males and 41.6% of females had gone for help. Based on logistic regression models, the variables associated with need were being female, divorced, having a chronic physical disease, and low income (for males only), while predictors of help seeking were living in a big city and not being a recent immigrant. The major sources of help in descending order were: mental health professionals (46%), family physician (25%), family or friends (19%), and other (10%). CONCLUSIONS: A majority of people who feel that they need help for mental health problems do not get help.

Evaluating the Israeli health care reform: strategy, challenges and lessons.

Evaluating the implementation of health care reform provides important information on its effect, as well as a factual basis for deciding upon mid-course modifications. Although researchers in various countries are addressing the impact of reform, only few governments have initiated a structured, planned evaluation to accompany reform efforts. In Israel, the 1995 National Health Insurance Law earmarked 0.1% of the health care budget for research on the law, coordinated by the National Institute for Health Policy and Health Services Research. This paper describes the evaluation strategy of the JDC-Brookdale Institute which is taking part in the research efforts. Implementation of the evaluation strategy and the challenges of evaluating a major reform of the health system are discussed. The evaluation strategy combines elements of formative and summative evaluation using a 'case study' approach which seeks to integrate in-depth understanding of the changing health system and of health care provider's organizational behavior, with a variety of outcome measures. The Israeli case provides support for the proposition that an integrated approach to evaluating health reform provides a better understanding of the subject under review and thus a better basis for making useful recommendations to policy makers. In addition, such an approach enhances the validity and credibility of the data and thus the probability of making an impact, which is a main objective of formative evaluation. Examination of the Israeli case, provides important insights about evaluation of health system reform, and may benefit researchers in other countries attempting to evaluate health care reform.

Assessment of lead exposure in schoolchildren from Jakarta.

Children attending schools in urban areas with high traffic density are a high risk group for lead poisoning. We assessed the magnitude of lead exposure in schoolchildren from Jakarta by analyzing blood lead concentrations and biomarkers of heme biosynthesis. A total of 131 children from four public elementary schools in Jakarta (two in the southern district and two in the central district) were enrolled in the study. To evaluate lead pollution in each area, soil samples and tap water were collected. The mean blood lead concentration was higher in the central district than in the southern district (8.3 +/- 2.8 vs. 6.9 +/- 3.5 microg/100 ml; p<0.05); 26.7% of the children had lead levels greater than 10 microg/100 ml. In 24% of the children, zinc protoporphyrin concentrations were over 70 micromol/mol hemoglobin; in 17% of the samples, hemoglobin was less than 11 g/100 ml. All other values were within the physiological range. Blood lead concentration and hematological biomarkers were not correlated. Analyses of tap water revealed lead values under 0. 01 mg/l; lead contamination of soil ranged from 77 to 223 ppm. Our data indicate that Indonesian children living in urban areas are at increased risk for blood lead levels above the actual acceptable limit. Activities to reduce pollution (e.g., reduction of lead in gasoline) and continuous monitoring of lead exposure are strongly recommended.

Urinary iodine excretion is the most appropriate outcome indicator for iodine deficiency at field conditions at district level.

To empower local authorities to plan and evaluate adequate interventions, appropriate iodine deficiency disorders (IDD) indicators need to be identified. The aim of this study was to describe the magnitude and severity of IDD with different outcome indicators and associate them with functional indicators. Schoolchildren (n = 544) aged 8-10 y were assessed in 11 villages within five subdistricts of Malang District, East Java, Indonesia. Outcome indicators of IDD were goiter size as measured by palpation and ultrasonography (USG), urinary iodine excretion (UIE) and serum thyroid stimulating hormone (TSH) concentration in blood as well as functional indicators such as intellectual performance (IQ: Catell's Culture Fair Intelligence Test) and anthropometric indices. The total goiter rate (TGR) measured by palpation and USG were 35.7 and 54.4%, respectively. Based on UIE and TSH, the prevalence of iodine deficiency was 63.7 and 3.4%, respectively. In individuals, goiter, thyroid volume and UIE were associated significantly (r = -0.35; P < 0.001 and r = -0.30; P = 0.02 respectively). Among villages, TGR measured by palpation was significantly correlated with thyroid volume (r = 0.61; P = 0.045) and UIE (r = 0.68; P = 0.021), whereas TSH was not significantly associated with any of the observed indicators in individuals or groups. Multiple regression analysis showed that USG (beta = -0.67; P < 0.001) and UIE (beta = 4.39; P = 0.008) related significantly with cognitive performance (IQ). The associations between IDD indicators and cognitive performance and height-for-age Z scores suggest that socioeconomically advantaged children had better iodine status. We suggest that UIE is the best indicator for local authorities to assess iodine deficiency.

Quality of care and patient satisfaction in budget-holding clinics.

