Addressing 6 challenges in generative AI for digital health: A scoping review

Generative artificial intelligence (AI) can exhibit biases, compromise data privacy, misinterpret prompts that are adversarial attacks, and produce hallucinations. Despite the potential of generative AI for many applications in digital health, practitioners must understand these tools and their limitations. This scoping review pays particular attention to the challenges with generative AI technologies in medical settings and surveys potential solutions. Using PubMed, we identified a total of 120 articles published by March 2024, which reference and evaluate generative AI in medicine, from which we synthesized themes and suggestions for future work. After first discussing general background on generative AI, we focus on collecting and presenting 6 challenges key for digital health practitioners and specific measures that can be taken to mitigate these challenges. Overall, bias, privacy, hallucination, and regulatory compliance were frequently considered, while other concerns around generative AI, such as overreliance on text models, adversarial misprompting, and jailbreaking, are not commonly evaluated in the current literature.

College students' preferences for tobacco treatment: a discrete choice experiment

The purpose of this study was to elicit preferences for the 'format' and 'content' of tobacco treatment among college student smokers, using an online discrete choice experiment (DCE) survey. A DCE survey, supplemented with a think-aloud method, was conducted among 54 college students who smoked combustible cigarettes and/or e-cigarettes. Conditional logistic regression models were constructed to determine optimal profiles of treatment. Cutting down nicotine rather than quitting 'cold turkey' (P < 0.001) and two-way communication (P < 0.001) were viewed as the most critical attributes for the intervention 'format'; changing behaviors rather than social groups/peers (P < 0.001) and autonomy (P < 0.001) were viewed as the most critical attributes for the intervention 'content'. Some preferences varied based on smoking subgroups. Combustible cigarette users preferred interventions with a longer time commitment (P < 0.05) and without nicotine replacement therapies (NRTs) (P < 0.001). Think-aloud data supported the DCE findings and further revealed a strong desire for cutting down nicotine and keeping social groups/peers and misconceptions regarding NRTs. Our study findings can guide tobacco treatment tailored to college students. These treatments should be tailored to specific smoker subgroups.

Democracies Linked To Greater Universal Health Coverage Compared With Autocracies, Even In An Economic Recession

Despite widespread recognition that universal health coverage is a political choice, the roles that a country's political system plays in ensuring essential health services and minimizing financial risk remain poorly understood. Identifying the political determinants of universal health coverage is important for continued progress, and understanding the roles of political systems is particularly valuable in a global economic recession, which tests the continued commitment of nations to protecting their health of its citizens and to shielding them from financial risk. We measured the associations that democracy has with universal health coverage and government health spending in 170 countries during the period 1990-2019. We assessed how economic recessions affect those associations (using synthetic control methods) and the mechanisms connecting democracy with government health spending and universal health coverage (using machine learning methods). Our results show that democracy is positively associated with universal health coverage and government health spending and that this association is greatest for low-income countries. Free and fair elections were the mechanism primarily responsible for those positive associations. Democracies are more likely than autocracies to maintain universal health coverage, even amid economic recessions, when access to affordable, effective health services matters most.

Autocratisation and universal health coverage: synthetic control study

OBJECTIVE

To assess the relation between autocratisation-substantial decreases in democratic traits (free and fair elections, freedom of civil and political association, and freedom of expression)-and countries' population health outcomes and progress toward universal health coverage (UHC).

DESIGN

Synthetic control analysis.

SETTING AND COUNTRY SELECTION

Global sample of countries for all years from 1989 to 2019, split into two categories: 17 treatment countries that started autocratising during 2000 to 2010, and 119 control countries that never autocratised from 1989 to 2019. The treatment countries comprised low and middle income nations and represent all world regions except North America and western Europe. A weighted combination of control countries was used to construct synthetic controls for each treatment country. This statistical method is especially well suited to population level studies when random assignment is infeasible and sufficiently similar comparators are not available. The method was originally developed in economics and political science to assess the impact of policies and events, and it is now increasingly used in epidemiology.

MAIN OUTCOME MEASURES

HIV-free life expectancy at age 5 years, UHC effective coverage index (0-100 point scale), and out-of-pocket spending on health per capita. All outcome variables are for the period 1989 to 2019.

RESULTS

Autocratising countries underperformed for all three outcome variables in the 10 years after the onset of autocratisation, despite some improvements in life expectancy, UHC effective coverage index, and out-of-pocket spending on health. On average, HIV-free life expectancy at age 5 years increased by 2.2% (from 64.7 to 66.1 years) during the 10 years after the onset of autocratisation. This study estimated that it would have increased by 3.5% (95% confidence interval 3.3% to 3.6%, P<0.001) (from 64.7 to 66.9 years) in the absence of autocratisation. On average, the UHC effective coverage index increased by 11.9% (from 42.5 to 47.6 points) during the 10 years after the onset of autocratisation. This study estimated that it would have increased by 20.2% (95% confidence interval 19.6% to 21.2%, P<0.001) (from 42.5 to 51.1 points) in the absence of autocratisation. Finally, on average, out-of-pocket spending on health per capita increased by 10.0% (from $4.00 (£3.1; €3.4) to $4.4, log transformed) during the 10 years after the onset of autocratisation. This study estimated that it would have increased by only 4.4% (95% confidence interval 3.9% to 4.6%, P<0.001) (from $4.0 to $4.2, log transformed) in the absence of autocratisation.

CONCLUSIONS

Autocratising countries had worse than estimated life expectancy, effective health service coverage, and levels of out-of-pocket spending on health. These results suggest that the noticeable increase in the number of countries that are experiencing democratic erosion in recent years is hindering population health gains and progress toward UHC. Global health institutions will need to adjust their policy recommendations and activities to obtain the best possible results in those countries with a diminishing democratic incentive to provide quality healthcare to populations.

The relationships between democratic experience, adult health, and cause-specific mortality in 170 countries between 1980 and 2016: an observational analysis

BACKGROUND

Previous analyses of democracy and population health have focused on broad measures, such as life expectancy at birth and child and infant mortality, and have shown some contradictory results. We used a panel of data spanning 170 countries to assess the association between democracy and cause-specific mortality and explore the pathways connecting democratic rule to health gains.

METHODS

We extracted cause-specific mortality and HIV-free life expectancy estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 and information on regime type from the Varieties of Democracy project. These data cover 170 countries and 46 years. From the Financing Global Health database, we extracted gross domestic product (GDP) per capita, also covering 46 years, and Development Assistance for Health estimates starting from 1990 and domestic health spending estimates starting from 1995. We used a diverse set of empirical methods-synthetic control, within-country variance decomposition, structural equation models, and fixed-effects regression-which together provide a robust analysis of the association between democratisation and population health.

FINDINGS

HIV-free life expectancy at age 15 years improved significantly during the study period (1970-2015) in countries after they transitioned to democracy, on average by 3% after 10 years. Democratic experience explains 22·27% of the variance in mortality within a country from cardiovascular diseases, 16·53% for tuberculosis, and 17·78% for transport injuries, and a smaller percentage for other diseases included in the study. For cardiovascular diseases, transport injuries, cancers, cirrhosis, and other non-communicable diseases, democratic experience explains more of the variation in mortality than GDP. Over the past 20 years, the average country's increase in democratic experience had direct and indirect effects on reducing mortality from cardiovascular disease (-9·64%, 95% CI -6·38 to -12·90), other non-communicable diseases (-9·14%, -4·26 to -14·02), and tuberculosis (-8·93%, -2·08 to -15·77). Increases in a country's democratic experience were not correlated with GDP per capita between 1995 and 2015 (ρ=-0·1036; p=0·1826), but were correlated with declines in mortality from cardiovascular disease (ρ=-0·3873; p<0·0001) and increases in government health spending (ρ=0·4002; p<0·0001). Removal of free and fair elections from the democratic experience variable resulted in loss of association with age-standardised mortality from non-communicable diseases and injuries.

