His 9

1701: Public Health Rev. 1998;26(1):73-7.
Sources of nutritional data in Israel.
Kaluski DN, Meir C, Rotem N, Zadka P.
Department of Nutrition, Ministry of Health, Jerusalem, Israel.
PMID: 9775724 [PubMed - indexed for MEDLINE]
1702: Public Health Rev. 1998;26(1):55-63.
Experiences with dietary assessment in the Middle East.
Harrison GG.
Department of Community Health Sciences, UCLA School of Public Health and

Associate Director, UCLA Center for Human Nutrition 90095, USA.
1703: Occup Environ Med. 1998 May;55(5):300-9.
Comprehensive evaluation of long-term trends in occupational

exposure: Part 1. Description of the database.
Symanski E, Kupper LL, Rappaport SM.
University of Texas Health Science Center, Houston, School of Public Health

77030, USA.
OBJECTIVES: To conduct a comprehensive evaluation of long term changes in

occupational exposure among a broad cross section of industries worldwide.
METHODS: A review of the scientific literature identified studies that reported
historical changes in exposure. About 700 sets of data from 119 published and
several unpublished sources were compiled. Data were published over a 30 year
period in 25 journals that spanned a range of disciplines. For each data set, the
average exposure level was compiled for each period and details on the
contaminant, the industry and location, changes in the threshold limit value
(TLV), as well as the type of sampling method were recorded. Spearman rank
correlation coefficients were used to identify monotonic changes in exposure over
time and simple linear regression analyses were used to characterise trends in
exposure. RESULTS: About 78% of the natural log transformed data showed
linear trends towards lower exposure levels whereas 22% indicated increasing
trends. (The Spearman rank correlation analyses produced a similar breakdown
between exposures monotonically increasing or decreasing over time.) Although
the rates of reduction for the data showing downward trends ranged from -1% to -
62% per year, most exposures declined at rates between -4% and -14% per year
(the interquartile range), with a median value of -8% per year. Exposures seemed
to increase at rates that were slightly lower than those of exposures which have
declined over time. Data sets that showed downward (versus upward) trends were
influenced by several factors including type and carcinogenicity of the
contaminant, type of monitoring, historical changes in the threshold limit values
(TLVs), and period of sampling. CONCLUSIONS: This review supports the
notion that occupational exposures are generally lower today than they were years
or decades ago. However, such trends seem to have been affected by factors
related to the contaminant, as well as to the period and type of sampling.
Publication Types:
• Research Support, U.S. Gov't, P.H.S.

• Review
PMCID: PMC1757580
1704: J UOEH. 1998 Sep 1;20(3):201-12.
[A plan of the life-long learning support system of UOEH--

possibility for the introduction of distance learning system by the
Internet]
[Article in Japanese]
Matsuda S, Funatani F.
Department of Preventive Medicine and Community Health, School of Medicine,

Kitakyushu, Japan.
In order to keep up with the rapid advance in knowledge and skills in various
industrial sectors, the needs for the life-long learning has increased recently. This
is also the case for the University of Occupational and Environmental Health,
Japan, which has as its aim the education of occupational health specialists. In
fact, there are many universities and colleges which have organized some post-
graduate courses for the workers. However, most of these courses are for workers
who can come to classes in the daytime or evening. In the case of UOEH, it is not
enough to organize such type of classes in order to respond to the social needs,
because it has to offer an opportunity of life-long learning for all occupational
health specialists in all parts of Japan. In order to solve this problem, it is
recommended that a distance learning system based on modern information
technology such as the internet be organized. In this report, the authors present the
distance learning system of Wisconsin University in the USA, and that of
Tamagawa Gakuen University of Japan. After evaluating these two systems, a
plan for a life-long learning support system of UOEH is suggested, which consists
of a distance learning system based on the internet.
Publication Types:
• English Abstract
1705: Int J Epidemiol. 1998 Aug;27(4):672-6.
Comparison of key informant and survey methods for ascertainment

of childhood epilepsy in West Bengal, India.
Pal DK, Das T, Sengupta S.
Neurosciences Unit, Institute of Child Health, University College London, UK.
BACKGROUND: This study aimed to compare efficacy and cost of key

informants and survey for ascertainment of childhood epilepsy within a treatment
context in rural India. METHODS: The study was set in a non-governmental,
community programme for the functional and socioeconomic rehabilitation of
children with disabilities in rural West Bengal, India. Ascertainment was by two
methods: house-to-house survey of 15000 households and also by 430 key
informants including village leaders, health workers and 670 schoolchildren.
Methods were compared for positive predictive value, and sensitivity by capture-
recapture technique. Ninety four children were enrolled into treatment. Predictors
of treatment success were determined by multiple logistic regression analysis,
giving adjusted odds ratios for remission. The costs of identifying one case and
one treatment success were measured by costing personnel, materials and
overheads. RESULTS: The survey was four times as sensitive as key informants
although the positive predictive values were similar (36%, 40%). The survey had
an absolute sensitivity of only 59%. Identification by key informants strongly
predicted successful treatment outcome (odds ratio [OR] = 4.74, 95% confidence
interval [CI] : 1.19-18.85). The cost of finding one case was US$11 and US$14,
and of finding one successful treatment outcome US$35 and US$67 for
informants and survey respectively. Key informants were essential in attaining
longer term programme objectives. CONCLUSIONS: In the context of a
treatment programme, key informants were the more cost-effective method, but
community involvement was traded against low sensitivity in the short term.
Overall ascertainment costs were significant in the context of primary health care
in India.
PIP: Epilepsy is the most important neurological problem in developing countries,

with a total of 50 million people worldwide having the condition. 33 million of
these cases are children in developing countries, of whom 90% are untreated. To
determine the number of children with active epilepsy in a given developing
country community, previous studies have either ascertained information directly
from key informants in the community or through more broad-based two-stage
surveys. Findings are reported from a study conducted in 46 villages of district 24
Parganas South, a rural district south of Calcutta, comparing the two approaches'
sensitivity, efficacy, and costs. Village leaders, health workers, and students were
interviewed as key informants, while house-to-house surveys were conducted in
15,000 households. The survey was 4 times as sensitive as the key informant
approach, although the approaches had similar positive predictive values. The
survey had an absolute sensitivity of 59%. Case identification by key informants
strongly predicted successful treatment outcomes. The cost of finding 1 case was
US$11 and US$14, and of finding one successful treatment outcome US$35 and
US$67 for informants and survey, respectively. The use of key informants was
essential to attaining longer-term program objectives.
Publication Types:
• Comparative Study
• Research Support, Non-U.S. Gov't
1706: Int J Med Inform. 1998 Jul;51(1):59-68.,
MERIT-9: a patient information exchange guideline using MML,

HL7 and DICOM.
Kimura M, Ohe K, Yoshihara H, Ando Y, Kawamata F, Tsuchiya F,

Furukawa H, Horiguchi S, Sakusabe T, Tani S, Akiyama M.
Department of Medical Informatics, School of Medicine, Hamamatsu University,

Japan. kimura@hama-med.ac.jp
To realize clinical data exchange between healthcare providers, there must be

many standards in many layers. Terms and codes should be standardized, syntax
to wrap the data must be mutually parsable, then transfer protocol or exchange
media should be agreed. Among many standards for the syntax, HL7 and DICOM
are most successful. However, everything could not be handled by HL7 solely.
DICOM is good for radiology images, but, other clinical images are already
handled by other 'lighter' data formats like JPEG, TIFF. So, it is not realistic to
use only one standard for every area of clinical information. For description of
medical records, especially for narrative information, an standard generalized
mark-up language, document type definition (SGML DTD) for medical
information, called MML (medical markup language) had been created in Japan.
It is already implemented in more than ten healthcare providers. However, it is
again not realistic to use MML solely for clinical information in various level of
detail. Therefore, we proposed a guideline for use of available medical standards
to facilitate clinical information exchange between healthcare providers. It is
called MERIT-9 (Medical Records, Images, Texts, -Information Exchange). A
typical use is HL7 messages, DICOM files, referred from an MML file in a
patient record, as external entities. Both MML and MERIT-9 have been research
projects of Japanese Ministry of Health and Welfare and the purpose is to
facilitate clinical data exchanges. They are becoming to be used in technical
specifications for new hospital information systems in Japan.
1707: J Biosoc Sci. 1998 Jul;30(3):333-48.
Infant and child mortality in Bangladesh: age-specific effects of

previous child's death.
Alam N, David PH.
Health and Population Surveillance Programme, International Centre for

