Current trends in treatment of obesity in Karachi and possibilities of cost minimization

Our study finds out drug usage trends in over weight and obese patients without any compelling indications in Karachi, looks for deviations of current practices from evidence based antihypertensive therapeutic guidelines and identifies not only cost minimization opportunities but also communication strategies to improve patients' awareness and compliance to achieve therapeutic goal. In present study two sets were used. Randomized stratified independent surveys were conducted in hospital doctors and family physicians (general practitioners), using pretested questionnaires. Sample size was 100. Statistical analysis was conducted on Statistical Package for Social Science (SPSS). Opportunities of cost minimization were also analyzed. One the basis of doctors' feedback, preference is given to non-pharmacologic management of obesity. Mass media campaign and media usage were recommended to increase patients awareness and patients' education along with strengthening family support systems was recommended for better compliance of the patients to doctor's advice. Local therapeutic guidelines for weight reduction were not found. Feedbacks showed that global therapeutic guidelines were followed by the doctors practicing in the community and hospitals in Karachi. However, high price branded drugs were used instead of low priced generic therapeutic equivalents. Patient's education is required for better awareness and improving patients' compliance. The doctors found preferring brand leaders instead of low cost options. This trend increases cost of therapy by 0.59 to 4.17 times. Therefore, there are great opportunities for cost minimization by using evidence-based clinically effective and safe medicines.

The association between social support and mental health among vulnerable adolescents in five cities: findings from the study of the well-being of adolescents in vulnerable environments

PURPOSE

Globally, adolescents are at risk of depression, traumatic stress, and suicide, especially those living in vulnerable environments. This article examines the mental health of 15- to 19-year-old youth in five cities and identifies the social support correlates of mental health.

METHODS

A total of 2,393 adolescents aged 15-19 years in economically distressed neighborhoods in Baltimore, MD; New Delhi, India; Ibadan, Nigeria; Johannesburg, South Africa; and Shanghai, China were recruited in 2013 via respondent-driven sampling to participate in a survey using an audio computer-assisted self-interview. Weighted logistic regression and general linear models were used to explore the associations between mental health and social supports.

RESULTS

The highest levels of depression and posttraumatic stress symptoms were displayed in Johannesburg among females (44.6% and 67.0%, respectively), whereas the lowest were among New Delhi females and males (13.0% and 16.3%, respectively). The prevalence of suicidal ideation ranged from 7.9% (New Delhi female adolescents) to 39.6% (Johannesburg female adolescents); the 12-month prevalence of suicide attempts ranged from 1.8% (New Delhi females) to 18.3% (Ibadan males). Elevated perceptions of having a caring female adult in the home and feeling connected to their neighborhoods were positively associated with adolescents' levels of hope across the sites while negatively associated with depression and posttraumatic stress symptoms with some variation across sites and gender.

CONCLUSIONS

Adolescents living in the very economically distressed areas studied register high levels of depression and posttraumatic stress. Improving social supports in families and neighborhoods may alleviate distress and foster hope. In particular, strengthening supports from female caretakers to their adolescents at home may improve the outlooks of their daughters.

Ecological momentary assessment of environmental and personal factors and snack food intake in African American women

This study examined contributions of environmental and personal factors (specifically, food availability and expense, daily hassles, self-efficacy, positive and negative affect) to within-person and between-person variations in snack food intake in 100 African American women. Participants were signaled at random five times daily for seven days to complete a survey on a study-provided smartphone. Women reported consuming snack foods at 35.2% of signals. Easier food availability accounting for one's usual level was associated with higher snack food intake. Being near outlets that predominately sell snacks (e.g., convenience stores), while accounting for one's usual proximity to them, was associated with higher snack food intake. Accounting for one's usual daily hassle level, we found that on days with more frequent daily hassles snack food intake was higher. The positive association between within-person daily hassles frequency and snack food intake was stronger when foods were easily available. Public and private policies to curb ubiquitous food availability and mobile health interventions that take into account time-varying influences on food choices and provide real-time assistance in dealing with easy food availability and coping with stressors may be beneficial in improving African American women's day to day food choices.