INTERPRETATION

When enforced by free and fair elections, democracies are more likely than autocracies to lead to health gains for causes of mortality (eg, cardiovascular diseases and transport injuries) that have not been heavily targeted by foreign aid and require health-care delivery infrastructure. International health agencies and donors might increasingly need to consider the implications of regime type in their efforts to maximise health gains, particularly in the context of ageing populations and the growing burden of non-communicable diseases.

FUNDING

Bloomberg Philanthropies and the Bill & Melinda Gates Foundation.

Lower-Income Countries That Face The Most Rapid Shift In Noncommunicable Disease Burden Are Also The Least Prepared

Demographic and epidemiological changes are shifting the disease burden from communicable to noncommunicable diseases in lower-income countries. Within a generation, the share of disease burden attributed to noncommunicable diseases in some poor countries will exceed 80 percent, rivaling that of rich countries, but this burden is likely to affect much younger people in poorer countries. The health systems of lower-income countries are unprepared for this change. We examined the shift to noncommunicable diseases and estimated preparedness for the shift by ranking 172 nations using a health system capacity index for noncommunicable disease. We project that the countries with the greatest increases in the share of disease burden attributable to noncommunicable disease over the next twenty-five years will also be the least prepared for the change, as they ranked low on our capacity index and are expected to have the smallest increases in national health spending. National governments and donors must invest more in preparing the health systems of lower-income countries for the dramatic shift to noncommunicable diseases and in reducing modifiable noncommunicable disease risks.

Trends in future health financing and coverage: future health spending and universal health coverage in 188 countries, 2016-40

BACKGROUND

Achieving universal health coverage (UHC) requires health financing systems that provide prepaid pooled resources for key health services without placing undue financial stress on households. Understanding current and future trajectories of health financing is vital for progress towards UHC. We used historical health financing data for 188 countries from 1995 to 2015 to estimate future scenarios of health spending and pooled health spending through to 2040.

METHODS

We extracted historical data on gross domestic product (GDP) and health spending for 188 countries from 1995 to 2015, and projected annual GDP, development assistance for health, and government, out-of-pocket, and prepaid private health spending from 2015 through to 2040 as a reference scenario. These estimates were generated using an ensemble of models that varied key demographic and socioeconomic determinants. We generated better and worse alternative future scenarios based on the global distribution of historic health spending growth rates. Last, we used stochastic frontier analysis to investigate the association between pooled health resources and UHC index, a measure of a country's UHC service coverage. Finally, we estimated future UHC performance and the number of people covered under the three future scenarios.

FINDINGS

In the reference scenario, global health spending was projected to increase from US$10 trillion (95% uncertainty interval 10 trillion to 10 trillion) in 2015 to $20 trillion (18 trillion to 22 trillion) in 2040. Per capita health spending was projected to increase fastest in upper-middle-income countries, at 4·2% (3·4-5·1) per year, followed by lower-middle-income countries (4·0%, 3·6-4·5) and low-income countries (2·2%, 1·7-2·8). Despite global growth, per capita health spending was projected to range from only $40 (24-65) to $413 (263-668) in 2040 in low-income countries, and from $140 (90-200) to $1699 (711-3423) in lower-middle-income countries. Globally, the share of health spending covered by pooled resources would range widely, from 19·8% (10·3-38·6) in Nigeria to 97·9% (96·4-98·5) in Seychelles. Historical performance on the UHC index was significantly associated with pooled resources per capita. Across the alternative scenarios, we estimate UHC reaching between 5·1 billion (4·9 billion to 5·3 billion) and 5·6 billion (5·3 billion to 5·8 billion) lives in 2030.

INTERPRETATION

We chart future scenarios for health spending and its relationship with UHC. Ensuring that all countries have sustainable pooled health resources is crucial to the achievement of UHC.

FUNDING

The Bill & Melinda Gates Foundation.

The financing gaps framework: using need, potential spending and expected spending to allocate development assistance for health

As growth in development assistance for health levels off, development assistance partners must make allocation decisions within tighter budget constraints. Furthermore, with the advent of comprehensive and comparable burden of disease and health financing estimates, empirical evidence can increasingly be used to direct funding to those most in need. In our 'financing gaps framework', we propose a new approach for harnessing information to make decisions about health aid. The framework was designed to be forward-looking, goal-oriented, versatile and customizable to a range of organizational contexts and health aims. Our framework brings together expected health spending, potential health spending and spending need, to orient financing decisions around international health targets. As an example of how the framework could be applied, we develop a case study, focused on global goals for child health. The case study harnesses data from the Global Burden of Disease 2013 Study, Financing Global Health 2015, the WHO Global Health Observatory and National Health Accounts. Funding flows are tied to progress toward the Sustainable Development Goal's target for reductions in under-five mortality. The flexibility and comprehensiveness of our framework makes it adaptable for use by a diverse set of governments, donors, policymakers and other stakeholders. The framework can be adapted to short- or long-run time frames, cross-country or subnational scales, and to a number of specific health focus areas. Depending on donor preferences, the framework can be deployed to incentivize local investments in health, ensuring the long-term sustainability of health systems in low- and middle-income countries, while also furnishing international support for progress toward global health goals.

US Spending on Personal Health Care and Public Health, 1996-2013

IMPORTANCE

US health care spending has continued to increase, and now accounts for more than 17% of the US economy. Despite the size and growth of this spending, little is known about how spending on each condition varies by age and across time.

OBJECTIVE

To systematically and comprehensively estimate US spending on personal health care and public health, according to condition, age and sex group, and type of care.

DESIGN AND SETTING

Government budgets, insurance claims, facility surveys, household surveys, and official US records from 1996 through 2013 were collected and combined. In total, 183 sources of data were used to estimate spending for 155 conditions (including cancer, which was disaggregated into 29 conditions). For each record, spending was extracted, along with the age and sex of the patient, and the type of care. Spending was adjusted to reflect the health condition treated, rather than the primary diagnosis.

EXPOSURES

Encounter with US health care system.

MAIN OUTCOMES AND MEASURES

National spending estimates stratified by condition, age and sex group, and type of care.

