What can ecological data tell us about reasons for divergence in health status between West Central Scotland and other regions of post-industrial Europe?

BACKGROUND: The link between the effects of de-industrialization (unemployment, poverty) and population health is well understood. Post-industrial decline has, therefore, been cited as an underlying cause of high mortality in Scotland's most de-industrialized region. However, previous research showed other comparably de-industrialized regions in Europe to have better and faster improving health (with, in many cases, a widening gap evident from the early to mid-1980s). OBJECTIVES: To explore whether ecological data can provide insights into reasons behind the poorer, and more slowly improving, health status of West Central Scotland (WCS) compared with other European regions that have experienced similar histories of post-industrial decline. Specifically, this study asked: (1) could WCS's poorer health status be explained purely in terms of socio-economic factors (poverty, deprivation etc.)? and (2) could comparisons with other health determinant information identify important differences between WCS and other regions? These aims were explored alongside other research examining the historical, economic and political context in WCS compared with other de-industrialized regions. STUDY DESIGN AND METHODS: A range of ecological data, derived from surveys and routine administrative sources, were collected and analysed for WCS and 11 other post-industrial regions. Analyses were underpinned by the collection and analysis of more detailed data for four particular regions of interest. In addition, the project drew on accompanying literature-based research, analysing important contextual factors in de-industrialized regions, including histories of economic and welfare policies, and national and regional responses to de-industrialization. RESULTS: The poorer health status of WCS cannot be explained in terms of absolute measures of poverty and deprivation. However, compared with other post-industrial regions in Mainland Europe, the region is distinguished by having wider income inequalities and associated social characteristics (e.g. more single adults, lone parent households, higher rates of teenage pregnancy). Some of these distinguishing features are shared by other UK post-industrial regions which experienced the same economic history as WCS. CONCLUSION: From the collection of data and supporting analyses of important contextual factors, one can argue that poor health in WCS can be attributed to three layers of causation: the effects of de-industrialization (which have impacted on health in all post-industrial regions); the impact of 'neoliberal' UK economic policies, resulting in wider inequalities in WCS and the other UK regions; and an as-yet-unexplained (but under investigation) set of factors that cause WCS to experience worse health outcomes than similar regions within the UK.

Making the case for a 'fifth wave' in public health.

This paper will argue that the UK has seen several phases of public health improvement since the Industrial Revolution, and that each of these can be linked to major shifts in thinking about the nature of society and health itself. The authors are not, however, attempting to delineate firm sequences of events (or imply causality) as this would require a level of analysis of the relationship between economy, society and culture which is beyond the scope of this paper. Rather, it is suggested that each phase of health improvement can be thought of in metaphorical terms as a 'wave'. The first wave is associated with great public works and other developments arising from social responses to the profound disruptions which followed the Industrial Revolution. The second wave saw the emergence of medicine as science. The third wave involved the redesign of our social institutions during the 20th Century and gave birth to the welfare state. The fourth wave has been dominated by efforts to combat disease risk factors and the emergence of systems thinking. Although a trough of public health activity continues from each wave, none exerts the same impact as when it first emerged. This paper will discuss the complex challenges of obesity, inequality and loss of wellbeing, together with the broader problems of exponential growth in population, money creation and energy usage. As exponential growth is unsustainable on a finite planet, inevitable change looms. Taken together, these analyses suggest that a fifth wave of public health development is now needed; one which will need to differ radically from its forerunners. The authors invite others to join them in envisioning its nature and in furthering the debate about future public health.

It's not 'just deprivation': why do equally deprived UK cities experience different health outcomes?