A global study on the influence of neighborhood contextual factors on adolescent health

PURPOSE

This study uses data collected as part of the Well-Being of Adolescents in Vulnerable Environments study to (1) compare the perceptions of neighborhood-level factors among adolescents across five different urban sites; (2) examine the associations between factors within the physical and social environments; and (3) examine the influence of neighborhood-level factors on two different health outcomes-violence victimization in the past 12 months and ever smoked.

METHODS

Across five urban sites (Baltimore, New Delhi, Johannesburg, Ibadan, and Shanghai), 2,320 adolescents aged 15-19 years completed a survey using audio computer-assisted self-interview technology. To recruit adolescents, each site used a respondent-driven sampling method, which consisted of selecting adolescents as "seeds" to serve as the initial contacts for recruiting the entire adolescent sample. All analyses were conducted with Stata 13.1 statistical software, using complex survey design procedures. To examine associations between neighborhood-level factors and among our two outcomes, violence victimization and ever smoked, bivariate and multivariate analyses were conducted.

RESULTS

Across sites, there was great variability in how adolescents perceived their neighborhoods. Overall, adolescents from Ibadan and Shanghai held the most positive perceptions about their neighborhoods, whereas adolescents from Baltimore and Johannesburg held the poorest. In New Delhi, despite females having positive perceptions about their safety and sense of social cohesion, they had the highest sense of fear and the poorest perceptions about their physical environment. The study also found that one of the most consistent neighborhood-level factors across sites and outcomes was witnessing community violence, which was significantly associated with smoking among adolescents in New Delhi and Johannesburg and with violence victimization across nearly every site except Baltimore. No other neighborhood-level factor exerted greater influence.

CONCLUSIONS

This study confirms the important associations between perceptions of a neighborhood and adolescent health. At the same time, it demonstrates that not all neighborhood-level factors are associated with adolescent health outcomes in the same way across different urban contexts. Further longitudinal research is needed to examine the direction of causation between adolescent health neighborhood contexts and health outcomes and the reasons for why different urban contexts may exert varying levels of influence on the health of adolescents.

Using technology to promote postpartum weight loss in urban, low-income mothers: a pilot randomized controlled trial

OBJECTIVE

To examine the feasibility, acceptability, and initial efficacy of a technology-based weight loss intervention for urban, low-income mothers.

METHODS

Eighteen obese, ethnic minority, socioeconomically disadvantaged mothers in the first year after childbirth were randomly assigned to either: 1) technology-based intervention, which included empirically supported behavior-change strategies, daily skills, and self-monitoring text messages with personalized feedback, biweekly counseling calls from a health coach, and access to a Facebook support group, or 2) usual-care control.

RESULTS

After 14 weeks of treatment, the technology-based intervention participants had significantly greater weight loss (-2.9 ± 3.6 kg) than usual care (0.5 ± 2.3 kg; adjusted mean difference: -3.2 kg, 95% confidence interval -6.2 to -0.1 kg, P = .04). One-third of intervention participants (3 of 9) and no control participants lost > 5% of their initial body weight at follow up.

CONCLUSIONS AND IMPLICATIONS

Results suggest the potential for using technology to deliver a postpartum weight loss intervention among low-income racial/ethnic minorities.

Buying food on sale: a mixed methods study with shoppers at an urban supermarket, Philadelphia, Pennsylvania, 2010-2012

INTRODUCTION

The obesity epidemic has drawn attention to food marketing practices that may increase the likelihood of caloric overconsumption and weight gain. We explored the associations of discounted prices on supermarket purchases of selected high-calorie foods (HCF) and more healthful, low-calorie foods (LCF) by a demographic group at high risk of obesity.

METHODS

Our mixed methods design used electronic supermarket purchase data from 82 low-income (primarily African American female) shoppers for households with children and qualitative data from focus groups with demographically similar shoppers.

RESULTS

In analyses of 6,493 food purchase transactions over 65 weeks, the odds of buying foods on sale versus at full price were higher for grain-based snacks, sweet snacks, and sugar-sweetened beverages (odds ratios: 6.6, 5.9, and 2.6, respectively; all P < .001) but not for savory snacks. The odds of buying foods on sale versus full price were not higher for any of any of the LCF (P ≥ .07). Without controlling for quantities purchased, we found that spending increased as percentage saved from the full price increased for all HCF and for fruits and vegetables (P ≤ .002). Focus group participants emphasized the lure of sale items and took advantage of sales to stock up.