RESULTS

From 1996 through 2013, $30.1 trillion of personal health care spending was disaggregated by 155 conditions, age and sex group, and type of care. Among these 155 conditions, diabetes had the highest health care spending in 2013, with an estimated $101.4 billion (uncertainty interval [UI], $96.7 billion-$106.5 billion) in spending, including 57.6% (UI, 53.8%-62.1%) spent on pharmaceuticals and 23.5% (UI, 21.7%-25.7%) spent on ambulatory care. Ischemic heart disease accounted for the second-highest amount of health care spending in 2013, with estimated spending of $88.1 billion (UI, $82.7 billion-$92.9 billion), and low back and neck pain accounted for the third-highest amount, with estimated health care spending of $87.6 billion (UI, $67.5 billion-$94.1 billion). The conditions with the highest spending levels varied by age, sex, type of care, and year. Personal health care spending increased for 143 of the 155 conditions from 1996 through 2013. Spending on low back and neck pain and on diabetes increased the most over the 18 years, by an estimated $57.2 billion (UI, $47.4 billion-$64.4 billion) and $64.4 billion (UI, $57.8 billion-$70.7 billion), respectively. From 1996 through 2013, spending on emergency care and retail pharmaceuticals increased at the fastest rates (6.4% [UI, 6.4%-6.4%] and 5.6% [UI, 5.6%-5.6%] annual growth rate, respectively), which were higher than annual rates for spending on inpatient care (2.8% [UI, 2.8%-2.8%] and nursing facility care (2.5% [UI, 2.5%-2.5%]).

CONCLUSIONS AND RELEVANCE

Modeled estimates of US spending on personal health care and public health showed substantial increases from 1996 through 2013; with spending on diabetes, ischemic heart disease, and low back and neck pain accounting for the highest amounts of spending by disease category. The rate of change in annual spending varied considerably among different conditions and types of care. This information may have implications for efforts to control US health care spending.

Development assistance for health: past trends, associations, and the future of international financial flows for health

BACKGROUND

Disbursements of development assistance for health (DAH) have risen substantially during the past several decades. More recently, the international community's attention has turned to other international challenges, introducing uncertainty about the future of disbursements for DAH.

METHODS

We collected audited budget statements, annual reports, and project-level records from the main international agencies that disbursed DAH from 1990 to the end of 2015. We standardised and combined records to provide a comprehensive set of annual disbursements. We tracked each dollar of DAH back to the source and forward to the recipient. We removed transfers between agencies to avoid double-counting and adjusted for inflation. We classified assistance into nine primary health focus areas: HIV/AIDS, tuberculosis, malaria, maternal health, newborn and child health, other infectious diseases, non-communicable diseases, Ebola, and sector-wide approaches and health system strengthening. For our statistical analysis, we grouped these health focus areas into two categories: MDG-related focus areas (HIV/AIDS, tuberculosis, malaria, child and newborn health, and maternal health) and non-MDG-related focus areas (other infectious diseases, non-communicable diseases, sector-wide approaches, and other). We used linear regression to test for structural shifts in disbursement patterns at the onset of the Millennium Development Goals (MDGs; ie, from 2000) and the global financial crisis (impact estimated to occur in 2010). We built on past trends and associations with an ensemble model to estimate DAH through the end of 2040.

FINDINGS

In 2015, US$36·4 billion of DAH was disbursed, marking the fifth consecutive year of little change in the amount of resources provided by global health development partners. Between 2000 and 2009, DAH increased at 11·3% per year, whereas between 2010 and 2015, annual growth was just 1·2%. In 2015, 29·7% of DAH was for HIV/AIDS, 17·9% was for child and newborn health, and 9·8% was for maternal health. Linear regression identifies three distinct periods of growth in DAH. Between 2000 and 2009, MDG-related DAH increased by $290·4 million (95% uncertainty interval [UI] 174·3 million to 406·5 million) per year. These increases were significantly greater than were increases in non-MDG DAH during the same period (p=0·009), and were also significantly greater than increases in the previous period (p<0·0001). Between 2000 and 2009, growth in DAH was highest for HIV/AIDS, malaria, and tuberculosis. Since 2010, DAH for maternal health and newborn and child health has continued to climb, although DAH for HIV/AIDS and most other health focus areas has remained flat or decreased. Our estimates of future DAH based on past trends and associations present a wide range of potential futures, although our mean estimate of $64·1 billion (95% UI $30·4 billion to $161·8 billion) shows an increase between now and 2040, although with a large uncertainty interval.

INTERPRETATION

Our results provide evidence of two substantial shifts in DAH growth during the past 26 years. DAH disbursements increased faster in the first decade of the 2000s than in the 1990s, but DAH associated with the MDGs increased the most out of all focus areas. Since 2010, limited growth has characterised DAH and we expect this pattern to persist. Despite the fact that DAH is still growing, albeit minimally, DAH is shifting among the major health focus areas, with relatively little growth for HIV/AIDS, malaria, and tuberculosis. These changes in the growth and focus of DAH will have critical effects on health services in some low-income countries. Coordination and collaboration between donors and domestic governments is more important than ever because they have a great opportunity and responsibility to ensure robust health systems and service provision for those most in need.

FUNDING

Bill & Melinda Gates Foundation.

National spending on health by source for 184 countries between 2013 and 2040

BACKGROUND

A general consensus exists that as a country develops economically, health spending per capita rises and the share of that spending that is prepaid through government or private mechanisms also rises. However, the speed and magnitude of these changes vary substantially across countries, even at similar levels of development. In this study, we use past trends and relationships to estimate future health spending, disaggregated by the source of those funds, to identify the financing trajectories that are likely to occur if current policies and trajectories evolve as expected.

METHODS

We extracted data from WHO's Health Spending Observatory and the Institute for Health Metrics and Evaluation's Financing Global Health 2015 report. We converted these data to a common purchasing power-adjusted and inflation-adjusted currency. We used a series of ensemble models and observed empirical norms to estimate future government out-of-pocket private prepaid health spending and development assistance for health. We aggregated each country's estimates to generate total health spending from 2013 to 2040 for 184 countries. We compared these estimates with each other and internationally recognised benchmarks.

FINDINGS

Global spending on health is expected to increase from US$7·83 trillion in 2013 to $18·28 (uncertainty interval 14·42-22·24) trillion in 2040 (in 2010 purchasing power parity-adjusted dollars). We expect per-capita health spending to increase annually by 2·7% (1·9-3·4) in high-income countries, 3·4% (2·4-4·2) in upper-middle-income countries, 3·0% (2·3-3·6) in lower-middle-income countries, and 2·4% (1·6-3·1) in low-income countries. Given the gaps in current health spending, these rates provide no evidence of increasing parity in health spending. In 1995 and 2015, low-income countries spent $0·03 for every dollar spent in high-income countries, even after adjusting for purchasing power, and the same is projected for 2040. Most importantly, health spending in many low-income countries is expected to remain low. Estimates suggest that, by 2040, only one (3%) of 34 low-income countries and 36 (37%) of 98 middle-income countries will reach the Chatham House goal of 5% of gross domestic product consisting of government health spending.

INTERPRETATION

Despite remarkable health gains, past health financing trends and relationships suggest that many low-income and lower-middle-income countries will not meet internationally set health spending targets and that spending gaps between low-income and high-income countries are unlikely to narrow unless substantive policy interventions occur. Although gains in health system efficiency can be used to make progress, current trends suggest that meaningful increases in health system resources will require concerted action.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013: quantifying the epidemiological transition

BACKGROUND

The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age-sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development.

METHODS

We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time.

FINDINGS

Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6-6·6), from 65·3 years (65·0-65·6) in 1990 to 71·5 years (71·0-71·9) in 2013, HALE at birth rose by 5·4 years (4·9-5·8), from 56·9 years (54·5-59·1) to 62·3 years (59·7-64·8), total DALYs fell by 3·6% (0·3-7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6-29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non-communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries.

INTERPRETATION

Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition--in which increasing sociodemographic status brings structured change in disease burden--is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions.

FUNDING

Bill & Melinda Gates Foundation.