BACKGROUND: The link between deprivation and health is well established. However, recent research has highlighted the existence of a 'Scottish effect', a term used to describe the higher levels of poor health experienced in Scotland over and above that explained by socio-economic circumstances. Evidence of this 'excess' being concentrated in West Central Scotland has led to discussion of a more specific 'Glasgow effect'. However, within the UK, Glasgow is not alone in experiencing relatively high levels of poor health and deprivation; Liverpool and Manchester are two other cities which also stand out in this regard. Previous analyses of this 'effect' were also constrained by limitations of data and geography. OBJECTIVES: To establish whether there is evidence of a so-called 'Glasgow effect': (1) even when compared with its two most similar and comparable UK cities; and (2) when based on a more robust and spatially sensitive measure of deprivation than was previously available to researchers. STUDY DESIGN AND METHODS: Rates of 'income deprivation' (a measure very highly correlated with the main UK indices of multiple deprivation) were calculated for small areas (average population size: 1600) in Glasgow, Liverpool and Manchester. All-cause and cause-specific standardized mortality ratios were calculated for Glasgow relative to Liverpool and Manchester, standardizing for age, gender and income deprivation decile. In addition, a range of historical census and mortality data were analysed. RESULTS: The deprivation profiles of Glasgow, Liverpool and Manchester are almost identical. Despite this, premature deaths in Glasgow are more than 30% higher, with all deaths approximately 15% higher. This 'excess' mortality is seen across virtually the entire population: all ages (except the very young), both males and females, in deprived and non-deprived neighbourhoods. For premature mortality, standardized mortality ratios tended to be higher for the more deprived areas (particularly among males), and approximately half of 'excess' deaths under 65 years of age were directly related to alcohol and drugs. Analyses of historical data suggest that it is unlikely that the deprivation profile of Glasgow has changed significantly relative to Liverpool and Manchester in recent decades; however, the mortality gap appears to have widened since the early 1970s, indicating that the 'effect' may be a relatively recent phenomenon. CONCLUSION: While deprivation is a fundamental determinant of health and, therefore, an important driver of mortality, it is only one part of a complex picture. As currently measured, deprivation does not explain the higher levels of mortality experienced by Glasgow in relation to two very similar UK cities. Thus, additional explanations are required.

How will area regeneration impact on health? Learning from the GoWell study.

OBJECTIVES: To establish the theoretical and perceived links between area regeneration and health in a Scottish context in order to inform a comprehensive evaluation of regeneration activity. The evaluation will include health outcomes. STUDY DESIGN: Mixed method combining and comparing key informant interviews with policy analysis. METHODS: Analysis of identified links between elements of regeneration activity and health was undertaken of published policies and strategies which described regeneration for Scotland and the city of Glasgow. Interviews with key informants explored their understanding of the inputs to regeneration, and the pathways between regeneration and better health outcomes. RESULTS: The policy analysis and interviews revealed a holistic approach to a complex problem. Both identified a need for action to improve housing, neighbourhoods and services, education, employment, community participation and social issues. Improved health was identified as an emergent property. Interviewees identified a need to augment the established structural components with a more person-centred approach, fostering confidence and higher aspirations, but were uncertain how to achieve this. The interviews revealed a lack of confidence that current practice would deliver all the components of the holistic model. CONCLUSIONS: A holistic model of regeneration appears to inform policy, but is proving difficult to deliver. Improved health and reduced health inequalities were not primary objectives but emergent properties. In light of this, the ability of regeneration to actively maximize positive health impacts, particularly if this requires focused planning or opportunity costs to other activities, is questioned.

What can health professionals contribute to the challenge of sustainability?

Just as doctors have led aspects of social change in the past, health professionals today must contribute to and lead actions on sustainability. Exponential growth and unsustainability can be observed in the global population, energy use, money supply and greenhouse gas emissions. As with all unsustainable systems, they will become sustainable, but the timing and manner are undecided and carry profound health threats. We are trapped using outmoded forms of thinking and by our cognitive dissonance as we consider these threats in the light of our own lifestyles. The aim should be a transition that will lessen inequalities, combat problems such as obesity, depression and addictive behaviours, and improve well-being. The challenge is similar to other major public health issues in that the problem needs to be identified, evidence gathered, theories developed, alliances built, policies formulated and actions taken. This paper outlines how this can be done but suggests that the response needed will be unprecedented, and calls for action on what is known and debate about what is uncertain.

Can primary care reduce inequalities in mental health?