Diarrhoeal Disease Research, Dhaka, Bangladesh.
This study examines whether mortality of two adjacent siblings in families is age-
specific and is modified by the MCH-FP programme and fertility and mortality
declines in Matlab, Bangladesh, using data for singleton births during 1977-78,
1985-86 and 1989-90 in the treatment (MCH-FP) and comparison areas. Logistic
regression was used to estimate the net effects of survival status of elder siblings
on mortality of younger siblings in the neonatal, postneonatal and toddler periods,
controlling for birth order, previous birth interval, maternal age, education and
religion, household possession of valuable items and sex of the child. Odds of
neonatal and postneonatal deaths of younger siblings were found to be higher if
the elder sibling had died at the same age than if the sibling had survived infancy.
Toddler mortality was lower if the elder sibling had died in infancy. The
association between two siblings'mortality risks did not decline over time in either
area. The results suggest that a family history of child deaths by age is important
to identify when subsequent infants would be at a higher risk of dying.
PIP: This study examined the patterns of 2 adjacent siblings' mortality risk at
different ages in 3 birth cohorts in treatment and comparison areas of Matlab,
Bangladesh. Data were obtained from records of the Matlab demographic
surveillance system and Matlab Household Socioeconomic Censuses in 1974 and
1982. The sample included singleton births occurring in 1977-78, 1985-86, and
1989-90. Findings indicate that the odds of neonatal and postneonatal deaths of
index children were higher, if an elder sibling had died at the same age. Toddler
mortality was lower, if the older sibling had died as an infant. In the 2 later
cohorts, the odds of neonatal deaths were very high among cases where the
survival status of the older sibling was unknown. The odds of neonatal death were
significantly higher, if the elder sibling died in the neonatal period rather than as a
toddler. A short preceding birth interval and higher birth order were associated
with higher odds of neonatal deaths. In all 3 cohorts, the odds of postneonatal
mortality were significantly higher if the elder sibling had died in the postneonatal
period rather than as a toddler. Infant death of an older sibling reduced the odds of
a toddler death in the 1985-86 cohort. Program factors did not reduce siblings'
shared mortality risk. The odds of dying were lower in later cohorts. Mortality
decline was faster in the toddler group. Findings suggest family factors associated
with infant mortality risk were not associated with the absolute level of mortality.
Higher order births had higher mortality risk at all ages. The age pattern of sibling
mortality risk varied widely by all factors.
1708: Bull World Health Organ. 1998;76(3):237-44.
WHO Global Oral Data Bank, 1986-96: an overview of oral health

surveys at 12 years of age.
Nithila A, Bourgeois D, Barmes DE, Murtomaa H.
Division of Noncommunicable Diseases, World Health Organization, Geneva,

Switzerland.
The global oral health situation of 12-year-old children--decayed, missing, filled

teeth (DMFT) index and the percentage of population affected--is described in
this article using the latest representative studies for 80 countries included in the
WHO Global Oral Data Bank (GODB) between 1986 and 1996. The quantity of
information varied considerably: 68% of developed market economies had at least
one national data set, compared with 38% of developing countries and 36% of
economies in transition. By WHO region, the proportions were as follows:
Eastern Mediterranean, 55%; European, 50%; Western Pacific, 48%; African,
39%; South-East Asia, 30%; and the Americas, 26%. Globally, the weighted
DMFT index for all data in the GODB is < 3.0%, the WHO/Fédération Dentaire
Internationale goal for the year 2000. For the data reviewed in this article,
achievement and nonachievement of this goal are discussed, as is the variation in
DMFT means and proportions of children affected for various country groupings.
There are difficulties in obtaining recent data for many countries, but the article
emphasizes the need to maintain and develop the GODB to facilitate the
compilation of valid, reliable and comparable data on oral health.
1709: Eff Clin Pract. 1998 Oct-Nov;1(2):90-3.
Computer-prompted diabetes care.
Spero M, Kenet A, Porter B.
Maccabi Health Care Services, Jerusalem, Israel.
1710: Int J Med Inform. 1998 Mar;49(1):53-8.
Related Articles, Links
Development of the electronic health record in Japan.
Yoshihara H.
Medical Information Centre, Miyayaki Medical College Hospital, Japan.
In Japan, the order entry system has been employed in almost all university
hospitals and popularisation of this system has also started in medium-sized
hospitals. However, there has been a tendency in general hospitals in Japan to
consider the electronic chart system where there has been no order entry system.
Moreover, in small-scale clinics, there is no benefit in using the order entry
system. Young doctors in Japan are beginning to employ the electronic chart
system directly for the first time, without experience with the order entry system.
In this paper, the development of the hospital information system in Japan and
that of the electronic health record system are described.
1711: Rinsho Byori. 1998 Jul;46(7):699-705.
The status and future of clinical pathology in Korea.
Cho HI.
Seoul National University Hospital, Korea.
Since its introduction half a century ago, modern clinical pathology in Korea has
become an essential part of medical practice. The foundations of such fast
development are manpower development systems, the government-certified
clinical pathologist board system, the medical technologist license system, a
medical insurance system providing universal coverage and the decisive
introduction of modern technologies. Current issues in clinical pathology are the
below cost fee system, the high rate at which claims are rejected, the
government's intention to introduce an alternative fee system and 'overheated'
competition among commercial laboratories. The 'fee-for-service system'
inducing deviated medical practices and low publicity for the discipline-leading to
reduction in the number of applications for residency-are serious issues which
demand a solution. For continuing success, total laboratory automation (TLA),
together with information and core laboratory systems, and an accreditation and
audit system must be introduced. Clinical pathologists should, in addition, be
trained as laboratory physicians. To extend laboratory usage by developing new
demands and needs and expanding the future market for laboratories, effective
publicity campaigns through the mass media and internet should be emphasized.
1712: Rinsho Byori. 1998 Jul;46(7):695-8.
[Laboratory medicine in Taiwan]
Chen JS.
Department of Laboratory Medicine, National Taiwan University Hospital, Taipei

Institute of Pathology, Taiwan.
Laboratory medicine and hospital central laboratory system were adopted in

Taiwan after World War II. In medical schools, laboratory medicine or clinical
pathology teaching is allocated to junior students. Three years of clinical
pathology or four years of anatomical pathology training is required for pathology
resident. Recent trend indicates that both the hospitals and the young doctors
favor the five years combined C.P. (two-years) and A.P. (three years) training
program. At present, 75 clinical pathologists and 213 anatomical pathologists are
qualified. Approximately 70% of them work in medical centers and medical
schools. Consequently, the medium and small size hospitals suffer from serious
shortage of pathologist. Studies during the part 50 years indicate substantial
difference in the improvement of laboratory medicine and central laboratory
before and after 1975. Significant improvement in the working space, facility,
equipment, staff, quality control and productivity was evident after 1975. The
three health care policies contributing to the overall improvement are: 1. hospital
accreditation project, 2. medical care network plan, and 3. medical specialist
system.
Publication Types:
1713: Soc Sci Med. 1998 Jul;47(2):255-67.
Can prostitutes marry? Thai attitudes toward female sex workers.
Peracca S, Knodel J, Saengtienchai C.
Population Studies Center, University of Michigan, Ann Arbor 48104, USA.
This study explores popular attitudes towards female sex workers in Thailand by
examining the general public's perceptions of a prostitute's ability to marry based
on focus group data. The tentative conclusion emerging from our findings that the
general public believes sex workers can marry is that a relative lack of severe or
lasting social stigma is an important part of a Thai context that facilitates
recruitment into prostitution and permits it to persist on a widespread scale. We
interpret this conclusion in terms of the broader value system in Thai society.
Although our findings are implicitly comparative in nature, a lack of comparable
information from other countries on how those who provide commercial sex are
viewed by the general population prevents a more definitive conclusion. There is
an obvious need for research on this topic as well as on how sex workers view
themselves, and how this translates into actual behavior. Data set used: focus
group transcripts from the project "The influence of primary female partners and
male peers on male extramarital sexual behavior in Thailand".
Publication Types:
1714: Br J Fam Plann. 1998 Jul;24(2):75-7.
Contraceptive practices of women living in rural areas of Bihar.
Kumari C.
Bihar State Health Services, Bihar, India.
A prospective survey of 972 married (sexually active) women living in rural areas
of Lalganj block of Vaishali district in Bihar state of India was carried out. The
study was aimed at obtaining first hand information from the rural women
regarding their contraceptive practices and to use the information thus gained to
identify those spheres of concern where greater attention needs to be paid to make
the family planning system more efficient. The population investigated consisted
of women attending the combined obstetric and gynaecology clinic located at
Lalganj. Tubal sterilisation was the commonest method of contraception among
women surveyed ( 20.6 per cent of women). The incidence of sterilisation
increased significantly as the age increased-11.6 per cent of women aged 21 to 30
had tubal sterilisation, whereas the incidence was 51 per cent in women aged 31
to 40 years. Reversible forms of contraception (IUD, oral pills and condoms) were
used by only 6.8 per cent of women included in the study. Married girls aged 15
to 20 were not using any contraceptive. It was also noted that none of the women
surveyed had used any contraceptive prior to her first pregnancy. Fortyper cent of
women in the age group 21 to 30 years and a similar percentage (41.1 per cent) in
the age group 31 to 40 years had two or more live children but did not use any
contraceptive. The results reveal that tubal sterilisation is the most popular
method of contraception among women living in rural areas of the state. Birth
spacing, or delaying the birth of the first child by the use of reversible forms of
contraception, is not the common practice among these women.
PIP: Bihar, one of India's most populous states, has a population of approximately
94.9 million and a crude birth rate of 30.7/1000. At the time of India's 1994
National Family Health Survey, the state had a contraceptive prevalence rate of
only 26%. 86.8% of Bihar state's population is rural. 972 sexually active, married
women living in rural areas of Lalganj block of Vaishali district, Bihar state, were
prospectively surveyed to learn about their contraceptive behavior and to use
lessons learned to identify ways in which the family planning system should be
improved. Study participants were recruited while attending the combined
obstetric and gynecology clinic in Lalganj. Only 6.8% of the women used
reversible forms of contraception such as the IUD, oral pills, and condoms.
However, 20.6% of the women used tubal sterilization, the most commonly
practiced method of contraception. The incidence of sterilization increased
significantly as age increased; 11.6% of women aged 21-30 years had undergone
the procedure, compared to 51% of women aged 31-40 years. Married women
aged 15-20 years were using no contraception. In fact, no woman surveyed had
used any contraception before her first pregnancy. 40.3% of women aged 21-30
years and 41.1% aged 31-40 had 2 or more living children, but used no
contraception.
1715: Vox Sang. 1998;74 Suppl 2:409-17.
Requirements for the electronic crossmatch.
Judd WJ.
Department of Pathology, University of Michigan, Ann Arbor, USA.