Sources and Focus of Health Development Assistance, 1990-2014

IMPORTANCE

The governments of high-income countries and private organizations provide billions of dollars to developing countries for health. This type of development assistance can have a critical role in ensuring that life-saving health interventions reach populations in need.

OBJECTIVES

To identify the amount of development assistance that countries and organizations provided for health and to determine the health areas that received these funds.

EVIDENCE REVIEW

Budget, revenue, and expenditure data on the primary agencies and organizations (n = 38) that provided resources to developing countries (n = 146-183, depending on the year) for health from 1990 through 2014 were collected. For each channel (the international agency or organization that directed the resources toward the implementing institution or government), the source and recipient of the development assistance were determined and redundant accounting of the same dollar, which occurs when channels transfer funds among each other, was removed. This research derived the flow of resources from source to intermediary channel to recipient. Development assistance for health (DAH) was divided into 11 mutually exclusive health focus areas, such that every dollar of development assistance was assigned only 1 health focus area.

FINDINGS

Since 1990, $458.0 billion of development assistance has been provided to maintain or improve health in developing countries. The largest source of funding was the US government, which provided $143.1 billion between 1990 and 2014, including $12.4 billion in 2014. Of resources that originated with the US government, 70.6% were provided through US government agencies, and 41.0% were allocated for human immunodeficiency virus (HIV)/AIDS. The second largest source of development assistance for health was private philanthropic donors, including the Bill and Melinda Gates Foundation and other private foundations, which provided $69.9 billion between 1990 and 2014, including $6.2 billion in 2014. These resources were provided primarily through private foundations and nongovernmental organizations and were allocated for a diverse set of health focus areas. Since 1990, 28.0% of all DAH was allocated for maternal health and newborn and child health; 23.2% for HIV/AIDS, 4.3% for malaria, 2.8% for tuberculosis, and 1.5% for noncommunicable diseases. Between 2000 and 2010, DAH increased 11.3% annually. However, since 2010, total DAH has not increased as substantially.

CONCLUSIONS AND RELEVANCE

Funding for health in developing countries has increased substantially since 1990, with a focus on HIV/AIDS, maternal health, and newborn and child health. Funding from the US government has played a substantial role in this expansion. Funding for noncommunicable diseases has been limited. Understanding how funding patterns have changed across time and the priorities of sources of international funding across distinct channels, recipients, and health focus areas may help identify where funding gaps persist and where cost-effective interventions could save lives.

Random-effects, fixed-effects and the within-between specification for clustered data in observational health studies: a simulation study

Background

When unaccounted-for group-level characteristics affect an outcome variable, traditional linear regression is inefficient and can be biased. The random- and fixed-effects estimators (RE and FE, respectively) are two competing methods that address these problems. While each estimator controls for otherwise unaccounted-for effects, the two estimators require different assumptions. Health researchers tend to favor RE estimation, while researchers from some other disciplines tend to favor FE estimation. In addition to RE and FE, an alternative method called within-between (WB) was suggested by Mundlak in 1978, although is utilized infrequently.

Methods

We conduct a simulation study to compare RE, FE, and WB estimation across 16,200 scenarios. The scenarios vary in the number of groups, the size of the groups, within-group variation, goodness-of-fit of the model, and the degree to which the model is correctly specified. Estimator preference is determined by lowest mean squared error of the estimated marginal effect and root mean squared error of fitted values.

Results

Although there are scenarios when each estimator is most appropriate, the cases in which traditional RE estimation is preferred are less common. In finite samples, the WB approach outperforms both traditional estimators. The Hausman test guides the practitioner to the estimator with the smallest absolute error only 61% of the time, and in many sample sizes simply applying the WB approach produces smaller absolute errors than following the suggestion of the test.

Conclusions

Specification and estimation should be carefully considered and ultimately guided by the objective of the analysis and characteristics of the data. The WB approach has been underutilized, particularly for inference on marginal effects in small samples. Blindly applying any estimator can lead to bias, inefficiency, and flawed inference.

Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100,000 livebirths) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery.

METHODS

We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990-2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values.

FINDINGS

292,982 (95% UI 261,017-327,792) maternal deaths occurred in 2013, compared with 376,034 (343,483-407,574) in 1990. The global annual rate of change in the MMR was -0·3% (-1·1 to 0·6) from 1990 to 2003, and -2·7% (-3·9 to -1·5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290-2866) maternal deaths were related to HIV in 2013, 0·4% (0·2-0·6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most deaths occurred intrapartum or postpartum. Causes varied by region and between 1990 and 2013. We recorded substantial variation in the MMR by country in 2013, from 956·8 (685·1-1262·8) in South Sudan to 2·4 (1·6-3·6) in Iceland.

INTERPRETATION

Global rates of change suggest that only 16 countries will achieve the MDG 5 target by 2015. Accelerated reductions since the Millennium Declaration in 2000 coincide with increased development assistance for maternal, newborn, and child health. Setting of targets and associated interventions for after 2015 will need careful consideration of regions that are making slow progress, such as west and central Africa.

FUNDING

Bill & Melinda Gates Foundation.

Comparison of personal characteristics, tobacco use, and health states in Chaldean, Arab American, and non-Middle Eastern White adults

This study compared and contrasted personal characteristics, tobacco use (cigarette and water pipe smoking), and health states in Chaldean, Arab American and non-Middle Eastern White adults attending an urban community service center. The average age was 39.4 (SD = 14.2). The three groups differed significantly (P < .006) on ethnicity, age, gender distribution, marital status, language spoken, education, employment, and annual income. Current cigarette smoking was highest for non-Middle Eastern White adults (35.4%) and current water pipe smoking was highest for Arab Americans (3.6%). Arab Americans were more likely to smoke both cigarettes and the narghile (4.3%). Health problems were highest among former smokers in all three ethnic groups. Being male, older, unmarried, and non-Middle Eastern White predicted current cigarette smoking; being Arab or Chaldean and having less formal education predicted current water pipe use.

Transtheoretical Model and substance use in HIV-positive youth

The purpose of the study was to test constructs of the Transtheoretical Model (TTM) for predicting alcohol and other drug use in HIV-positive youth (ages 16-25). Questionnaires and interviews about alcohol and other drug use, stage of change, self-efficacy, emotional distress and social support were obtained from 64 HIV-positive youth. Structural equation modeling with standard errors determined by methods appropriate to small samples, demonstrated that self-efficacy mediated the relationship between stage of change and alcohol use and between social support and alcohol use. The same pattern of results emerged for marijuana use. The models predicted 47% of the variance in alcohol use and 69% of the variance in marijuana use. Results supported the TTM and highlight the potential of interventions that seek to boost self-efficacy and social support specific to reducing substance use.

Chronic venous insufficiency in persons with a history of injection drug use

Persons with a history of injection drug use have many risk factors for the development of chronic venous insufficiency (CVI), yet this phenomenon has not been studied systematically in this population. Persons (N = 204) with a history of injection drug use who were in enrolled in a treatment center were examined for clinical manifestations of CVI. The CVI clinical classification was graded on a 7-point scale for each leg. Most participants (n = 179, 87.7%) exhibited clinical evidence of CVI. Significant predictors of CVI clinical manifestations were leg infections/cellulitis (rho =.53); years injection in the veins of the groin, legs, and feet (rho =.47); deep vein thrombosis (rho =.37); and total years injection heroin (rho =.27). There was a linear functional relationship between years of injection drug use and the CVI clinical classification, but only when the injections were in the veins of the groin, legs, or feet; otherwise, the specific mechanisms of this relationship were not evident. The findings indicate that CVI is a common occurrence in persons who have injected drugs.