OBJECTIVES: To explore the contributions that primary care could make to reducing and preventing inequalities in mental health through policy, local strategy and practice. STUDY DESIGN: The study used an interpretive policy analysis framework to investigate the ways in which inequalities in mental health and inequalities in health were interpreted by health and social policies, incorporated into a local strategic process in a primary care organization, and understood and acted upon by frontline primary care and mental health practitioners. The study involved analysis of nine health and social policy documents, observation of a mental health needs assessment process, and interviews with 21 frontline professionals from 14 different disciplines. METHODS: Data were collected using document analysis, observation, and interviews with frontline staff which included a vignette. Data were sorted using the Atlas-ti software programme, and a grounded theory approach guided the data collection and analysis. RESULTS: Policy documents demonstrated a disjointed picture of definitions and actions, and lacked a clear overall interpretation of inequalities in health or inequalities in mental health. The mental health needs assessment did not incorporate discussion about inequalities in mental health, despite some individual steering group members demonstrating concerns about inequalities in mental health. Frontline professionals defined inequalities as being linked to access to health services rather than social factors, and were often uncomfortable about discussing inequalities in mental health. A small minority suggested that they would explore or take action on the social circumstances of a patient presenting with potential mental health problems. CONCLUSIONS: The study found that policies were not driving practice for reducing inequalities in mental health within primary care, and the primary care organization studied was not conducive to addressing inequalities in mental health. However, some building blocks were in place at all levels that have the potential to be developed to enable primary care to address inequalities in mental health.

Peak oil: will it be public health's greatest challenge?

The health of populations is determined more by the social and economic determinants of health than by changes in technology, health services or short-term policy interventions. In the near future, there is likely to be a significant shortfall in energy supply, resulting in high energy prices and a reversal of many of the aspects of globalization that are currently taken for granted. If this happens, economic recession and restructuring could have a negative impact on health, not dissimilar to that experienced by the former Soviet Union when it attempted a rapid change in its economy. There is, however, the potential, through economic planning and sustainable development, to reduce the adverse effects of this change and use this opportunity to impact on a range of diseases which are, at least in part, caused by overconsumption, inequality and loss of community.

Climate change and rising energy costs will change everything: a new mindset and action plan for 21st century public health.

Western governments currently prioritize economic growth and the pursuit of profit above alternative goals of sustainability, health and equality. Climate change and rising energy costs are challenging this consensus. The realization of the transformation required to meet these challenges has provoked denial and conflict, but could lead to a more positive response which leads to a health dividend; enhanced well-being, less overconsumption and greater equality. This paper argues that public health can make its best contribution by adopting a new mindset, discourse, methodology and set of tasks.

Climate change and rising energy costs: a threat but also an opportunity for a healthier future?

Health problems caused by overconsumption, growing inequalities and diminished well-being are issues that have been attributed to the prioritization of economic growth as the central purpose of society. It is also known that climate change and rising energy prices will inevitably bring changes to the globe's economic models. Doctors and the wider public health community have campaigned successfully in the past on issues such as the threat of nuclear war. Is it now time for this constituency to make its distinctive contribution to these new threats to health?

An analysis of the link between behavioural, biological and social risk factors and subsequent hospital admission in Scotland.

OBJECTIVE: To determine the association between risk factors and hospital admission. METHODS: The 1998 Scottish Health Survey was linked to the Scottish hospital admission database. FINDINGS: Smoking was the most important behavioural risk factor (hazard ratio: 1.90, 95% CI: 1.59-2.27). Other behavioural risk factors yielded small but largely anticipated results. Hazard ratios for biological risks increased predictably but with some exceptions (blood pressure and total cholesterol). The top quintile for C-reactive protein showed almost double the risk of admission compared with the bottom quintile (hazard ratio: 1.93, 95% CI: 1.52-2.46). Elevated body mass index (BMI) increased the risk of serious admission (hazard ratio: 1.23, 95% CI: 1.03-1.47) and raised gamma-GT increased this risk by 20% (hazard ratio: 1.20, 95% CI: 1.04-1.38). Forced expiratory volume was the 'biological' factor with the largest risk (hazard ratio for lowest category: 1.82, 95% CI: 1.49-2.22). All the measures of social position showed variable effects on the risk of hospital admission. Large effects on risk were associated with self assessed health, longstanding illness and previous admission. CONCLUSION: The linkage of national surveys with a prospective hospitalization database will develop into an increasingly powerful tool.

Successful ageing in an area of deprivation: part 2--a quantitative exploration of the role of personality and beliefs in good health in old age.