johnjudd@umich.edu
With the integration of laboratory information systems into transfusion services, it

is now possible to develop standard operating procedures (SOPs) for an electronic
crossmatch (EXM) to replace the immediate-spin crossmatch for detecting ABO
incompatibility between the blood sample submitted for pre-transfusion testing
and the donor unit selected for transfusion. Essential to the safety of an EXM are
requirements that: 1) the computer contains logic to prevent assignment and
release of ABO incompatible blood; 2) no clinically significant antibodies are
detected in the recipient's serum/plasma and there is no record of previous
detection of such antibodies; 3) there are concordant results of at least two
determinations of the recipient's ABO type on record, one of which is from a
current sample; 4) critical elements of the system have been validated on-site;
and, 5) there are mechanisms to verify the correct entry of data prior to release of
blood. EXM procedures are in use in at least 10 North American facilities,
Scandinavia, Hong Kong and Australia. Some provide blood at remote sites
lacking laboratory services. Experience has shown that a combination of properly
programmed computer software and carefully developed SOPs can provide a safe
and efficient means of detecting ABO incompatibility without performing a
serological crossmatch.
Publication Types:
• Review
1716: Nihon Arukoru Yakubutsu Igakkai Zasshi. 1998 Jun;33(3):225-33.
[Coordination or competence: an emerging problem in the

development of network treatment for alcoholics]
Shimizu S.
National Institute of Mental Health, NCNP, Chiba, Japan.
The author recognizes the significance and relevance of the network treatment for
alcoholics is such a way as an effort to respond not only to the medical needs but
also to social service needs, in order to support the recovery of alcoholics.
Consequently we are faced to an indispensable task to look back historically the
developmental process of the treatment service for alcoholics in Japan. A recent
policy development in the alcohol treatment is stimulating the shift from the
overweight medical approach to a more comprehensive approach including social
services. This innovation is bringing about not only a wider treatment options but
also a newly emerging problem of "coordination or competence" as well. It was
implied in this paper that a concept of "shared function" is promising to consider
this new problem.
Publication Types:
• Review
1717: Nihon Arukoru Yakubutsu Igakkai Zasshi. 1998 Jun;33(3):219-24.
[Dealing with alcoholism--networking of social resources in Kochi

prefecture]
Takeshima T, Tani N.
National Institute of Mental Health, NCNP, Ichikawa, Japan.
1718: Soc Sci Med. 1998 Sep;47(5):613-20.
Disparity of medical care utilization among different health

insurance schemes in Taiwan.
Cheng SH, Chiang TL.
Graduate Institute of Public Health and Center for Health Policy Research,
National Taiwan University, College of Public Health, Taipei.
Potential excess use of health care services caused by insurance has been a major
concern for almost every industrialized county. Moral hazard problems and fee-
for-service payment methods are considered to be important factors for higher
medical care utilization among those insured. Health care availability is another
feature reportedly associated with health care use. Using the data from a National
Health Interview Survey in Taiwan in 1990, this study examined differences in
medical care utilization by beneficiaries under three major social insurance plans
(i.e. Labor Insurance-LI, Government Employees' Insurance-GEI, and Farmers'
Insurance-FI) which covered about half the population at that time. Logistic and
Poisson regression models were applied to examine the effects of relevant factors
on the probability and volume of physician visits. Results from the analyses
revealed that (1) persons with different insurance plans had a similar higher
probability of seeing a doctor than the uninsured, with the odds ratios ranged from
1.8 to 2.0. Also (2) the LI/FI participants consumed 60 73% more physician
services than the uninsured, while the GEI enrollees utilized only 30% more
physician services. Findings from our study concerning the access and use of
physician services in different insurance plans provide some useful information
for reforming a health care delivery system.
Publication Types:
1719: J Med Syst. 1998 Aug;22(4):203-10.
Coding medical information: classification versus nomenclature and

implications to the Israeli medical system.
Vardy DA, Gill RP, Israeli A.
Soroka University Medical Center, Beer-Sheva, Israel.
The efficient retrieval of medical information is essential for all functional aspects
of a health system. Such retrieval is possible only by coding data (as it is
produced or after it is produced) and entering it into a data-base. The
completeness and accuracy of retrieved information depend, therefore, on the
coding system employed. The main coding system that is in use in Israel is the
ICD-9: International Classification of Diseases and its clinical modification (ICD-
9-CM). Using such a statistical classification system for coding has met the basic
needs for statistical and administrative purposes, but causes distortion and loss of
information. With the recent growth and availability of information technology,
more detailed data can be coded and processed than was possible before. A
detailed nomenclature system such as SNOMED (the Systematized Nomenclature
Of Human and Veterinary Medicine) can be used as a coding system that enables
a more comprehensive and flexible medical information data base. This article
discusses some aspects of coding medical information and suggests that a national
revision of medical coding systems be considered as the computerized-patient-
record is further developed and implemented.
Publication Types:
1720: Soc Work Health Care. 1998;27(4):83-96.
Mass casualties: an organizational model of a hospital information

center in Tel Aviv.
Drory M, Posen J, Vilner D, Ginzburg K.
Social Work Department, Tel Aviv Sourasky Medical Center, Israel.
The article describes an organizational model of an information center, developed

by the social work department of Tel Aviv Sourasky Medical Center. The
information center is designed to provide information when mass casualties are
brought to the hospital following terrorist attacks or other catastrophes. The
information center is comprised of a number of interrelated units within the
hospital and is in contact with a range of organizations in the community. The
structure and activities of the various units is described. The article also discusses
a number of aspects relevant to personnel organization in crisis intervention.
1721: Soc Sci Med. 1998 Jun;46(12):1587-98.
Contextual determinants of maternal mortality in rural Pakistan.
Midhet F, Becker S, Berendes HW.
National Institute of Child Health and Human Development, Bethesda, MD

20892, USA.
Maternal mortality is high in Pakistan, particularly in the rural areas which have
poor access to health services. We investigated the risk factors associated with
maternal mortality in sixteen rural districts of Balochistan and the North-West
Frontier (NWFP) provinces of Pakistan. We designed a nested case-control study
comprising 261 cases (maternal deaths reported during last five years) and 9135
controls (women who survived a pregnancy during last five years). Using
contextual analysis, we estimated the interactions between the biological risk
factors of maternal mortality and the district-level indicators of health services.
Women under 19 or over 39 yr of age, those having their first birth, and those
having a previous history of fetal loss were at greater risk of maternal death.
Staffing patterns of peripheral health facilities in the district and accessibility of
essential obstetric care (EOC) were significantly associated with maternal
mortality. These indicators also modified the effects of the biological risk factors
of maternal mortality. For example, nulliparous women living in the under-served
districts were at greater risk than those living in the better-served districts. Our
results are consistent with several studies which have pointed out the role of
health services in the causation of maternal mortality. Many such studies have
implicated distance to hospital (an indicator of access to EOC) and lack of
prenatal care as major determinants of maternal mortality. We conclude that better
staffing of peripheral health facilities and improved access to EOC could reduce
the risk of maternal mortality among women in rural Balochistan and the NWFP.
Publication Types:

1722: Injury. 1998 Jan;29(1):43-6.
Structure and process components of trauma care services in Israeli

acute-care hospitals.
Ben Abraham R, Heruti RJ, Abramovitch Y, Marganit B, Shemer J, Stein

M.
Israel Defense Force, Medical Corps, Israel.
In recent years a vigorous effort has been made to improve primary trauma care in
Israel. The Ministry of Health and other authorities have invested in new facilities
in various hospitals which are engaged in trauma care. A survey was conducted in
order to identify deficiencies in organization, personnel and equipment required to
provide optimal trauma care. A cross-country survey was conducted by using a
questionnaire that dealt with structure and process components of trauma care.
The questionnaire was submitted to medical directors of emergency departments
in all 24 acute-care hospitals in Israel. Additional information was obtained by a
telephone poll when required. Inter-hospital variation concerning structure of
trauma services, protocols and qualification of manpower responsible for primary
care of the injured was found. The conclusions are that an increase in
homogeneity in the field of trauma care is still needed. A continuous effort should
be made in order to structurally and functionally further develop independent
trauma units in all hospitals in Israel. Methods should be found to encourage
young physicians to enter the field of trauma care. The establishment of a
nationwide trauma registry system will undoubtedly contribute to future
improvement in the initial care of the injured in Israel.
1723: Methods Inf Med. 1998 Jun;37(2):147-50.
Dietary balance chart for an on-line computerized graphical support

system in MHTS.
Hinohara S, Nishino R, Nakazato R, Takahashi T, Matsumoto H, Hori S,

Masuyama Y, Hinohara S, Horie M, Robinson D.
St. Luke's International Hospital, Nihon Medical University, Tokyo, Japan.
Dietary habits are believed to play an important role in the etiology of adult
disease. For this reason, it is necessary to include effective dietary guidance in
multiphasic health testing and services (MHTS) programmes for primary disease
prevention. We have developed such a programme of simple dietary advice, using
a computer system for the MHTS. Examinees' dietary habits are checked using
optical character record (OCR) questionnaire forms, and the results are displayed
on the screen of a colour display terminal. They are required to prepare a menu of
their usual daily dietary intake in terms of quantity and type of food. Thus the data
collected relate to the nutritional composition of the examinee's usual diet.
Nutritional requirements of the Japanese according to sex, height, and level of
physical activity, in accordance with criteria set by the Japanese Ministry of
Health and Welfare, are fed into the computer in advance. For each examinee,
these criteria and the results of the assessment of the diet are displayed together
on the screen in the form of colour graphs for comparison.
1724: Methods Inf Med. 1998 Jun;37(2):130-3.
HRA model for hypercholesterolemia based on a longitudinal health

database.
Takahashi E, Kishimoto T, Iida Y, Yoshida K, Miyakawa M, Sugimori H,

Izuno T, Okazaki N, Tamura M, Hinohara S.
Dept of Preventive Medicine, St. Marianna University School of Medicine, Japan.
To evaluate the risk factors for hypercholesterolemia, we examined 4,371 subjects

(3,207 males and 1,164 females) who received medical checkups more than twice
at an AMHTS in Tokyo during the period from 1976 through 1991; and whose
serum total cholesterol was under 250 mg/dl. The mean follow-up duration was
6.6 years. A self-registering questionnaire was administered at the time of the
health checkup. The endpoint of this study was the onset of hypercholesterolemia
when the level of serum total cholesterol was 250 mg/dl and over. We compared
two prognosis groups (normal and hypercholesterol) in terms of age, examination
findings and lifestyle. After assessing each variable, we employed Cox's
proportional hazards model analysis to determine the factors related to the
occurrence of hypercholesterolemia. According to proportional hazards model
analysis, total cholesterol, triglyceride and smoking at the beginning, and
hypertension during the observation period were selected in males; and total
cholesterol at the beginning and age were selected in females to determine the
factors related to the occurrence of hypercholesterolemia.
Publication Types:
1725: Acad Med. 1998 Jun;73(6):662-8.
Considering primary care in Japan.
Otaki J.
Primary Care Unit, Hokkaido University Medical Hospital, Sapporo, Japan.
Involved in global competition and with a rapidly aging population, Japan is

experiencing major reform in its medical care system and medical education
system. Although compulsory national health insurance and accessibility to
medical care are supported by the overwhelming majority of the Japanese people,
rapidly increasing medical costs have been an important problem. The Japanese
government is in the midst of changing the health insurance system from fee-for-
service to capitation, and it moved in the 1980s to reduce the number of new
physicians as a way to control expenditures. With the lessening of government
regulation in the 1990s, each medical school has begun to revise its curriculum to
cope with the increasing amount of medical information available and to promote
efficient learning. Because postgraduate clinical training programs with defined,
comprehensive curricula are rare, and because virtually all clinical training is in
inpatient settings, Japanese physicians' clinical competence tends to be
insufficient for providing first-class community-based primary care. Japan must
try to develop effective education systems in order to deliver better and more
efficient medical care, especially primary care.
Publication Types:
1726: Health Policy. 1998 Aug;45(2):99-117.
Evaluating the Israeli health care reform: strategy, challenges and

lessons.
Gross R, Rosen B, Chinitz D.
JDC-Brookdale Institute, Jerusalem, Israel. Revital@JDC.org.il
Evaluating the implementation of health care reform provides important

information on its effect, as well as a factual basis for deciding upon mid-course
modifications. Although researchers in various countries are addressing the
impact of reform, only few governments have initiated a structured, planned
evaluation to accompany reform efforts. In Israel, the 1995 National Health
Insurance Law earmarked 0.1% of the health care budget for research on the law,
coordinated by the National Institute for Health Policy and Health Services
Research. This paper describes the evaluation strategy of the JDC-Brookdale
Institute which is taking part in the research efforts. Implementation of the
evaluation strategy and the challenges of evaluating a major reform of the health
system are discussed. The evaluation strategy combines elements of formative
and summative evaluation using a 'case study' approach which seeks to integrate
in-depth understanding of the changing health system and of health care
provider's organizational behavior, with a variety of outcome measures. The
Israeli case provides support for the proposition that an integrated approach to
evaluating health reform provides a better understanding of the subject under
review and thus a better basis for making useful recommendations to policy
makers. In addition, such an approach enhances the validity and credibility of the
data and thus the probability of making an impact, which is a main objective of
formative evaluation. Examination of the Israeli case, provides important insights
about evaluation of health system reform, and may benefit researchers in other
countries attempting to evaluate health care reform.
Publication Types:
1727: Healthc Inform. 1998 Aug;15(8):50-2, 54, 56-8 passim.
Payoff in the pacific.
Schneider P.
Asia Pacific economies are struggling to cope with the past year's series of
financial catastrophies and regain the market stature and confidence they once
enjoyed. Despite the turmoil, all industries including healthcare continue to
demonstrate their commitment toward privatization and modernization through
technology. Advances in healthcare IT in the Asia Pacific region are narrowing
the differences in healthcare between East and West. Is the information age
speeding healthcare toward a global standard?
1728: Bull World Health Organ. 1998;76(2):161-71.
Causes of childhood deaths in Bangladesh: results of a nationwide

verbal autopsy study.
Baqui AH, Black RE, Arifeen SE, Hill K, Mitra SN, al Sabir A.
International Centre for Diarrhoeal Disease Research, Bangladesh.