CONCLUSION

Strategies that shift supermarket sales promotions from price reductions for HCF to price reductions for LCF might help prevent obesity by decreasing purchases of HCF.

Racial/ethnic and sociodemographic factors associated with micronutrient intakes and inadequacies among pregnant women in an urban US population

OBJECTIVE

To assess sociodemographic correlates of micronutrient intakes from food and dietary supplements in an urban, ethnically diverse sample of pregnant women in the USA.

DESIGN

Cross-sectional analyses of data collected using a validated semi-quantitative FFQ. Associations between racial, ethnic and sociodemographic factors and micronutrient intakes were examined using logistic regression controlling for pre-pregnancy BMI, maternal age and smoking status.

SETTING

Prenatal clinics, Boston, MA, USA.

SUBJECTS

Analyses included pregnant women (n 274) in the PRogramming of Intergenerational Stress Mechanisms (PRISM) study, an urban longitudinal cohort designed to examine how stress influences respiratory health in children when controlling for other environmental exposures (chemical stressors, nutrition).

RESULTS

High frequencies of vitamin E (52 %), Mg (38 %), Fe (57 %) and vitamin D (77 %) inadequacies as well as suboptimal intakes of choline (95 %) and K (99 %) were observed. Factors associated with multiple antioxidant inadequacies included being Hispanic or African American, lower education and self-reported economic-related food insecurity. Hispanics had a higher prevalence of multiple methyl-nutrient inadequacies compared with African Americans; both had suboptimal betaine intakes and higher odds for vitamin B₆ and Fe inadequacies compared with Caucasians. Nearly all women (98 %) reported Na intakes above the tolerable upper limit; excessive intakes of Mg (35 %), folate (37 %) and niacin (38 %) were also observed. Women reporting excessive intakes of these nutrients were more likely Caucasian or Hispanic, more highly educated, US-born and did not report food insecurity.

CONCLUSIONS

Racial/ethnic and other sociodemographic factors should be considered when tailoring periconceptional dietary interventions for urban ethnic women in the USA.

Determinants of child malnutrition in rural and urban Ecuadorian highlands

OBJECTIVE

To identify and compare the sociodemographic determinants of stunting, wasting and overweight among infants of urban and rural areas in the Ecuadorian highlands.

DESIGN

Cross-sectional study.

SETTING

Nabon (rural) and Cuenca (urban) cantons, Azuay Province, Ecuador.

SUBJECTS

A total of 703 children aged 0-24 months and their caregivers (227 rural and 476 urban) recruited during the period from June to September 2008.

RESULTS

Stunting prevalence was significantly higher in the rural area (37·4 % v. 17·7 %; P < 0·001) while wasting (7·1 %) and overweight (17·1 %) prevalence were more similar between areas. Determinants of stunting for the pooled sample were male gender (OR = 1·43; 95 % CI 1·06, 1·92; P = 0·02), preterm delivery (OR = 1·65; 95 % CI 1·14, 2·38; P = 0·008), child's age (OR = 1·04; 95 % CI 1·01, 1·07; P = 0·011), maternal education (OR = 0·95; 95 % CI 0·92, 0·99; P = 0·025) and facility-based delivery (OR = 0·57; 95 % CI 0·45, 0·74; P < 0·001). The latter was also a determinant of overweight (OR = 0·39; 95 % CI 0·25, 0·62; P < 0·001). Rural determinants of stunting were maternal height (OR = 0·004; 95 % CI 0·00004, 0·39; P = 0·018), diarrhoea prevalence (OR = 2·18; 95 % CI 1·13, 4·21; P = 0·02), socio-economic status (OR = 0·79; 95 % CI 0·64, 0·98; P = 0·030) and child's age (OR = 1·07; 95 % CI 1·02, 1·11; P = 0·005). Urban determinants were: maternal BMI for stunting (OR = 0·91; 95 % CI 0·84, 0·99; P = 0·027), cough prevalence (OR = 0·57; 95 % CI 0·34, 0·96; P = 0·036) and facility-based delivery (OR = 0·25; 95 % CI 0·09, 0·73; P = 0·011) for overweight, and hygiene for wasting (OR = 0·57; 95 % CI 0·36, 0·89; P = 0·013).