Prenatal alcohol exposure and childhood behavior at age 6 to 7 years: I. dose-response effect

OBJECTIVE

Moderate to heavy levels of prenatal alcohol exposure have been associated with alterations in child behavior, but limited data are available on adverse effects after low levels of exposure. The objective of this study was to evaluate the dose-response effect of prenatal alcohol exposure for adverse child behavior outcomes at 6 to 7 years of age.

METHODS

Beginning in 1986, women attending the urban university-based maternity clinic were routinely screened at their first prenatal visit for alcohol and drug use by trained research assistants from the Fetal Alcohol Research Center. All women reporting alcohol consumption at conception of at least 0.5 oz absolute alcohol/day and a 5% random sample of lower level drinkers and abstainers were invited to participate to be able to identify the associations between alcohol intake and child development. Maternal alcohol, cigarette, and illicit drug use were prospectively assessed during pregnancy and postnatally. The independent variable in this study, prenatal alcohol exposure, was computed as the average absolute alcohol intake (oz) per day across pregnancy. At each prenatal visit, mothers were interviewed about alcohol use during the previous 2 weeks. Quantities and types of alcohol consumed were converted to fluid ounces of absolute alcohol and averaged across visits to generate a summary measure of alcohol exposure throughout pregnancy. Alcohol was initially used as a dichotomous variable comparing children with no prenatal alcohol exposure to children with any exposure. To evaluate the effects of different levels of exposure, the average absolute alcohol intake was relatively arbitrarily categorized into no, low (>0 but <0.3 fl oz of absolute alcohol/day), and moderate/heavy (>/=0.3 fl oz of absolute alcohol/day) for the purpose of this study. Six years later, 665 families were contacted. Ninety-four percent agreed to testing. Exclusions included children who missed multiple test appointments, had major congenital malformations (other than fetal alcohol syndrome), possessed an IQ >2 standard deviations from the sample mean, or had incomplete data. The Achenbach Child Behavior Checklist (CBCL) was used to assess child behavior. The CBCL is a parent questionnaire applicable to children ages 4 to 16 years. It is widely used in the clinical assessment of children's behavior problems and has been extensively used in research. Eight syndrome scales are further grouped into Externalizing or undercontrolled (Aggressive and Delinquent) behavior and Internalizing or overcontrolled (Anxious/Depressed, Somatic Complaints, and Withdrawn) behaviors. Three syndromes (Social, Thought, and Attention Problems) fit neither group. Higher scores are associated with more problem behaviors. Research assistants who were trained and blinded to exposure status independently interviewed the child and caretaker. Data were collected on a broad range of control variables known to influence childhood behavior and/or to be associated with prenatal alcohol exposure. These included perinatal factors of maternal age, education, cigarette, cocaine, and other substances of abuse and the gestational age of the baby. Postnatal factors studied included maternal psychopathology, continuing alcohol and drug use, family structure, socioeconomic status, children's whole blood lead level, and exposure to violence. Data were collected only from black women as there was inadequate representation of other racial groups.

STATISTICAL ANALYSES

Statistical analyses were performed using the SPSS statistical package. Frequency distribution, cross-tabulation, odds ratio, and chi(2) tests were used for analyzing categorical data. Continuous data were analyzed using t tests, analyses of variance (ANOVAs) with posthoc tests, and regression analysis.

RESULTS

Testing was available for 501 parent-children dyads. Almost one fourth of the women denied alcohol use during pregnancy. Low levels of alcohol use were reported in 63.8% and moderate/heavy use in 13% of pregnancies. Increasing prenatal alcohol exposure was associated with lower birth weight and gestational age, higher lead levels, higher maternal age, and lower education level, prenatal exposure to cocaine and smoking, custody changes, lower socioeconomic status, and paternal drinking and drug use at the time of pregnancy. Children with any prenatal alcohol exposure were more likely to have higher CBCL scores on Externalizing (Aggressive and Delinquent) and Internalizing (Anxious/Depressed and Withdrawn) syndrome scales and the Total Problem Score. The odds ratio of scoring in the clinical range for Delinquent behavior was 3.2 (1.3-7.6) in children with any prenatal exposure to alcohol compared with nonexposed controls. The threshold dose was evaluated with the 3 prenatal alcohol exposure groups. One-way ANOVA revealed a significant between group difference for Externalizing (Aggressive and Delinquent) and the Total Problem Score. (ABSTRACT TRUNCATED)

Couples' adjustment to breast disease during the first year following diagnosis

The objectives were to determine (a) the extent to which psychosocial, demographic, and medical variables predict women's and husbands' adjustment to breast disease during the first year following diagnosis; (b) the degree of autocorrelation among and intercorrelation between partners' adjustment scores; (c) the extent to which baseline levels of adjustment predict adjustment 1 year later; and (d) the extent to which one partner's adjustment affects the other partner's adjustment. A stress-coping framework guided this study. The sample consisted of 131 couples, 58 couples received a cancer diagnosis and 73 received a benign diagnosis. Couples were interviewed at 1 week, 2 months, and 1 year postdiagnosis. Structural equation modeling was used to analyze the data. The strongest predictors of adjustment for women were severity of the illness and hopelessness and for husbands, their own baseline level of adjustment. Husbands' and wives' levels of adjustment at 1 year had a significant direct effect on each other's adjustment.

Predicting success using individualized scheduled toileting for memory-impaired elders at home

The purpose of this research was to evaluate the effectiveness of an individualized scheduled toileting (IST) program on incontinent, memory-impaired elders being cared for at home. Using a 2 x 2 mixed design analysis of variance (group by time), 118 patients were randomly assigned to experimental or control groups. Caregivers in the experimental group were taught the IST procedure. Urinary incontinence (UI) was measured at baseline and at 6 months. Weeklong voiding records were kept by caregivers and were used to calculate the percentage of times the incontinence occurred. UI significantly decreased in the experimental group, whereas in the control group it did not. The baseline cognitive ability, mobility, and consistency of implementing IST were entered into a discriminant function equation and significantly predicted patients who would improve with IST. Cognitive ability was the best predictor, with mobility also emerging as a meaningful predictor. Candidates for IST should be selected based on elders' cognitive ability and their ability to cooperate with toileting. Moderately cognitively impaired elders and ones able to cooperate with toileting protocols are prime candidates for IST.

Expressive language development of children exposed to cocaine prenatally: literature review and report of a prospective cohort study

It was hypothesized that prenatal exposure to cocaine and other substances would be related to delayed expressive language development. Speech and language data were available for 458 6-year olds (204 were exposed to cocaine). No significant univariate or multivariate differences by cocaine exposure group were observed. Classification and regression tree modeling was then used to identify language variable composites predictive of cocaine exposure status. Meaningful cut points for two language measures were identified and validated. Children with a type token ratio of less than 0.42 and with fewer than 97 word types were classified into a low language group. Low language children (n = 57) were more likely to be cocaine exposed (63.1%), with cocaine-exposed children 2.4 times more likely to be in the low language group compared with control children after adjustment for covariates. Prenatal cigarette, but not alcohol exposure, was also significantly related to expressive language delays.