While knowledge of causes of deaths is important for health sector planning, little
is known from conventional sources about the causes of deaths in Bangladesh.
This is partly due to deficiencies in the registration system and partly because few
deaths are attended by qualified physicians. The present study was undertaken to
update the information available on causes of deaths among under-5-year-olds,
taking advantage of advances in verbal autopsy methodology and of the national
Bangladesh Demographic and Health Survey conducted in 1993-94. About 25%
of the deaths were associated with acute lower respiratory infections (ALRI) and
about 20% with diarrhoea. Neonatal tetanus and measles remained important
causes of death, and drowning was a major cause for 1-4-year-olds. Research and
programmes to enable mothers to identify ALRI cases, particularly pneumonia,
and to encourage timely and appropriate care-seeking and strengthening of ALRI
case management at the primary care facilities are important priorities. While
promotion of oral rehydration for watery diarrhoea and antibiotic treatment for
dysentery should continue, broader preventive interventions including provision
of safe water and sanitation, and improvements in personal hygiene require more
attention. Further intensification of immunization programmes and innovative
experimental interventions to reduce childhood from drowning should be
designed and tested.
PIP: Advances in verbal autopsy methodology and the availability of the 1993-94
Bangladesh Demographic and Health Survey data enabled an analysis of causes
of childhood deaths in Bangladesh. Few deaths in Bangladesh are attended by
qualified physicians and the registration system is deficient, making mortality
analyses difficult with conventional sources. A follow-up survey of the 828 deaths
of children under 5 years occurring in the 5 years preceding the 1993-94 survey
was conducted in 1995. 311 deaths involved neonates, 232 occurred in the 1-11
month age group, and 285 were among children 12-59 months of age. 24.2% of
deaths (40% of the infant deaths) were associated with acute lower respiratory
infection (ALRI), 19.0% with diarrhea, 8.8% were due to accidents, and 5.4%
were related to neonatal tetanus. Drowning accounted for 18.9% of deaths among
1-4 year olds. Malnutrition was associated with a third of the respiratory
infections and half the diarrhea deaths. Urban deaths represented less than 10% of
the total, but maternal educational status was not associated with different patterns
of child mortality. Girls were less likely than boys to die from ALRI and more
likely to die from malnutrition, measles, and diarrhea. Early recognition of
pneumonia cases and appropriate care-seeking by parents, use of properly
prepared oral rehydration solution in diarrhea, and measures to improve the
general nutritional status of children would help improve child survival. Verbal
autopsy instruments could be made more accurate if adapted based on mothers'
recognition of signs and symptoms and the terms they use to describe them.
Publication Types:

• Research Support, U.S. Gov't, Non-P.H.S.
1729: Hum Reprod. 1998 May;13(5):1394-6.
Trends in male:female ratio among newborn infants in 29 countries

from five continents.
Parazzini F, La Vecchia C, Levi F, Franceschi S.
Istituto di Ricerche Farmacologiche Mario Negri, Prima Clinica Ostetrico

Ginecologica, Università degli Studi di Milano, Italy.
We have analysed trends in male:female ratios among newborns between 1950

and 1990 in 29 countries from five continents. The numbers of liveborn males and
females over the period 1950-1994 were derived from the World Health
Organization (WHO) database. Countries for which reliable data were available
included 20 major European countries (excluding the former Soviet Union,
Albania and a few small countries), Canada, the USA, selected countries of
Central and South America, Japan, Australia and New Zealand. From the original
numbers of males and females, we computed the proportion of males among
liveborns for each country and for selected broader areas within Europe. In most
countries the proportion of male liveborns was constant during the study period.
In particular, the proportion of male newborns in the European Union was 0.515
in 1950-1954, 0.514 in 1970-1974 and 0.514 in 1990-1994. In the USA,
corresponding values were 0.513, 0.513 and 0.512. In Japan the ratios were 0.513
in 1950-1954, 0.516 and 1970-1974 and 0.514 in 1990-1994. Decreasing ratios
were observed in some northern and eastern European countries plus Greece and
Portugal and, particularly, in Mexico. In contrast, the proportion of male liveborns
tended to increase in southern Europe and Australia. Overall, among the 29
countries considered, the proportion of males declined in 16, increased in six, and
remained stable in seven.
Publication Types:

1730: J Telemed Telecare. 1998;4 Suppl 1:100-2.
A survey of physicians' acceptance of telemedicine.
Sheng OR, Hu PJ, Chau PY, Hjelm NM, Tam KY, Wei CP, Tse J.
Department of Management Information Systems, University of Arizona, USA.

olivia@bpa.arizona.edu
Physicians' acceptance of telemedicine is an important managerial issue facing

health-care organizations that have adopted, or are about to adopt, telemedicine.
Most previous investigations of the acceptance of telemedicine have lacked
theoretical foundation and been of limited scope. We examined technology
acceptance and usage among physicians and specialists from 49 clinical
departments at eight public tertiary hospitals in Hong Kong. Out of the 1021
questionnaires distributed, 310 were completed and returned, a 30% response rate.
The preliminary findings suggested that use of telemedicine among clinicians in
Hong Kong was moderate. While 18% of the respondents were using some form
of telemedicine for patient care and management, it accounted for only 6.3% of
the services provided. The intensity of their technology usage was also low,
accounting for only 6.8% of a typical telemedicine-assisted service. These
preliminary findings have managerial implications.
1731: Jt Comm J Qual Improv. 1998 May;24(5):280-98.
Can Western quality improvement methods transform the Russian

health care system?
Tillinghast SJ.
Alliance for Medical Systems Transformation, Davis, CA, USA. Sjtill@aol.com
BACKGROUND: The Russian health care system largely remains the same
system that was in place during the existence of the Soviet Union. It is almost
entirely state owned and operated, although ownership and management have
developed from the central government to the oblast (province). The
ZdravReform (Health Reform) Program (ZRP) in Russia, which began in 1993,
included the goal of improving the quality and cost-effectiveness of the health
care system. Work on introducing continuous quality improvement (CQI),
evidence-based practice guidelines, and indicators of quality was conducted in
1995-1996. INTRODUCING EVIDENCE-BASED MEDICINE: As a result of
the poor quality of Russian-language medical journals and the inability to gain
access to the knowledge available in Western medical literature, Russian medical
practices have not kept up with the rapid evolution of evidence-based medical
practice that has begun transforming Western medicine. A number of evidence-
based clinical practice guidelines were translated and disseminated to Russian-
speaking physicians working in facilities participating in ZRP in Russia and
Central Asia. DEVELOPING INDICATORS OF QUALITY OF CARE: Given
the limitations of existing measures of the quality of care, indicators were
developed for participating ambulatory polyclinics in several oblasts in Siberia.
Russian physicians responsible for quality of care for their respective oblasts
formed a working group to develop the indicators. A clinical information system
that would provide automated collection and analysis of the indicator data-as well
as additional patient record information-was also developed. EXAMPLES OF
CLINICAL QI WORK IN SIBERIA: CQI activities, entailing a multidisciplinary,
participatory team approach, were conducted in four oblasts in western Siberia.
Projects addressed the management of community-acquired pneumonia and
reduction of length of stay after myocardial infarction (MI). One of the oblasts
provided an example of a home-grown evidence-based protocol for post-MI care,
which was adopted in the other three oblasts. LESSONS FROM THE RUSSIAN
EXPERIENCE: Evidence-based medicine is critically needed to improve the
quality of research and publications, medical education, and medical practice.
Physicians everywhere are data driven; they change their practices when
convinced by good data. The key to successful introduction of evidence-based
medicine is understanding the fundamentals of good scientific method as applied
to medicine. The Russian health care system's experience in reporting to higher
authorities' process and outcomes data that resemble our modern indicators can
provide the basis for accurate and valid measures of quality. CONCLUSIONS: In
contrast with American expectations that a significant cultural change in an
organization could take years, even with great effort, Russian physicians and
other clinicians rapidly assimilated the new concepts of QI and put them to use.
More on-site assistance by international medical consultants will still be needed
for several years to hasten the process of change and ensure that it does not
become stalled.
Publication Types:
• Review

1732: Jpn Hosp. 1998 Jul;17:37-43.
Related Articles
Creating clinical path based on analysis using hospital information

system.
Uto Y, Muranaga F, Kumamoto I.
Dep. of Medical Informatics, Kagoshima University Hospital.
1733: Jpn Hosp. 1998 Jul;17:33-5.
Local health care system utilizing the LPG (liquid propane gas)
network.
Umemoto T, Hoshi H, Tsuda M, Horio S, Itou N, Neriki T.
Division of Medical Informatics, Gifu University Hospital, Gifu City, Japan.
JAC's LPG monitoring network system is mainly provided in mountain villages.

However, by using this system, it will be possible to start a Digital Network
Program for the Elderly while maintaining superior economic feasibility and
public benefit using existing information infrastructures. This project also has the
capabilities for the creation of a fire/disaster monitoring system, as well as a
health care system by using conventional LPG monitoring systems. Telemedicine
is an option for the future, as well, by connecting medical equipment and a tele-
conferencing system.
1734: J Public Health Med. 1998 Mar;20(1):5-10.
Health care systems in transition. II. Taiwan, Part I. A general

overview of the health care system in Taiwan.
Liu CT.
National Defence Medical Centre, Taipei, Taiwan.
Publication Types:
• Historical Article
• Review
1735: Int J Med Inform. 1998 Feb;48(1-3):57-60.
Standardization and security for the EMR.
Toyoda K.
IBM Global Services Japan, IBM Japan, Tokyo. kent@jp.ibm.com
The Ministry of Health and Welfare of Japan announced 'Healthcare Information

Strategy 21' in 1994. This report shows that the Healthcare Information System is
the key to improving the quality and efficiency of healthcare. One of the elements
for realizing the new Healthcare Information System is the Electronic Medical
Record (EMR). Following the publication of this report, work began with the aim
of discovering a way to recognize the EMR as formal documentation and four
national projects of research and development have been started. The themes of
these projects are: 'Interoperability of EMR', 'Standardization of EMR', 'Modeling
of the Clinical Process' and 'Security for EMR'. The Japanese Association of the
Healthcare Information Systems Industry (JAHIS) is in charge of 'Security for
EMR'. There are many discussions in relation to the security for EMR. However,
many of these discussions relate to information technology, while there are few
discussions regarding definitions of security. Therefore, there are many different
theories about security itself, which will be an obstacle to standardization. To
design the security system for EMR, JAHIS has defined 'Security for EMR' as the
first step. The present study was conducted with medical informatics and security
specialists. It has designed 'Requirement Definitions', 'Goals of Security',
'Estimation of threats to security', 'Necessity conditions' and a 'Security Model'.
This paper covers these definitions and our security design concept.