CONCLUSIONS

Infant malnutrition was associated with different sociodemographic determinants between urban and rural areas in the Ecuadorian highlands, a finding which contributes to prioritize the determinants to be assessed in nutritional interventions.

Disadvantaged pre-schoolers attending day care in Salvador, Northeast Brazil have a low prevalence of anaemia and micronutrient deficiencies

OBJECTIVE

To examine the micronutrient status of disadvantaged pre-schoolers from Northeast Brazil, following the introduction of pro-poor policies, by assessing the prevalence of anaemia and micronutrient deficiencies and the role of sociodemographic factors, genetic Hb disorders and parasitic infections.

DESIGN

In a cross-sectional study, data on sociodemographic status, health, growth, genetic Hb disorders, parasites and nutrient supply from day-care meals were obtained. Fasting blood samples were collected and analysed for Hb, serum ferritin, transferrin receptor, folate, vitamin B₁₂, retinol, Zn and Se.

SETTING

Seven philanthropic day-care centres serving urban slums in Salvador, Northeast Brazil.

SUBJECTS

Pre-schoolers aged 3-6 years from disadvantaged households.

RESULTS

Of the 376 sampled children, 94 % were of black or mixed race; 33 % and 29 % had at least one genetic Hb disorder and intestinal parasite, respectively. Stunting and underweight were ≤5 %; 14 % were overweight. Day-care centres supplied micronutrient-dense meals and snacks each weekday. Less than 10 % of pre-schoolers had anaemia and micronutrient deficiencies. Predictors (P < 0·05) of Hb were α(3·7) thalassaemia, Se and retinol (but not ferritin). Micronutrient predictors (P < 0·05) were: elevated α₁-glycoprotein for ferritin, Hb AS and BMI Z-score >1 for transferrin receptor, Zn and elevated α₁-glycoprotein for retinol, sex and helminths for Se, helminths for vitamin B₁₂, and Giardia intestinalis infection for serum folate.

CONCLUSIONS

Impaired growth, anaemia and micronutrient deficiencies were uncommon among these disadvantaged pre-schoolers attending day care. A range of interventions including provision of micronutrient-dense, fortified day-care meals, deworming and vitamin A supplementation likely contributed to improved micronutrient status, suggesting expanded coverage of these programmes.

Mediterranean diet adherence rates in Sicily, southern Italy

OBJECTIVE

To assess adherence to the Mediterranean diet and nutrient intakes in a population of Sicily, southern Italy and to evaluate possible determinants, particularly socio-cultural and lifestyle factors.

DESIGN

Cross-sectional.

SETTING

Urban and rural areas of eastern Sicily.

SUBJECTS

Between May 2009 and December 2010, 3090 adults were randomly recruited through the collaboration of fourteen general practitioners. Adherence to the Mediterranean diet was measured by the MedDietScore. Nutrient intakes were assessed through the 24 h recall of the previous day's dietary intake.

RESULTS

Rural participants were barely more adherent to the Mediterranean diet than their urban counterparts (mean scores were 27·8 and 27·2, respectively, P = 0·037). The MedDietScore was correlated with intakes of MUFA, fibre and vitamin C, as well as with consumption of non-refined cereals, vegetables, fruit, meat, dairy products, alcohol and nuts. Regression analysis revealed that older and more educated people were more likely to be in the highest tertile of MedDietScore (OR = 1.90; 95 % CI 1·39, 2·59 and OR = 1·29; 95 % CI 1·05, 1·58, respectively). A significant difference in quantity (moderate) and quality (red wine and beer) of alcohol was found according to adherence to the Mediterranean diet. Finally, more active participants were 1·5 times more likely to form part of the high-adherence group.

CONCLUSIONS

A slow but concrete moving away from traditional patterns has been observed in younger people and low educated people. Public health interventions should focus on these target populations in order to improve the quality of their diet.