Indicators of quality of care in clinics: patients' perspectives

Despite extensive research on defining and measuring quality of care, less attention has been given to consumers' views. The purpose of the study reported here was to identify indicators of quality of healthcare and nursing care important to clinic patients. The most important indicators of healthcare quality were getting better, getting care and services when needed, and having diagnoses and treatment options explained. The most important indicators of nursing care quality were communicating with the nurse, being treated with respect, being cared for by nurses who were up-to-date, teaching by the nurse, and not being rushed through the visit.

Teacher-assessed behavior of children prenatally exposed to cocaine

OBJECTIVE

Prenatal cocaine exposure has been associated with alterations in neonatal behavior and more recently a dose-response relationship has been identified. However, few data are available to address the long-term behavioral effects of prenatal exposures in humans. The specific aim of this report is to evaluate the school-age behavior of children prenatally exposed to cocaine.

METHODS

All black non-human immunodeficiency virus-positive participants in a larger pregnancy outcomes study who delivered singleton live born infants between September 1, 1989 and August 31, 1991 were eligible for study participation. Staff members of the larger study extensively screened study participants during pregnancy for cocaine, alcohol, cigarettes, and other illicit drugs. Prenatal drug exposure was defined by maternal history elicited by structured interviews with maternal and infant drug testing as clinically indicated. Cocaine exposure was considered positive if either history or laboratory results were positive. Six years later, 665 families were contacted; 94% agreed to participate. The child, primary caretaker (parent), and, when available, the biologic mothers were tested in our research facilities. Permission was elicited to obtain blinded teacher assessments of child behavior with the Achenbach Teacher's Report Form (TRF). Drug use since the child's birth was assessed by trained researchers using a structured interview.

RESULTS

Complete laboratory and teacher data were available for 499 parent-child dyads, with a final sample size for all analyses of 471 (201 cocaine-exposed) after the elimination of mentally retarded subjects. A comparison of relative Externalizing (Aggressive, Delinquent) to Internalizing (Anxious/Depressed, Withdrawn, Somatic Complaints) behaviors of the offspring was computed for the TRF by taking the difference between the 2 subscales to create an Externalizing-Internalizing Difference (T. M. Achenbach, personal communication, 1998). Univariate comparisons revealed that boys were significantly more likely to score in the clinically significant range on total TRF, Externalizing-Internalizing, and Aggressive Behaviors than were girls. Children prenatally exposed to cocaine had higher Externalizing-Internalizing Differences compared with controls but did not have significantly higher scores on any of the other TRF variables. Additionally, boys prenatally exposed to cocaine were twice as likely as controls to have clinically significant scores for externalizing (25% vs 13%) and delinquent behavior (22% vs 11%). Gender, prenatal exposures (cocaine and alcohol), and postnatal risk factors (custody changes, current drug use in the home, child's report of violence exposure) were all related to problem behaviors. Even after controlling for gender, other prenatal substance exposures, and home environment variables, cocaine-exposed children had higher Externalizing-Internalizing Difference scores. Prenatal exposure to alcohol was associated with higher total score, increased attention problems, and more delinquent behaviors. Prenatal exposure to cigarettes was not significantly related to the total TRF score or any of the TRF subscales. Postnatal factors associated with problem behaviors included both changes in custody status and current drug use in the home. Change in custody status of the cocaine-exposed children, but not of the controls, was related to higher total scores on the TRF and more externalizing and aggressive behaviors. Current drug use in the home was associated with higher scores on the externalizing and aggressive subscales.

CONCLUSIONS

Results of this study suggest gender-specific behavioral effects related to prenatal cocaine exposure. Prenatal alcohol exposure also had a significant impact on the TRF. Postnatal exposures, including current drug use in the home and the child's report of violence exposure, had an independent effect on teacher-assessed child behavioral problems. (ABSTRACT TRUNCATE

Parents' perceptions of quality health care

PURPOSE

To examine differences in definitions of health care quality and the importance of indicators of quality between consumers with dependent children and consumers with no dependents.

STUDY DESIGN AND METHODS

This was an exploratory study using a convenience sample of 229 consumers--96 with one or more dependent children and 133 with no dependent children. Consumers were asked four open-ended questions as to their definitions of health care and nursing care quality. Consumers then rated the importance of 27 indicators of quality care.

RESULTS

There were no differences between parents with dependent children and other consumers in how quality care was defined. Important indicators of quality nursing care to parents with children were: Being cared for by nurses who are up to date, well informed, and certified in their specialty; being able to communicate with the nurse; spending enough time with the nurse; and teaching by the nurse. Although having access to midwives was of lowest importance to consumers overall, it was significantly more important to subjects with children (p < 0.05). Getting care and services when needed was also more important to parents than to consumers without children (p = 0.05). Parents gave more importance to their interactions with the nurse than did subjects without children (t = 1.93, df = 229, p = 0.05).

CLINICAL IMPLICATIONS

Parents and consumers without children have similar views of what constitutes quality nursing care--having nurses who are concerned about them and their children, demonstrating caring behaviors and staying attentive to their needs, being competent and skilled, communicating effectively, and providing the teaching needed for managing their own and their family's health problems.

Important attributes of quality health care: consumer perspectives

PURPOSE

Despite extensive research on defining and measuring health care quality, little attention has been given to consumers' perspectives of high-quality health care. The purposes of this study were to (a) identify the importance to consumers of attributes of health care quality and nursing care quality, and (b) examine the relationship of consumer perspectives to health status and selected demographic variables.

DESIGN

Exploratory. Consumers (N = 239) were recruited from waiting rooms of clinics and in neighborhoods of a large metropolitan area in the Midwestern United States that included both urban and suburban populations.

METHODS

Participants completed the Quality Health Care Questionnaire (QHCQ) and the SF-36 Health Survey. On the QHCQ, they rated the importance of 27 attributes of health care and nursing care quality. The SF-36 is a 36-item instrument for measuring health status in eight general areas.

FINDINGS

The most important indicators of high-quality nursing care to consumers were: being cared for by nurses who are up-to-date and well informed; being able to communicate with the nurse; spending enough time with the nurse and not feeling rushed during the visit; having a nurse teach about the illness, medications, treatments, and staying healthy; and being able to call a nurse with questions. The lowest-rated item was having an opportunity to be cared for by nurse practitioners. Ratings differed by race, age, years of education, income, and health status.

CONCLUSIONS

The importance that consumers place on teaching by the nurse was emphasized, particularly among people with less education, low income levels, and chronic illnesses.

Psychosocial adjustment, coping, and quality of life in persons with venous ulcers and a history of intravenous drug use

OBJECTIVE/PURPOSE

Psychosocial adjustment, coping, and quality of life for persons with a venous ulcer and a history of intravenous drug use were examined.

DESIGN

A cross-sectional design was used.

SETTING AND SUBJECTS

Data were collected in an urban outpatient clinic. All eligible persons were asked to participate. Thirty-two patients agreed to participate, providing an 89% response rate. The mean age of participants was 44.6 years (SD = 4.3); 91% were African American, and 72% were male.

INSTRUMENTS

Subjects responded to questions about their health and substance abuse history and completed the Quality of Life With a Leg Ulcer Questionnaire, Psychosocial Adjustment to Illness Scale (PAIS), Ways of Coping Instrument, and Pain Questionnaire. Leg ulcer tracings were measured with the SigmaScan computer program.