1736: Telemed J. 1998 Spring;4(1):39-41.
Telemedicine in border area of China.
Liu Y, Wang L.
Xiamen Zhongshan Hospital, Xiamen, P.R. of China.
Publication Types:
• Case Reports
1737: Wkly Epidemiol Rec. 1998 Apr 24;73(17):121-5.
Expanded programme on immunization (EPI). Measles elimination

in Oman.
[Article in English, French]
[No authors listed]
1738: J Med Syst. 1998 Apr;22(2):69-75.
A study on home health care support information system for health

evaluation.
Inada H, Horio H, Nakazawa K, Sekita Y, Yamanaka T, Harasawa E,

Hosaka H, Ishikawa K.
National Cardiovascular Center Research Institute, Suita, Japan.

The need for home health care has been increasing in Japan and the application of
various techniques such as medical informatics are desired to support home health
care services. Therefore, we developed an information system for health
evaluation of the elderly including patients at home by applying multifunctional
telephone set and an IC memory card, by which complaints, symptoms, and
conditions by them can be collected, recorded, and transmitted to medical
facilities. We also conducted an experiment for trial use of the system with the
cooperation of elderly female volunteers. It was recognized that the elderly
volunteers could operate the system with the help of public health nurses and their
health information could be collected by the system. Although the developed
system has some problems, it was suggested that the system would be useful for
the support of health evaluation of elderly at home.
1739: Indian Pediatr. 1997 Nov;34(11):1039-42.
Neonatal morbidity and mortality: report of the National Neonatal-

Perinatal Database.
[No authors listed]
PIP: This paper reports the creation of India's national neonatal-perinatal

database. The database has a continuous reporting format, uniform in its
definitions, and is checked and compiled at a nodal center, which is a necessity
for planning and monitoring health care. Data were compiled from intramural
births of 16 centers, which included neonatal morbidity and mortality data for the
year 1995. Furthermore, the database comprised data on 38,592 births, 37,082 of
which were live-born and 1510 stillborn. Statistics show that the incidence of low
birth weight (LBW) was 32.8% and that of preterms 12.3%, while two-thirds of
the LBW infants were term babies. Among institutional births, the incidence of
birth asphyxia would approximate 5%, while septicemia was observed in 3.9% of
intramural live births. Birth asphyxia, septicemia, and causes related to
immaturity account for almost three-fourths of the neonatal deaths, a majority of
which could be prevented.
1740: Natl Med J India. 1998 Jan-Feb;11(1):27-34.

Comment in:
• Natl Med J India. 1998 Mar-Apr;11(2):104.

• Natl Med J India. 1998 May-Jun;11(3):152.
Does India perform medical research in areas where it is most

needed?
Arunachalam S.
M. S. Swaminathan Research Foundation, Tamil Nadu, India.
This paper attempts to map medical research in India and answer an important
policy question by literature analysis. I match the disease pattern on the basis of
mortality and morbidity statistics with journals used by Indian medical
researchers to publish their work as shown by the Science Citation Index (SCI).
The former reflects the needs while the latter reflects the areas in which research
is being done. The limited statistics available from both the Government of India
and the World Health Organization point to diarrhoeal diseases, diseases of
children, respiratory diseases, circulatory system diseases, infectious diseases,
malaria and tuberculosis as the major medical problems faced by India. The
journals used often by Indian medical researchers to publish their work, as seen
from the SCI (1981-85), show that in terms of number of publications, they are
mainly active in general medicine, pharmacology, tropical medicine,
neurosciences, radiology, oncology and pathology. In terms of the share of the
world's literature in different subfields, India is second only to USA in andrology,
third in tropical medicine after the USA and the UK, tenth in hygiene and public
health, and eleventh in general and internal medicine, and radiology and nuclear
medicine. Overall, India's share in the medical journal literature is not only much
less than that of many other countries, both advanced and middle level, but also
much less than that of India's share of the literature in physics, chemistry,
mathematics and engineering. Data on the observed citation impact of Indian
research in different subfields of medicine show that the work done in India in
general is not integrated well into international research. India could be much
more purposive in her research priorities and probably should invest much more
in medical research.
1741: Eur J Epidemiol. 1998 Feb;14(2):179-86.
Hospitalizations for infectious diseases in Jewish and Bedouin

children in southern Israel.
Levy A, Fraser D, Vardi H, Dagan R.
Epidemiology Department, Faculty of Health Sciences, Ben-Gurion University of

the Negev, Israel.
Two different population groups reside in the Negev region of southern Israel and
have equal, and free from financial barrier, access to tertiary care at a single
regional hospital. The Jewish population has a largely urban and industrialized
lifestyle, while the Moslem Bedouins are in transition from their traditional
nomadic life to settlement. To examine the differences in morbidity patterns
reflected in hospitalizations, the computerized hospitalization records of children
<15 years of age, for 1989-1991 were used (n=15,947). Rates of hospitalizations
for infectious diseases were significantly higher for Bedouins in comparison to
Jews (250 and 121/10,000 child years, respectively, odds ratio (OR): 2.1, 95%
confidence interval (CI): 2.0-2.2, p < 0.001). Rates of hospitalization per 10,000
child years in Bedouins and Jews for diarrhea were 114 and 32 (OR: 3.7, 95% CI:
3.3-4.0, p < 0.001), respectively, and for pneumonia 55 and 19 (OR: 2.9, 95% CI:
2.6-3.3, p < 0.001), respectively. In infants the differences were even more
pronounced, especially for diarrheal diseases. In Bedouin children infectious
diseases were associated with longer hospital stay, more pediatric Intensive Care
hospitalizations (OR: 2.7, 95% CI: 1.7-4.5,p < 0.001), and higher in-hospital
mortality (OR: 5.7, 95% CI: 2.8-12.2, p < 0.001). Thus, Bedouin children are at
higher risks of hospitalizations for infectious diseases in early childhood, as
compared to Jewish children. This may reflect the differences in lifestyle,
environmental and social conditions of the two populations.
Publication Types:
1742: J Med Syst. 1998 Feb;22(1):43-9.
Development of a health promotion system for the elderly:

Committee of Health Evaluation for Elderly Persons Council of
Japan AMHTS Institutions.
Shibata S, Tuchiya A, Tamura M, Sasamori N, Yoshida K, Iwai Y, Hattori

M, Otsuka Y, Tohyama S, Uchiyama A.
Toshiba Medical Systems Co. Ltd., Tokyo, Japan.
A new health promotion approach for elderly persons is required which maintains
not only their physical health but also their quality of life. We are developing a
health promotion system which makes use of questionnaires dealing with physical
conditions and quality of life, and makes health reports. Health evaluation is
carried out in three steps. First, detailed information about the physical health of
each client is collected. Second, quality of life is evaluated according to five
health indicators. Last, health recommendations are generated. An artificial
intelligence (AI) program produces detailed questions to collect necessary
information for the evaluation of a client's health. The information related to
quality of life is converted into five health indicators and presented as a radar-
chart in documents and displays. The knowledge-based AI program automatically
generates the health recommendation documents. This information is available for
physicians and nurses for health counseling.
Publication Types:
1743: J Med Syst. 1998 Feb;22(1):27-32.
Health risk assessment for diabetes mellitus based on longitudinal

analysis of MHTS database.
Sugimori H, Miyakawa M, Yoshida K, Izuno T, Takahashi E, Tanaka C,

Nakamura K, Hinohara S.
Department of Hygiene and Preventive Medicine, Showa University School of