Domestic solid waste management and its impacts on human health and the environment in Sharg El Neel Locality, Khartoum State, Sudan

Due to rapid urbanization in Khartoum State, Domestic Solid Waste (DSW) management remains the biggest obsession that recurrently attracts the attention of the concern authorities and stakeholders. As one of the seven localities comprised the state, the Sharg El Neel Locality was chosen to study the DSW management efficiency. The materials and methods employed in collection of data is a package of techniques, one of which was by conducting interviews using structured and unstructured questions mainly directed to appropriate persons i.e., householders and particular government employees directly engaged in DSW management operations. The main findings reached in this study were that local authorities lack the necessary capacities to handle the immense problems of DSW management. Shortages of funds, inadequate number of workers, lack of transport and facilities and weakness of attitudes of respondents found to be among factors hindering the DSW management. Accordingly, proper scheduled and timing, well-trained public health officers and sanitary overseers and strict sustainable program to controlling flies, rodents, cockroach and other disease vectors are essential to properly managing DSW. Otherwise, problems resulting from solid waste generation in the study area will be magnitudized and the surrounding environment will definitely be deteriorated.

[Social inequalities in cervical cancer mortality in the Autonomous City of Buenos Aires, 1999-2003 and 2004-2006]

The aim of this study was to describe the spatial distribution of cervical cancer mortality in the Autonomous City of Buenos Aires during the period 1999-2003 and its relationship to the socioeconomic conditions of the population, as well as to compare the distribution during this period with that of the triennium 2004-2006. This ecological study used electoral districts as the unit of analysis. The selected socioeconomic indicators were educational deficit, lack of health insurance and the Material Deprivation of Households Index (Índice de Privación Material de Hogares), taken from the National Population and Housing Census (Censo Nacional de Población, Hogares y Viviendas) of 2001. The stratification of the city into areas according to these conditions and the analysis of standardized mortality ratios showed an increased risk of dying from cervical cancer associated with worse socioeconomic conditions. The stratification and death risks demonstrated a clear spatial pattern, with the south of the city presenting the highest death risks, and the northern and central areas presenting the lowest risks.

Mental health and poverty in the inner city

Rapid urbanization globally threatens to increase the risk to mental health and requires a rethinking of the relationship between urban poverty and mental health. The aim of this article is to reveal the cyclic nature of this relationship: Concentrated urban poverty cultivates mental illness, while the resulting mental illness reinforces poverty. The authors used theories about social disorganization and crime to explore the mechanisms through which the urban environment can contribute to mental health problems. They present some data on crime, substance abuse, and social control to support their claim that mental illness reinforces poverty. The authors argue that, to interrupt this cycle and improve outcomes, social workers and policymakers must work together to implement a comprehensive mental health care system that emphasizes prevention, reaches young people, crosses traditional health care provision boundaries, and involves the entire community to break this cycle and improve the outcomes of those living in urban poverty.

Valuing human leptospirosis prevention using the opportunity cost of labor

Leptospirosis is a serious public health concern in the Philippines, not only because of its increasing incidence rate, but also because of its significant health and economic impacts. Despite its relatively high seroprevalence, knowledge on the economic burden of disease, particularly on the value that the society places on disease prevention remains limited. Obtaining such information is important within the context of public health policy. This study was conducted in Metro Manila to determine the economic burden of leptospirosis, by asking respondents about their willingness to contribute to labor (WTCL) for the prevention of leptospirosis. The respondents pledged an average labor contribution of 10.66 h/month. The average WTCL corresponded to a monetary value of US$4.01 per month when valued using the opportunity cost of labor (leisure rate of time). From the monetized labor contribution, the total economic value of preventing leptospirosis was estimated at US$124.97 million per annum, which represents 1.13% of Metro Manila's gross domestic product (GDP). Estimates from a Tobit regression model identified the respondents' knowledge regarding leptospirosis, the susceptibility of their homes to flooding, and the proximity of their homes to sewers as significant factors to consider when developing resource contribution programs for leptospirosis prevention. More efforts need to be made in developing community level preventive programs, and in improving public's knowledge and awareness about leptospirosis.

Risk factors for severe cholera among children under five in rural and urban Bangladesh, 2000-2008: a hospital-based surveillance study

Background

Children under five bear the largest cholera burden. We therefore sought to identify modifiable risk factors among Bangladeshi children.