METHODS

Questionnaires were read to participants. Leg ulcers were traced at their borders onto plastic.

RESULTS

Wound area correlated significantly with the domestic environment (r = .43) and the psychosocial distress (r = .38) scores of the PAIS. Wound area was negatively correlated to Quality of Life With a Leg Ulcer Questionnaire score (r = -.52). Pain interference was significantly related to the self-controlling coping score (r = .40), domestic environment score of the PAIS (r = .51), and Quality of Life With a Leg Ulcer Questionnaire score (r = -.65). Cox and Wermuth's multiple regression modeling approach was used to summarize the study's variables.

CONCLUSIONS

A larger wound area was associated with greater illness-induced difficulties in the home environment, greater psychological distress, and poor quality of life. Pain Interference was associated with a greater effort to regulate one's feelings and actions, difficulties in the home, and poor quality of life.

Prevalence and types of wounds among children receiving care in the home

The purpose of this study was to determine the number of children with wounds receiving home care, determine the types of wounds among these children, and identify wound care products used in the treatment of children. This study was a multi-site, descriptive, cross-sectional, collaborative, study involving 13 home healthcare agencies and a university. Nurses (n = 281) were systematically selected to collect data for patients receiving home care visits during a 1-week period. The nurses recorded data on 77 children who ranged in age from less than 1 year to 18 years (mean = 3.1 years, SD = 4.72). The children included 47 males and 30 females, most of whom were African-American (n = 59). Among the 77 children, 16.9% had wounds. Children with wounds were significantly older and had more reasons for the home healthcare visit than children without wounds. The presence of a wound was not significantly related to the length of the visit, gender, or race. The most common wound was a surgical incision. The wound care treatments used most were tap water and gauze. In conclusion, wound care is frequently part of the care for a child in the home. Therefore, nurses need to be aware of wound assessment and wound care protocols that match a child's growth and development and family needs.

Couples' patterns of adjustment to colon cancer

The objectives for this longitudinal study were to: (a) compare colon cancer patients' and their spouses' appraisal of illness, resources, concurrent stress, and adjustment during the first year following surgery; (b) examine the influence of gender (male vs female) and role (patient vs spouse caregiver) on study variables; (c) assess the degree of correlation between patients' and spouses' adjustments; and (d) identify factors that affect adjustment to the illness. Fifty-six couples were interviewed at one week post diagnosis, and at 60 days and one year post surgery. Based on a cognitive-appraisal model of stress, the Smilkstein Stress Scale was used to measure concurrent stress; the Family APGAR, Social Support Questionnaire, and Dyadic Adjustment Scale were used to measure social resources; the Beck Hopelessness Scale and Mishel Uncertainty in Illness Scales were used to measure appraisal of illness; and the Brief Symptom Inventory and Psychosocial Adjustment to Illness Scale were used to measure psychosocial adjustment. Repeated Measures Analysis of Variance indicated that spouses reported significantly more emotional distress and less social support than patients. Gender differences were found, with women reporting more distress, more role problems, and less marital satisfaction, regardless of whether they were patient or spouse. Both patients and spouses reported decreases in their family functioning and social support, but also decreases in emotional distress over time. Moderately high autocorrelations and modest intercorrelations were found among and between patients' and spouses' adjustment scores over time. The strongest predictors of patients' role adjustment problems were hopelessness and spouses' role problems. The strongest predictors of spouses' role problems were spouses' own baseline role problems and level of marital satisfaction. Interventions need to start early in the course of illness, be family-focused, and identify the couples at risk of poorer adjustment to colon cancer.

Pain associated with venous ulcers in injecting drug users

Pain is a concern among people with venous ulcers. Although the prevalence is unknown, venous ulcers occur in those who have a history of illicit injecting drug use. The purpose of this study was to (a) examine the relationship between venous ulcer characteristics and pain severity, (b) ascertain factors that cause pain, (c) determine methods to alleviate pain, and (d) explore beliefs about pain medications among people with a history of injection drug use. Thirty-two patients answered pain and demographic questionnaires and had their venous ulcers traced onto plastic to identify wound area. Greater current pain, worse pain in 24 hours, and higher levels of pain relief from medications were significantly related to larger wound areas. Ibuprofen, compression dressing Unna's boot, and heroin ranked highest in decreasing pain. The most painful activities were working, walking outside, standing, and stair climbing. Many patients (41%) did not like to bother others with their complaints of pain. Participants were generally satisfied with pain treatments and the response of care providers to their pain. People who have used injected drugs and have venous ulcers do have pain. Therefore, research must continue to evaluate this pain as well as the best ways to treat it.

Prenatal cocaine exposure and child behavior

OBJECTIVE

The aim of this study was to evaluate previous teacher reports that children exposed to cocaine prenatally have more problem behaviors.

METHODS

A historical, prospective design was used. Maternal subjects (n = 116) of 6-year-old singleton, term (>/=36 weeks) children, and the children's first-grade teachers (n = 102) agreed to participate. The child's first-grade teacher, blinded to study design and exposure status, rated the child's behavior with the Conners' Teacher Rating Scales (CTRS) and an investigator-developed scale, the Problem Behavior Scale (PROBS 14), measuring behaviors reported by educators to be specific to cocaine exposure. Mothers were interviewed by telephone regarding demographic and socioeconomic factors.

RESULTS

Although the cocaine-exposed group had higher (more problem behaviors) for each of the CTRS subscales, the overall multivariate analysis of variance for the CTRS was not significant. Children exposed to cocaine prenatally had higher scores (more problem behaviors) for 11 of the 14 PROBS items and the overall multivariate analysis of variance relating prenatal cocaine exposure to the PROBS was significant (Wilkes' lambda =.775), even after controlling for gender and prenatal exposure to alcohol and cigarettes.

CONCLUSIONS

This pilot study supports that teachers blinded to exposure status of early elementary students did rate the cocaine-exposed group as demonstrating significantly more problem behaviors than control children. Although an important first step, postnatal factors that also may influence behavior were not evaluated; hence, causation is not addressed.

Prenatal coke: what's behind the smoke? Prenatal cocaine/alcohol exposure and school-age outcomes: the SCHOO-BE experience

Despite media reports and educators' concerns, little substantive data have been published to document or refute the emerging reports that children prenatally exposed to cocaine have serious behavioral problems in school. Recent pilot data from this institution have indeed demonstrated teacher-reported problem behaviors following prenatal cocaine exposure after controlling for the effects of prenatal alcohol use and cigarette exposure. Imperative in the study of prenatal exposure and child outcome is an acknowledgement of the influence of other control factors such as postnatal environment, secondary exposures, and parenting issues. We report preliminary evaluation from a large ongoing historical prospective study of prenatal cocaine exposure on school-age outcomes. The primary aim of this NIDA-funded study is to determine if a relationship exists between prenatal cocaine/alcohol exposures and school behavior and, if so, to determine if the relationship is characterized by a dose-response relationship. A secondary aim evaluates the relationship between prenatal cocaine/alcohol exposures and school achievement. Both relationships will be assessed in a black, urban sample of first grade students using multivariate statistical techniques for confounding as well as mediating and moderating prenatal and postnatal variables. A third aim is to evaluate the relationship between a general standardized classroom behavioral measure and a tool designed to tap the effects thought to be specific to prenatal cocaine exposure. This interdisciplinary research team can address these aims because of the existence of a unique, prospectively collected perinatal Database, funded in part by NIAAA and NICHD. The database includes repeated measures of cocaine, alcohol, and other substances for over 3,500 births since 1986. Information from this database is combined with information from the database of one of the largest public school systems in the nation. The final sample will be composed of over 600 first grade students for whom the independent variables, prenatal cocaine/alcohol exposures, were prospectively assessed and quantified at the university maternity center. After informed consent, the primary dependent variable, school behavior, is assessed, using the PROBS-14 (a teacher consensus developed instrument), the Child Behavior Check List, and the Conners' Teacher Rating Scale. The secondary dependent measure, school achievement, is measured by the Metropolitan Achievement Text and the Test of Early Reading Ability. Control variables, such as the environment and parenting, are measured by several instruments aimed at capturing the child and family ecology since birth. All analyses will be adjusted as appropriate for prospectively gathered control variables such as perinatal risk, neonatal risk, and other prenatal drug and cigarette exposures. Further adjustment will be made for postnatal social risk factors which may influence outcome. Of particular concern are characteristics of the home (adaptation of HOME), parent (depression, stress), and neighborhood (violence exposure). Finally, postnatal exposure to lead and other drugs is being considered.