Medicine, Tokyo, Japan.
This study was designed with a follow up of 16 years to provide the

epidemiological model evaluating the risk of developing diabetes mellitus in
Japan. A cohort of 2573 subjects (1851 males and 722 females) from a MHTS in
Tokyo, who were nondiabetic (fasting blood glucose (FBS) less than 110 mg/dl)
in the initial year, were selected. This cohort was followed every year to identify
the occurrence of diabetes mellitus. Diabetes Mellitus was defined as fasting
blood glucose over 110 mg/dl, or the initiation of diabetic therapy. We compared
two prognosis groups (a normal group and a diabetic group) in terms of age,
examination findings, and prevalence of health risks (lifestyle, stress, and working
form). We also assessed family history of diabetes and past histories including
hypertension, hypercholesterolemia, and hyperuricemia. After assessing each
variable by univariate analysis (t-test, chi 2 test), we employed Cox's proportional
hazards model analysis. We used stepwise model adopting risk factors. The
diabetic group had significant differences compared to the normal group in age,
BMI (body mass index), FBS, smoking, drinking, not eating breakfast, dairy
intake, hypertension, hypercholesterolemia, hyperuricemia, and family history by
univariate analysis. According to proportional hazards model analysis, FBS, age,
family history, hypertension, smoking, and BMI were incorporated into
significant risk factors for diabetes in males, and not eating breakfast, FBS, age,
drinking, and hypertension were incorporated in females. Diabetes seemed to be
related to fixed factors (age), or genetic factors (family history and FBS) in males.
For females, lifestyle (not eating breakfast and drinking habit) seemed to play an
important role. It will be worthwhile to assess the risks of developing diabetes
mellitus by this epidemiological model.
Publication Types:
1744: Methods Inf Med. 1998 Jan;37(1):75-85.
Towards a national patient card system in Japan.
Alkhateeb A, Takahashi T, Minato K.
Medical Informatics Department, Kyoto University Hospital, Japan.

arwa@kuhp.kyoto-u.ac.jp
Patient Card Systems (PCS) have been applied on a regional level to improve
access to patient information. However, current projects lack a vision of future
integration on a national level. In addition, Integrated Circuit cards and optical
cards were introduced without considering that their cost and capacity limits
impose significant constraints for future integration. The major arguments against
PCS are the huge costs incurred by such a system and the limitations of the card
capacities. In addition, standards and legislation have not been sufficiently
developed. In this study, we propose a new model of PCS that employs recent
communication and card technologies as a key to access a national medical
information center. We demonstrate that PCS are feasible if implemented in
several distinct phases and if the acceptance and cooperation of physicians and
patients are achieved. However, political consensus about the necessity of reform
in the health care sector must be established so that the necessary legislation can
be enacted.
1745: Bull Med Libr Assoc. 1998 Jan;86(1):40-5.
Who needs evidence-based health care?
Tsafrir J, Grinberg M.
Miriam Gutwirth Medical Library, Tel Hashomer, Israel. itsafrir@post.tau.ac.il
The vast amount of published material in clinical and biomedical sciences, and
conflicting results on diagnostic and therapeutic procedures may introduce doubts
in decision-making for patient care. Information retrieving skills and the critical
appraisal of published literature, together with elaboration of practice guidelines
based on epidemiological methodology, form the basis of the trend towards
evidence-based health care, which aims to overcome these problems. A survey
conducted by questionnaire at the Chaim Sheba Medical Center analyzed which
types of information sources are considered most relevant and useful for patient
care by a cross-section of physicians with varying degrees of experience. They
considered review articles and meta-analyses extremely reliable for information
purposes, while for practical patient-care purposes they tended to rely more on the
opinions of peers and experts. As the requirements of evidence-based health care
may influence the attitudes of clinicians to the published literature and its
evaluation, they have implications for medical libraries and information centers.
Specifically, information specialists will be called upon more and more to impart
information-retrieval and critical appraisal skills to clinicians. The involvement of
information specialists in information gathering and selection will provide added
value to the expertise and knowledge of in-house experts for decision-making.
PMCID: PMC226324
1746: Int J Med Inform. 1997 Nov;47(1-2):31-4.
Official versus unofficial outbreak reporting through the Internet.
Woodall J.
Griffin Laboratory, Wadsworth Center, New York State Department of Health,
Slingerlands 12159, USA. jack.woodall@wadsworth.org
Several countries, a number of regional bodies, and a handful of both commercial

and not-for-profit outfits and international organizations operate sites on the
World Wide Web on which disease outbreaks are reported. But there is only one
publicly accessible e-mail service with no subscription cost that reaches health
workers and the general public in countries, and remote regions within countries,
that are on the far fringes of the Internet. That service is ProMED-mail, a project
of the Federation of American Scientists operated by SatelLife, which is a not-for-
profit organization that brings medical information to the developing world.
ProMED-mail reaches more than 15000 e-mail subscribers in at least 140
countries by a combination of satellite, phone and ground radio links. It receives
reports of outbreaks of emerging infectious human, animal and plant diseases
from official sources, the media and subscribers, and disseminates them rapidly,
without any of the constraints that often delay official reporting. All reports pass
first through the hands of a panel of disease experts, to ensure as far as possible
reliability and completeness. ProMED-mail has reported outbreaks more rapidly
than official sources, and responded to calls for help from doctors battling
epidemics, or confronted with baffling cases. It is proving that public participation
in outbreak reporting complements official reporting systems in a highly practical
way.
1747: J Health Serv Res Policy. 1998 Apr;3(2):77-81.
Health policy in transition: terminal care and site of death in Japan.
Babazono A, Weiner J, Hamada H, Tsuda T, Mino Y, Hillman AL.
Institute of Health Science, Kyushu University, Japan.
OBJECTIVES: In Japan, hospitals have replaced homes as the predominant site

of death, especially for the elderly. Site of death is a reliable indicator of where
older people receive care before they die. We conducted a population-based study
to identify the factors that determine site of death in a typical rural area in Japan.
METHODS: Study subjects were residents of Kawakami town, aged 70 years or
older, who died during 1981 and 1990. Death certificates provided information on
age, gender, cause of death, duration of illness before death, family members,
family occupation, and site of death. RESULTS: Among 455 subjects, 52.7% died
at home, while 47.3% died in hospital. Multiple logistic regression analyses
indicated that subjects with cancer were 6.1 times more likely to die in hospitals
than those with other diseases. Subjects who died in their seventies were 2.3 times
more likely to die in hospital than older subjects. Members of non-farming
families were 1.7 times more likely to die in hospital than members of farming
families. Gender, duration of illness, and the presence of spouse or children in the
household were not significantly related to site of death according to multivariate
analyses, although trends did exist. CONCLUSION: This case study illustrates the
importance of developing geriatric care systems in Japan, utilizing alternatives to
hospitals, such as nursing homes and formal home care. This is particularly true
for patients with cancer. As the older population rapidly increases in Japan, the
need for alternatives in geriatric care grows more critical.
Publication Types:
1748: Health Phys. 1998 Mar;74(3):293-9.
Radioactive materials in recycled metals--an update.
Lubenau JO, Yusko JG.
U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, USA.
In April 1995, Health Physics published a review paper titled "Radioactive

Materials in Recycled Metals." At that time, 35 accidental meltings of radioactive
sources in metal mills were reported, including 22 in the U.S., along with 293
other events in the U.S. where radioactive material was found in metals for
recycling. Since that date, there have been additional accidental meltings of
radioactive sources in metal mills both in the U.S. and elsewhere. There also was
an incident in Texas that involved stolen radioactive devices, which resulted in
exposures of members of the general public. Also, the U.S. Nuclear Regulatory
Commission took steps to address the underlying problem of inadequate control
and accountability of radioactive materials licensed by the Nuclear Regulatory
Commission. The Steel Manufacturers Association made available data collected
by its members beginning in 1994 that expanded the database for radioactive
materials found by the metal recycling industry in recycled metal scrap to over
2,300 reports as of 30 June 1997.
Publication Types:
• Review

1749: Indian J Lepr. 1997 Oct-Dec;69(4):395-8.
Data utilization and analytical skills among NLEP managers.