OBJECTIVES: This paper presents further analysis of a study aimed at examining the determinants of good health and successful ageing in an area of deprivation. In this paper we report findings from the quantitative data related to two of the original eight research questions: (1) To what extent can health in old age be attributed to psychological/personality variables? and (2) What is the role of religious beliefs and 'spirituality' in healthy ageing? STUDY DESIGN: In-depth interview study in which standardized measures of personality and beliefs were administered, along with measures of beliefs devised for the study. METHODS: One hundred matched pairs of healthy and unhealthy 'agers' were interviewed face-to-face. Healthy ageing was assessed in terms of hospital morbidity and self-reported health. The sample comprised 106 males and 94 females (53 male matched pairs and 47 female matched pairs) ranging in age from 70 to 90 years of age with the majority (n=165) falling into the 71-80 age group and the remaining 35 in the 81-90 age group. All study participants were survivors of the Paisley/Renfrew (MIDSPAN) survey, a longitudinal study commenced in 1972 with continuous recording of morbidity and mortality since. Questionnaires assessing extraversion, neuroticism, psychoticism, health locus of control, sense of coherence, optimism, and religiosity were filled in by participants during the interviews. RESULTS: Compared to the unhealthy group, the healthy participants were less neurotic, more likely to endorse an internal locus of control belief and less likely to endorse a powerful others locus of control belief, and to report a greater sense of coherence. The unhealthy group scored higher on the religiosity/spirituality measure devised for this study. CONCLUSIONS: The findings are interesting in that, although they cannot address the issue of cause and effect, the very fact that the personality traits measured in this study were linked to health status in old age, further strengthens the argument that in general practice and hospital settings, an understanding of personality aids practitioners in dealing with patients. Finally, with the growing body of evidence that personality traits have a high degree of heritability, the routine gathering of information on personality traits would aid epidemiologists in their understanding of the determinants of healthy and successful ageing.

Getting strategic about the environment and health.

Historically, the physical environment has been a target for public health policy across the globe. This remains the case in developing countries where the enduring infectious and toxic challenge posed by the environment is tangible and its health impact is manifest. However, in Western societies, the relevance of the environment to health has become obscured. Even when this is not the case, the perspective is usually narrow, centering on specific toxic, infectious or allergenic agents in particular environmental compartments. It is rare for importance to be given to a health-determining role for the environment acting through broader psychosocial mechanisms. The result is that environmental manipulation is seen as a cornerstone of the public health response for comparatively few health concerns. This paper considers how public health policies and action on the physical environment may be pursued more optimally. The need for a more strategic approach, which employs a new conceptual model that recognizes the complexity and contextual issues affecting the relationship between the environment and health but retains sufficient flexibility and simplicity to have practical application, is identified. Building on recent work, a model is proposed and pointers are given for its use in a practical context.

Meeting the information needs of the 'Health for all' challenge--lessons from Scotland.

OBJECTIVE: To create a public health data resource for Scotland that is based on a socio-ecological model of the determinants of health and would, therefore, meets the needs of the emerging public health agenda. DESIGN: Action research, in which the approach moved logically through stages of action (conception, feasibility study, pilot projects, leading to a national set of integrated health and well-being profiles). Each stage built on the results of the previous research. RESULTS: The conceptual stage identified the need for an approach to public health data that kept pace with the increasingly accepted socio-ecological models of the determinants of health. A feasibility study concluded that sufficient data were available to populate the health fields that represented the important determinants of health. At this time strengths and weakness in data were defined. This led to the articulation of a 'vision' for integrated public heath data in Scotland that was the subject of a wide consultation. Pilot studies provided local stakeholders with imaginatively presented data (on population demographics, health and function, behaviour, social environment, economy, physical environment, morbidity and mortality) for their local communities. The response to these was so positive that a demand was created for a comprehensive set of 'community profiles'. These, in addition to parliamentary constituency profiles, have now been created and widely disseminated. CONCLUSIONS: It has been possible, despite many difficulties, to develop approaches to public health information that are informed by the socio-ecological model of health and create outputs that represent a significant advance on previous approaches to public health data. This is a work in progress and many issues remain unresolved. Interaction with others engaged in parallel tasks will facilitate the next steps.

Why is mortality higher in Scotland than in England and Wales? Decreasing influence of socioeconomic deprivation between 1981 and 2001 supports the existence of a 'Scottish Effect'.