Methodology/Principal Findings

We used multivariate Poisson regression to assess risk factors for severe cholera among diarrheal patients presenting at hospitals in Matlab (rural) and Dhaka (urban), Bangladesh. Risk increased with age. Compared to those under one, rural and urban four-year-olds had adjusted risk ratios (aRR) of 4.17 (95% confidence interval (CI) 2.43–7.15) and 6.32 (95% CI: 4.63–8.63), respectively. Breastfeeding halved the risk in both rural (aRR = 0.49, 95% CI: 0.35–0.67) and urban (aRR = 0.51, 95% CI: 0.41–0.62) settings. Rural children’s risk decreased with maternal education (P-trend: <0.001) and increased among those with a family member with diarrhea in the past week (aRR = 1.61, 95% CI: 1.22–2.14) and those with prior vitamin A supplementation (aRR = 1.65, 95% CI: 1.12–2.43). Urban children whose mothers daily (aRR = 0.41, 95% CI: 0.21–0.79) or occasionally (aRR = 0.55, 95% CI: 0.36–0.84) read a newspaper experienced reduced risk. Urban children from households with incomes between 34–84 USD/month had a 30% increased risk compared to those from households with incomes >84 USD/month.

Conclusion/Significance

Increasing age, lower socioeconomic status, and lack of breastfeeding are key correlates of increased risk for cholera hospitalization among those under five in rural and urban Bangladesh. In addition, having a family member with diarrhea in the past week was associated with increased risk among rural children. Continued attention should be directed to the promotion of breastfeeding. Further research is needed to elucidate the relationship between maternal education and cholera risk. Renewed research regarding the use of chemoprophylaxis among family members of cholera cases may be warranted in rural endemic settings.

The association between parental perception of neighborhood safety and asthma diagnosis in ethnic minority urban children

Low-income populations, minorities, and children living in inner cities have high rates of asthma. Recent studies have emphasized the role of psychosocial stress in development of asthma. Residence in unsafe neighborhoods is one potential source of increased stress. The study objective was to examine the association between parental perception of neighborhood safety and asthma diagnosis among inner city, minority children. Cross-sectional data from a community-based study of 6-8-year-old New York City children were used. Asthma was defined as parental report of physician-diagnosed asthma and at least one asthma-related symptom. Parental perceptions of neighborhood safety were assessed with a questionnaire. Associations between perceived neighborhood safety and asthma were examined using chi-squared tests. Multivariate logistic regression analyses were then performed. Five hundred four children were included with 79% female, 26.5% non-Hispanic Black, and 73.5% Hispanic. Asthma was present in 23.8% of children. There was an inverse association between feeling safe walking in the neighborhood and asthma with 45.7% of parents of asthmatic children reporting they felt safe compared to 60.9% of parents of non-asthmatic children (p = 0.006). Fewer parents of asthmatic children than of non-asthmatic children reported that their neighborhood was safe from crime (21.7% versus 33.9%, p = 0.018). In multivariate analyses adjusting for race/ethnicity, age, gender, socioeconomic status, number of smokers in the home and breastfeeding history, parents reporting feeling unsafe walking in the neighborhood were more likely to have a child diagnosed with asthma (OR = 1.89, 95%CI 1.13-3.14). Psychosocial stressors such as living in unsafe neighborhoods may be associated with asthma diagnosis in urban ethnic minority children. Addressing the increased asthma burden in certain communities may require interventions to decrease urban stressors.

Long-term Medicaid excess payments from alleged price manipulation of generic lorazepam

BACKGROUND

Cost savings from the use of generic drugs versus brand-name drugs are well known. Both private and public prescription drug plans encourage the use of generic drugs through a variety of mechanisms. The magnitude of cost savings for a given generic drug is dependent on the degree to which the generic market is competitive. Should the competitive structure become compromised, higher prices and reduced cost savings may result. An alleged conspiracy between Mylan Laboratories and its active-ingredient suppliers in 1997 was associated with an increase in seller concentration in the generic lorazepam market. The Federal Trade Commission (FTC) alleged that Mylan raised costs to consumers by $120 million because of price increases for generic lorazepam from March through December 1998 and for generic clorazepate from January through December 1998. In November 2002, a settlement with Mylan was approved by the FTC, and a federal district court required Mylan to pay $147 million, including $28.2 million to state agencies including Medicaid.