A budget-holding program was implemented in nine primary care clinics in the Negev district of Kupat Holim Clinic, Israel's largest sick fund. This study, carried out from 1991 to 1994, evaluates the impact of this program on patient satisfaction and other selected indicators of quality of care, using a controlled case study methodology. Structured questionnaires were used in face-to-face interviews with a representative stratified sample of 523 patients registered in the clinics. Patient reports were used to measure patient satisfaction, accessibility of services, comprehensiveness of care, responsiveness to patients' needs and performance of preventive medicine activities. Other research tools included staff surveys, in-depth interviews and administrative data on transfer among sick funds. The findings counter fears that budgetary control and cost-containment negatively affect quality of care and patient satisfaction. However, the program did not fulfill expectations regarding improvement in clinic services and patient satisfaction.

Ecological and geographic characteristics predict nutritional status of communities: rapid assessment for poor villages.

The quality of poverty alleviation programmes relies heavily on appropriate targeting and priority setting. Major problems in assessing poverty include identification of the indicators of poverty and the methods used for its assessment. Nutritional status, expressed by anthropometric indices, has been proposed as a poverty indicator because of its validity, objectivity, reliability and feasibility. This study was conducted to explore the application of remote sensing to poverty mapping based on nutritional status at the community level. Relationships between the nutritional status within a community and the ecological characteristics of the community were investigated. Multiple linear regression tests were executed, and the resultant equations were tested for their validity in predicting communities with poor nutritional status. Among geographical and ecological indicators used, distance to the nearest market, main soil type, rice field area, and perennial cultivation area were found to be most useful predictors for the ranking of the communities by nutritional status. Among non-ecological determinants, food consumption, health service status and living conditions were also found as predictors. The highest correlation was found if total population was also taken into account in the regression model (R2 = 0.69; p < 0.0001). In the assessment of the sensitivity and specificity of the eight models studied, 'undernutrition' was defined as a condition where a community belongs in the first quartile for nutritional status (highest prevalence of undernutrition), and the baseline nutritional survey was considered as a standard method for final diagnosis. Most models which included only ecological factors in the equations had lower sensitivity and specificity than models which included all determinant factors in the equations. All models which took into account the total population had higher sensitivity and specificity than those that did not take total population into account. The best model of those that took into account only the geographical and ecological characteristics of the community's living environment had similar sensitivity and specificity (80% and 94.1%, respectively) as the models that considered non-geographical and non-ecological variables in addition to geographical and ecological variables. In the case of West Sumatra, only four ecological and geographic characteristics were sufficient to predict poverty in village. Since these characteristics could be surveyed by remote sensing, it may well be possible to use remote sensing for a rapid method for poverty mapping.

PIP: The quality of poverty alleviation programs depends heavily upon appropriate targeting and priority setting. However, to assess poverty, the indicators of poverty and the methods used for assessment must first be identified. Findings are presented from a study of the application of remote sensing to poverty mapping based upon nutritional status at the community level. Sampling 43 villages, relationships between the nutritional status within a community and the ecological characteristics of the community were investigated. Multiple linear regression tests were executed and the resultant equations tested for their validity in predicting communities with poor nutritional status. Of the geographical and ecological indicators used, distance to the nearest market, main soil type, rice field area, and perennial cultivation area were found to be the most useful predictors for ranking communities by nutritional status. Among non-ecological determinants, food consumption, health service status, and living conditions were also determined to be predictors. The strongest correlation was found when total population was also considered in the regression model. Most models which included only ecological factors in the equations had lower sensitivity and specificity than models which included all determinant factors in the equations. All models which accounted for total population had higher sensitivity and specificity than those which did not take such consideration. If not the nutritional status in absolute terms, at least the rank of communities can be predicted solely by geographical and ecological factors.

Mid-upper-arm circumference development and its validity in assessment of undernutrition.

As part of a prospective, longitudinal study that was carried out in Hanoi, Vietnam (as from 1981), mid-upper-arm circumference (MUAC) measurements, and the weight and height of children were taken from children for the first year of life. These measurements were recorded monthly, 12-36 months: 3-monthly, 36-72 months: 6-monthly and yearly for children beyond 72 months. The aim of this study was to observe development of MUAC of children on a longitudinal basis. Mid-upper-arm circumference increases by about 1 cm for boys and 1.5 cm for girls between 1 and 5 years. To recognise malnutrition, the cut-off level of MUAC 13.5 cm gave high values for sensitivity and specificity only for children aged 6-12 months. The cut-off levels of 14.0, 14.5 and 15.0 cm were more appropriate for children aged 13-24, 25-36 and 37-60 months. These results suggest that a single cut-off point of MUAC 13.5 cm cannot be used in screening moderate malnutrition for all children under age 5 but should be elevated with the increasing age of children.