OBJECTIVES: To determine the degree to which changing patterns of deprivation in Scotland and the rest of Great Britain between 1981 and 2001 explain Scotland's higher mortality rates over that period. DESIGN: Cross-sectional analyses using population and mortality data from around the 1981, 1991 and 2001 censuses. SETTING: Great Britain (GB). PARTICIPANTS: Populations of Great Britain enumerated in the 1981, 1991 and 2001 censuses. MAIN OUTCOME MEASURES: Carstairs deprivation scores derived for wards (England and Wales) and postcode sectors (Scotland). Mortality rates adjusted for age, sex and deprivation decile. RESULTS: Between 1981 and 2001 Scotland became less deprived relative to the rest of Great Britain. Age and sex standardized all-cause mortality rates decreased by approximately 25% across Great Britain, including Scotland but mortality rates were on average 12% higher in Scotland in 1981 rising to 15% higher in 2001. While over 60% of the excess mortality in 1981 could be explained by differences in deprivation profile, less than half the excess could be explained in 1991 and 2001. After adjusting for age, sex and deprivation, excess mortality in Scotland rose from 4.7% (95% CI: 3.9% to 5.4%) in 1981 to 7.9% (95% CI: 7.2% to 8.7%) in 1991 and 8.2% (95% CI: 7.4% to 9.0%) in 2001. All deprivation deciles showed excess indicating that populations in Scotland living in areas of comparable deprivation to populations in the rest of Great Britain always had higher mortality rates. By 2001 the largest excesses were found in the most deprived areas in Scotland with a 17% higher mortality rate in the most deprived decile compared to similarly deprived areas in England and Wales. Excess mortality in Scotland has increased most among males aged <65 years. CONCLUSIONS: Scotland's relative mortality disadvantage compared to the rest of Great Britain, after allowing for deprivation, is worsening. By 1991 measures of deprivation no longer explained most of the excess mortality in Scotland and the unexplained excess has persisted during the 1990s. More research is required to understand what is causing this 'Scottish effect'.

Transport policy and health inequalities: a health impact assessment of Edinburgh's transport policy.

Health impact assessment (HIA) can be used to examine the relationships between inequalities and health. This HIA of Edinburgh's transport policy demonstrates how HIA can examine how different transport policies can affect different population groupings to varying degrees. In this case, Edinburgh's economy is based on tourism, financial services and Government bodies. These need a good transport infrastructure, which maintains a vibrant city centre. A transport policy that promotes walking, cycling and public transport supports this and is also good for health. The HIA suggested that greater spend on public transport and supporting sustainable modes of transport was beneficial to health, and offered scope to reduce inequalities. This message was understood by the City Council and influenced the development of the city's transport and land-use strategies. The paper discusses how HIA can influence public policy.

Developing principles for health impact assessment.

BACKGROUND: Policies and practice in many sectors affect health. Health impact assessment (HIA) is a way to predict these health impacts, in order to recommend improvements in policies to improve health. There has been debate about appropriate methods for this work. The Scottish Executive funded the Scottish Needs Assessment Programme to conduct two pilot HIAs and from these to develop guidance on HIA. METHODS: Case study 1 compared three possible future scenarios for developing transport in Edinburgh, based on funding levels. It used a literature review, analysis of local data and the knowledge and opinions of key informants. Impacts borne by different population groups.were compared using grids. Case study 2 assessed the health impacts of housing investment in a disadvantaged part of Edinburgh, using published literature, focus groups with community groups and interviews with professionals. RESULTS: Disadvantaged communities bore more detrimental effects from the low transport investment scenario, in the areas of: accidents; pollution; access to amenities, jobs and social contacts; physical activity; and impacts on community networks. The housing investment had greatest impact on residents' mental health, by reducing overcrowding, noise pollution, stigma and fear of crime. CONCLUSION: Although there is no single 'blueprint' for HIA that will be appropriate for all circumstances, key principles to inform future HIA were defined. HIA should be systematic; involve decision-makers and affected communities; take into account local factors; use evidence and methods appropriate to the impacts identified and the importance and scope of the policy; and make practical recommendations.

Achieving better health through health impact assessment.