OBJECTIVES

To (a) describe the seller concentration in the national Medicaid generic lorazepam market over a 19-year period from January 1991 through December 2009, (b) estimate the excess payments for generic lorazepam by Medicaid between 1998 and 2009, and (c) investigate potentially increased utilization and prices of 2 substitute pharmaceuticals: branded lorazepam (Ativan) and generic alprazolam (another widely used intermediate-acting benzodiazepine).

METHODS

Using Medicaid State Drug Utilization Data from the Centers for Medicare Medicaid Services, we calculated the 4-firm concentration ratio (CR₄) and the Herfindahl-Hirschman Index (HHI) for the Medicaid generic lorazepam market, along with pre-rebate reimbursement for pharmacy claims, number of claims (utilization), and average pre-rebate reimbursement per claim (average "price") for generic lorazepam, from 1991 through 2009. Medicaid's excess payments were estimated under 2 different assumptions regarding what the average generic lorazepam price would have been in the absence of the alleged conspiracy. To find counterfactual prices, the average per-claim reimbursement for lorazepam for the 4 quarters prior to the alleged conspiracy, $6.80, was inflated using (a) the quarterly change in the average per-claim reimbursement for generic alprazolam and (b) the Consumer Price Index (CPI) for all urban consumers, all goods. Potential impact of the alleged conspiracy on the branded lorazepam and generic alprazolam markets was investigated.

RESULTS

The average pre-rebate reimbursements per claim for generic lorazepam were $10.25, $23.12, and $8.48 in 1991, 1998, and 2009, respectively. For the same 3 years, CR₄ = 52.80, 76.02, and 86.74, while HHI = 905.71, 2,166.25, and 2,233.36. Medicaid's excess payments from 1998-2009 were estimated at approximately $625-$657 million. The data also suggest the possibility of small impacts on the utilization of branded lorazepam and the price of generic alprazolam.

CONCLUSIONS

Prior to the alleged conspiracy in 1997, average pre-rebate reimbursement per claim for generic lorazepam was declining, while seller concentration was rising. After a jump in average payment per claim in the years immediately following the alleged conspiracy, prices have gradually returned to their pre-1998 levels. However, the generic lorazepam market was more concentrated in 2009 than prior to the alleged conspiracy.

Food systems: New-Ruralism versus New-Urbanism

There is a growing debate on whether agricultural land in urban fringes should be maintained or converted to other uses. While 'pro-ruralists' believe agricultural land conversion can threaten food security and cause rural-urban migration, 'pro-urbanists' find it a necessary change for transition from a primitive agricultural-based community to an advanced industrial-based society which has the capacity to create mass productions. New-Ruralists follow an agricultural-based development approach that promotes small-medium farming and acknowledges rural lifestyle while New-Urbanists give a priority to large industrial-based sectors and encourage urban lifestyle. Given the unlike concerns of different societies, the paper concludes that the approaches might have different priorities in the less developed, developing, and developed world.

Food insecurity is associated with attitudes towards exclusive breastfeeding among women in urban Kenya

This study aimed to document whether food insecurity was associated with beliefs and attitudes towards exclusive breastfeeding (EBF) among urban Kenyan women. We conducted structured interviews with 75 human immunodeficiency virus (HIV)-affected and 75 HIV-status unknown, low-income women who were either pregnant or with a child ≤24 months and residing in Nakuru, Kenya to generate categorical and open-ended responses on knowledge, attitudes and beliefs towards EBF and food insecurity. We facilitated six focus group discussions (FGD) with HIV-affected and HIV-status unknown mothers (n = 50 women) to assess barriers and facilitators to EBF. Of 148 women with complete interview data, 77% were moderately or severely food insecure (FIS). Women in FIS households had significantly greater odds of believing that breast milk would be insufficient for 6 months [odds ratio (OR), 2.6; 95% confidence interval (95% CI), 1.0, 6.8], that women who EBF for 6 months would experience health or social problems (OR, 2.7; 95% CI, 1.0, 7.3), that women need adequate food to support EBF for 6 months (OR, 2.6; 95% CI, 1.0, 6.7) and that they themselves would be unable to follow a counsellor's advice to EBF for 6 months (OR, 3.2; 95% CI, 1.3, 8.3). Qualitative analysis of interview and FGD transcripts indicated that the maternal experience of hunger contributes to perceived milk insufficiency, anxiety about infant hunger and a perception that access to adequate food is necessary for successful breastfeeding. The lived experience of food insecurity among a sample of low-income, commonly FIS, urban Kenyan women reduces their capacity to implement at least one key recommended infant feeding practices, that of EBF for 6 months.