Couples' adjustment to breast cancer and benign breast disease: a longitudinal analysis

A comprehensive comparison of couples' adjustment to benign (n = 73 couples) and malignant breast disease (n = 58 couples) at the time of diagnosis and at two follow-up assessments at 60 days and 1 year is reported. Specific objectives were to: (a) compare the concurrent stress, resources, appraisal, and patterns of adjustment of couples in the benign and malignant groups; (b) compare the psychosocial responses of patients versus spouses; and (c) determine the amount of correspondence in levels of adjustment reported by patients and their husbands over time. Multiple instruments with reported reliability and validity were used to measure study variables: Smilkstein Stress Scale, Dyadic Adjustment Scale, Family APGAR, Social Support Questionnaire, Mishel Uncertainty in Illness Scale, Beck Hopelessness Scale, Brief Symptom Inventory, and Psychosocial Adjustment to Illness Scale. Mixed design analyses of covariance (ANCOVA) were used to assess differences between and among couples and examine changes in study variables over time. Significant differences were found in the resources, appraisal, and patterns of adjustment reported by couples in the benign and malignant groups. Couples facing breast cancer reported greater decreases in their marital and family functioning, more uncertain appraisals, and more adjustment problems associated with the illness. In addition, there was a high degree of correspondence between the levels of adjustment reported by women with breast cancer and their husbands over time. Couples who reported high distress or a high number of role problems at diagnosis were likely to remain highly distressed at 60 days and 1 year. Study findings underscore the importance of assisting couples, not just patients, to manage the adjustment difficulties associated with breast cancer.

Couples' adjustment to breast cancer and benign breast disease: a longitudinal analysis

A comprehensive comparison of couples' adjustment to benign (n = 73 couples) and malignant breast disease (n = 58 couples) at the time of diagnosis and at two follow-up assessments at 60 days and 1 year is reported. Specific objectives were to: (a) compare the concurrent stress, resources, appraisal, and patterns of adjustment of couples in the benign and malignant groups; (b) compare the psychosocial responses of patients versus spouses; and (c) determine the amount of correspondence in levels of adjustment reported by patients and their husbands over time. Multiple instruments with reported reliability and validity were used to measure study variables: Smilkstein Stress Scale, Dyadic Adjustment Scale, Family APGAR, Social Support Questionnaire, Mishel Uncertainty in Illness Scale, Beck Hopelessness Scale, Brief Symptom Inventory, and Psychosocial Adjustment to Illness Scale. Mixed design analyses of covariance (ANCOVA) were used to assess differences between and among couples and examine changes in study variables over time. Significant differences were found in the resources, appraisal, and patterns of adjustment reported by couples in the benign and malignant groups. Couples facing breast cancer reported greater decreases in their marital and family functioning, more uncertain appraisals, and more adjustment problems associated with the illness. In addition, there was a high degree of correspondence between the levels of adjustment reported by women with breast cancer and their husbands over time. Couples who reported high distress or a high number of role problems at diagnosis were likely to remain highly distressed at 60 days and 1 year. Study findings underscore the importance of assisting couples, not just patients, to manage the adjustment difficulties associated with breast cancer.

Social context variables as predictors of smoking cessation

OBJECTIVE

To examine positive and negative social support and other selected social context variables (age, education, marital status, gender, and exposure to other smokers inside and outside the home) as predictors of smoking cessation in non-hospitalised adults with diagnosed cardiovascular disease at follow up after one, six, and 12 months.

DESIGN

Discriminant function analyses (DFA) and longitudinal "lag" analyses.

SUBJECTS

137 Non-hospitalised adults with diagnosed cardiovascular health problems.

RESULTS

Examination of the concurrent DFAs revealed significant univariate F ratios for the predictor variables of gender and marital status at one year and low negative support at all three follow ups. Quitters reported significantly lower levels of negative support than non-quitters over the course of the year and tended to be male and married. Longitudinal "lag" analyses, however, revealed that higher positive social support at one month and higher negative support at six months were both predictive of smoking cessation at one year. At one year more men than women and more married than not married smokers were successful in quitting. No effects for age, education, or exposure to others smoking inside or outside the home were found on any of the concurrent DFAs or longitudinal analyses.

CONCLUSION

A series of concurrent DFAs revealed that positive support was a significant predictor of quitting at one year and negative support was predictive of not quitting at all three follow ups. Longitudinal "lag" analyses showed that positive support at one month and negative support at six months both predicted quitting at one year. Being male and married were found to contribute to quitting on both sets of analyses. The effects for positive and negative support on the smoking behaviour of adults with cardiovascular disease tended to change over the course of a year. These findings suggest that positive and negative social support may have differential effects over time. As the smoker moves along the "quitting trajectory" it may be that more "nagging" or negative interactions are needed at some point to get smokers to quit, if positive support has not worked or is not working. Progression of disease also may have served as a stimulus for family members and friends to become more insistent and negative about the person's continued smoking. More research is needed to examine the quitting process to determine which and how social context variables contribute.

A comparison of nursing interventions for smoking cessation in adults with cardiovascular health problems

OBJECTIVE

To examine the relative effectiveness of three different presentations of a smoking cessation program on the smoking behavior of adults with cardiovascular health problems.

DESIGN

A 2 x 2 x 2 x 4 experimental design with stratification by sex, smoking history, and a cardiovascular event, and randomization to Individual, Group, Written, or No Intervention groups.

SETTING

Six community hospital classrooms.

SUBJECTS

255 nonhospitalized adults. THEORETIC FRAMEWORK: Interaction Model of Client Health Behavior.

MEASUREMENTS

Study Intake: Professional referral form, demographic questionnaire, smoking habits questionnaire, health history, perceived threat survey, perceived health status. Follow up: smoking cessation and health questionnaire, saliva thiocyanate testing.

RESULTS

At 12-month follow-up, a nurse-client interaction was more effective than written self-help materials; however, smoking cessation rates were highest in the No Intervention control group, possibly related to having had coronary artery bypass graft surgery. Variables positively related to quitting were being male and married and having a higher income. With baseline factors considered, a quitter was most likely to be male and less than 48 years of age, have a high degree of perceived threat relative to medical diagnosis, and be in the individual intervention group. Only partial support for the study hypotheses was found.