OBJECTIVE: Health Impact Assessment (HIA) provides a method of predicting the health impacts of policies and activities, in order to recommend changes that would improve health. We piloted approaches to health impact assessment and made recommendations for its use as part of the planning and policy making processes in Scotland. DESIGN: Two Health Impact Assessments were done as case studies. One assessed the City of Edinburgh Council's Local Transport Strategy. The other assessed North Edinburgh Area Renewal Housing Strategy. Both were done in partnership with the professionals responsible for developing the strategies. RESULTS: The main health impacts of transport strategy were in the areas of: accidents, pollution, access to amenities, jobs and social contacts, opportunities for physical activity in walking and cycling and impacts on community networks. Overall, housing strategy impacted most on mental health, especially stress and depression. The recommendations of both HIAs are being used in developing the strategies further. CONCLUSIONS: Health impact assessment can make explicit the health consequences of decisions in different sectors, including impacts on health inequalities. Health Impact Assessment should be done as part of community planning and other partnership activities. Consideration of health impacts should become part of routine decision making.

Assessment of changes in general health status using the short-form 36 questionnaire 1 year following coronary artery bypass grafting.

OBJECTIVE: The problem addressed in the study was to gain a greater understanding of the health benefits of coronary artery bypass grafting (CABG). The purpose of the study was to assess general health status, using the short-form (SF)-36 questionnaire, approximately 12 months following CABG, and to document any associations between pre-operative health status, level of social support, coronary artery disease (CAD) risk factors, CAD symptom severity and post-operative health status. METHODS: The study was prospective and observational in design and included assessments at two time points, namely pre-operatively in a hospital outpatient department (1995-1996) and post-operatively at home (1996-1997). Two hundred and fourteen patients awaiting elective CABG were recruited a month before the expected date of operation. Pre-operative assessment included: (1), severity of symptoms; (2), CAD risk factors; (3), SF-36 questionnaire; and (4), social activities questionnaire. Post-operative assessment measured health status using the SF-36 instrument (mean, 16.4 months). Correlation and multiple linear regression analyses were used to identify factors associated with improved health status following CABG. RESULTS: Two hundred and fourteen patients were assessed pre-operatively and underwent CABG. There was a 4.8% 30-day mortality rate, and 183 patients were followed for a mean of 16.4 months after CABG. SF-36 scores following CABG were improved across all of the eight domains (P<0.001). A higher social network score and higher pre-operative health status were associated with improved health status. Patients with lower health levels (SF-36 scores) prior to CABG were less likely to gain improvement in health (SF-36 scores) following CABG. Lower SF-36 scores following operation were influenced by the presence of diabetes mellitus, cigarette smoking, younger age, a high socio-economic deprivation category and higher alcohol intake. Many patients had uncorrected CAD risk factors at pre-operative assessment. CONCLUSIONS: The SF-36 instrument was shown to be a useful and sensitive tool to assess differences and changes in the general health status of patients before and following CABG. High levels of social support were associated with improved health status post-operatively. Lower pre-operative general health status, the presence of diabetes mellitus and cigarette smoking were associated with poorer post-operative general health status.

Needs assessment in primary care: general practitioners' perceptions and implications for the future.

BACKGROUND: Health needs assessment can guide the appropriate shift to primary care by identifying the most effective and efficient resource allocation to meet the needs of populations. Assessing health care needs will be a continuing challenge for primary care trusts in Scotland (or equivalent groups in other parts of the United Kingdom); however, lessons must be learned from the experience of needs assessment that followed the 'internal market' reforms of the 1990s. AIM: To examine general practitioners' (GPs') awareness and experience of needs assessment, to identify barriers to needs assessment in primary care, and to ascertain how better progress might be made in the future. METHOD: A postal questionnaire survey of 1777 Scottish GPs (a one-in-two sample) was combined with a semistructured interview survey of 'lead' GPs from a random sample of 64 mainland Scottish practices between May and August 1996. RESULTS: Sixty-five per cent (1154) of GPs responded to the questionnaire, of which 54% (965) were completed. Over 73% (47) of interviews were completed. Most GPs were unfamiliar with the concept of needs assessment and there was no evidence that needs assessment had influenced commissioning decisions. Most GPs argued that it was not a 'core' activity and that they lacked training in the relevant skills. While the attitude of the majority was indifferent, cynical, and sometimes hostile, a minority, comprising mostly younger fundholders, was more enthusiastic about needs assessment. CONCLUSION: The motivation and attitude of the majority of GPs present a barrier to needs assessment in primary care. GPs will require more resources and training if they are to undertake this responsibility. Most GPs believe than incentives (financial or organisational) will be necessary. Primary care trusts and equivalent structures should be aware of these attitudes as they seek to establish plans based on estimates of population needs in defined locations.