[The sociomedical portrait of girls studying at a secondary special educational establishment]

The purpose of this investigation was to study a social portrait in 15-17-year-old girls studying at secondary specialized educational establishments and the characteristics of their families. The urban girls have better living conditions than the rural ones. The income of the families of first- and second-year students from other towns was significantly more frequently lower (63.9 and 57.5%, respectively) versus that of the urban students (14.7 and 20.8%). The urban students had more conflicts with their parents (66.1% versus 52.6%). There are also differences in the professional and educational level of their parents. The parents living in the rural areas had a lower education level and more frequently belong to a class of workers and, accordingly, had more often occupational harms and heavy working conditions than the urban dwellers. The spread of bad habits in the families of urban and rural inhabitants is rather high. Nearly one-third of the students of Moscow and other towns experienced emotional violence by the members of their families.

Urban policy engagement with social sustainability in metro Vancouver

This article presents an analysis of social sustainability in comparative theoretical context and as a challenge to the post-political interpretation of sustainability in policy practice at the urban and regional scales. Metro Vancouver provides a case study for improving our understanding of the meaning of social sustainability as a framework for social policy in that it is among the handful of cities around the world currently working to define and enact social sustainability in governance terms. Results of this participant research provide evidence that some cities are politically engaging alternative development pathways using the concept of social sustainability. For sustainable development to retain its promise as an alternative policy framework for cities, social sustainability must be at the forefront.

A comparison of complementary and alternative medicine users and use across geographical areas: a national survey of 1,427 women

BACKGROUND

Evidence indicates that people who reside in non-urban areas have a higher use of complementary and alternative medicine (CAM) than people who reside in urban areas. However, there is sparse research on the reasons for such differences. This paper investigates the reasons for geographical differences in CAM use by comparing CAM users from four geographical areas (major cities, inner regional, outer region, rural/remote) across a range of health status, healthcare satisfaction, neighbourhood and community factors.

METHODS

A cross-sectional survey of 1,427 participants from the Australian Longitudinal Study on Women's Health (ALSWH) conducted in 2009.

RESULTS

The average total cost of consultations with CAM practitioners was $416 per annum and was highest for women in the major cities, declining with increasing distance from capital cities/remoteness (p < 0.001). The average total cost of self-prescribed CAM was $349 per annum, but this did not significantly differ across geographical areas. The increased use of CAM in rural and remote areas appears to be influenced by poorer access to conventional medical care (p < 0.05) and a greater sense of community (p < 0.05) amongst these rural and remote residents. In contrast to the findings of previous research this study found that health status was not associated with the differences in CAM use between urban and non-urban areas.

CONCLUSION

It appears that a number of factors influence the different levels of CAM use across the urban/non-urban divide. Further research is needed to help tease out and understand these factors. Such research will help support health care policy and practice with regards to this topic.

Land rent and housing policy: a case study of the San Francisco Bay area rental housing market

In the San Francisco Bay Area, where residential rent is among the highest in the United States, an analysis of data from several sources demonstrates that high rent cannot be accounted for by higher quality, higher operating costs, or higher construction costs. At least one-third of the total rent paid is land rent. Despite increases in real incomes, very-low-income tenants in the Bay Area today have less income remaining after payment of rent than tenants did in 1960. High land rent is a long-term feature of the Bay Area rental market that results mostly from its geography, the density of its urban centers, and a strong economy, rather than from regulatory barriers to new multifamily construction. Deregulation is not a sufficient response to the effects of land rent on low-income tenants. Government should subsidize non-profit housing organizations, particularly land trusts that remove residential land from the market. Taxes on land rent would be a particularly appropriate funding source.