National Leprosy Elimination Programme.
Rao PS, Parkash I, Subramanian M.
Division of Epidemiology and Statistics, Central Leprosy Teaching and Research

Institute, Chengalpattu.
Mid-level managers of the National Leprosy Elimination Programme, India were

assessed regarding their ability to turn routine data received from primary units
into tools for management, analysis and decision making. Sixty-two managers (25
District leprosy officers, 37 Medical officers) were administered a questionnaire
containing 20 questions on calculations of rates, ratios, proportions, percentages
as well as construction and interpretation of graphs. It was found that 11% of the
study subjects scored very poor, 48% scored poor, 35% scored good and only 5%
of the managers scored very good. Among the district leprosy officers, 8%, 40%,
48% and 4% were rated as performing very poor, poor, good and very good,
respectively. Among the medical officers, the corresponding figures were 14%,
54%, 27% and 5%.
1750: Clin Chim Acta. 1997 Nov 6;267(1):87-102.
Simple devices and their possible application in clinical laboratory

downsizing.
Kasahara Y, Ashihara Y.
Fujirebio, Inc., Tokyo, Japan.
The pressure to contain medical costs prompted the development of sophisticated

downsizing options for the clinical laboratory, such as automation, information
systems, or miniaturization of analytical methods. Faced with an array of
approaches to choose from, medical institutions have to select the method that can
best serve their particular purposes and circumstances. However, the concept of
downsizing needs to be revised and applied to the entire medical system. One way
to reduce total medical expenditure would be to shift to near-patient or POC
testing, through the adoption of simple devices for immunoassay based on
immunochromatography. Recent advancements in the area of simple devices have
suggested their possible application for emergency testing sites. This paper
reviews the specific situation of Japan with respect to laboratory downsizing and
market environment, and discusses the possible future applications of simple
devices to near-patient or POC testing.
Publication Types:
• Review
1751: Ann Epidemiol. 1998 Jan;8(1):46-51.
Cancer in Lebanon: an epidemiological review of the American

University of Beirut Medical Center Tumor Registry (1983-1994).
Adib SM, Mufarrij AA, Shamseddine AI, Kahwaji SG, Issa P, el-Saghir NS.
Department of Epidemiology and Biostatistics, Faculty of Health Sciences,

American University of Beirut, Lebanon.
PURPOSE: Cancers recorded in the Tumor Registry at the American University

of Beirut Medical Center (AUBMC), the largest tertiary care center, in Lebanon
were reviewed. METHODS: Results were compared with those from the same
center 30 years ago and current data from western Asia. RESULTS: Between
1983 and 1994, 9364 cases were recorded, averaging 780 cases per year,
representing more than one-third of the national case-load. Cases were almost
equally distributed between males and females. Average age of females was
significantly younger (48.7 years) than that of males (52.2 years). Among males,
the five most frequently reported cancers were of the lung, bladder, larynx,
lymphoma, and leukemia. Among females, the four most frequently reported
cancers were of the breast, cervix uteri, lymphoma, and brain, with leukemia and
corpus uteri ranking equally as fifth. Over the past 30 years, the frequency of
colorectal cancer decreased and that of lung cancer increased in both sexes. Oral
cancer decreased dramatically among males. Digestive system cancers in this
series were less frequent than in cumulative data from western Asia area.
CONCLUSIONS: Cancer dynamics changed little since the 1950s, except regard
to cancers related to smoking and diet. Diet differences may explain the lower
frequencies of digestive cancers in Lebanon as compared with elsewhere in
western Asia. The potential impact of cancer prevention and early detection on
highly prevalent cancer types such as lung, larynx, breast, and cervix was
highlighted.
Publication Types:
1752: Indian J Gastroenterol. 1998 Jan;17(1):2-3.
Comment on:
• Indian J Gastroenterol. 1998 Jan;17(1):16-8.
What priority for prevention of hepatitis A in India?
John TJ, Chandy GM.
PIP: The recent development of a safe, effective vaccine against hepatitis A virus
(HAV) demands a reassessment of the public health importance and priority of
HAV in India. Although acute viral hepatitis is common among children in India,
the majority of HAV infections are asymptomatic. With increasing age at
infection, the proportion of persons developing symptomatic acute hepatitis
increases. Studies have indicated that virtually all children are infected with HAV
by 10-15 years of age, but the force of transmission is significantly lower in the
upper socioeconomic strata. In general, HAV is not as serious a public health
problem as hepatitis B, C, and E. More information is needed, however, on the
severity of HAV infection in chronic carriers of hepatitis B and C. Evaluation of
the feasibility of HAV immunization requires estimation of losses due to the
disease burden and calculation of the total costs of the intervention--neither of
which are possible through existing data systems. Given the high cost of HAV
immunization (US$20 per pediatric dose), any decision on HAV immunization as
a public health intervention should be postponed until epidemiologic data on
HAV and other infectious diseases in India have been assembled.
Publication Types:
• Comment
• Editorial

1753: Zh Mikrobiol Epidemiol Immunobiol. 1997 Nov-Dec;(6):39-42.
[The characteristics of the current stage in the development of the

7th cholera pandemic]
[Article in Russian]
Lomov IuM, Onishchenko GG, Moskvitina EA, Podosinnikova LS.
Research Institute for Plague Control, Rostov-on-Don, Russia.
The state and tendencies in the development of the epidemiological situation in

cholera in the world (1961-1996) are evaluated. As revealed in this investigation,
at the modern stage the development of the 7th pandemic characterized by the
formation of stable and temporary endemic foci in a number of countries of Asia,
Africa, Central and South America and by the import of cholera from these foci to
different countries of the world, including the CIS countries and Russia. The
"trigger mechanism" of epidemic manifestations in Russia is discussed, in
particular the epidemic of 1994 in Dagestan used as an example. Prognostication
is made on the basis of the analysis of the epidemiological situation.
Publication Types:
1754: Soc Sci Med. 1998 Feb-Mar;46(4-5):599-609.
Social network type and health status in a national sample of elderly

Israelis.
Litwin H.
Paul Baerwald School of Social Work, Hebrew University, Jerusalem, Israel.
A typology of social support networks was examined in relation to five health

measures in a national probability sample of Israelis aged 60 and over, using
multiple classification analysis (N = 4214). The procedure revealed that the more
resourceful diversified and friend and neighbor network types were consistently
associated with better scores on measures of basic and instrumental activities of
daily living, incontinence, vision and self-rated health, even when controlling for
respondents' age, sex and education. The religious family network type, also
endowed with considerable support potential, tended to correlate with lower
health scores. The narrow family focused network had average health ratings or
less, and a moderate support capability. The least resourceful network type, the
attenuated network, was most frequently associated with poor health.
1755: Health Care Superv. 1998 Mar;16(3):43-53.
Managing health care organizations in an age of rapid change.
Benjamin S, al-Alaiwat S.
Ministry of Health, State of Bahrain.
Health care managers find their work increasingly difficult, due in part to rapid
environmental change that plagues organizational life. Management practices and
attitudes that may have been appropriate in previous eras are ineffective today. A
study was conducted among managers in the Ministry of Health, State of Bahrain,
seeking information about current trends in the macro or external environment
that affect the Ministry of Health, as well as internal environmental pressures that
may be similar or different. This article provides a clear picture of the context in
which managers perform their work and offers recommendations for coping with
change in dynamic, complex organizations.
1756: Int J Parasitol. 1997 Oct;27(10):1177-84.
Control of parasites in cultured marine finfishes in Southeast Asia--

an overview.
Seng LT.
School of Biological Sciences, Universiti Sains Malaysia, Penang, Malaysia.

Mariculture in Southeast Asia began in the 1970s and expanded rapidly during the
1980s, with the commercial hatchery production of the seabass Lates calcarifer.
Other important cultured species were Epinephelus coioides, Epinephelus
malabaricus, Lutjanus johni, and Lutjanus argentimaculatus. Intensification in the
polyculture of these species and the large-scale international movement of
fingerlings or juveniles, as well as the rapid expansion and concentration of fish
farms, have caused severe problems resulting from parasitic infections. Infections
in maricultured fish are predominantly caused by monoxenous parasites, in
particular the capsalid and diplectanid monogeneans. Heteroxenous blood
parasites also successfully maintained transmission in the culture system despite
their requirement for an intermediate host. Prophylactic chemical treatments
helped to reduce parasitic infection but did not eliminate them and once
introduced into the floating netcage culture system, these parasites managed to
maintain their transmission successfully. Despite the current lack of information
regarding the biology of many parasites affecting cultured marine fishes, it
nevertheless is possible to develop methodologies to produce an integrated health
management system specifically designed to the needs of the mariculture
practiced in the Southeast Asian region. This system is important and should
include a sequence of prophylaxes, adequate nutrition, sanitation, immunization
and an effective system of marketing for farmed fishes.
Publication Types:
• Review
1757: Trop Med Int Health. 1997 Nov;2(11):1057-67.
Optimizing the malaria data recording system through a study of

case detection and treatment in Sri Lanka.
Abeysekera T, Wickremasinghe AR, Gunawardena DM, Mendis KN.
Department of Parasitology, Faculty of Medicine, University of Colombo, Sri

Lanka.
The potential of using malaria incidence data routinely collected from endemic
regions for disease control and research has increased with the availability of
advanced computer-based technologies, but will depend on the quality of the data
itself. We report here an investigation into the relevance of malaria statistics
provided by the routine data collection system in Moneragala, a rural malaria-
endemic region in Sri Lanka. All patients (n = 321) treated for malaria in 2
clusters of health care centres (HCCs) of both the private and the public sector in
the administrative regions of Moneragala and Buttala Divisional Secretariat
(D.S.). Divisions were studied in December 1995/ January 1996. The catchment
area of these HCCs included a population resident in 53 Grama Niladhari (GN)
areas, the smallest administrative units of the country. Almost equal numbers of
malaria patients were detected and treated at Government and private health care
institutions, and in 70% of them treatment was based on a diagnosis confirmed by
microscopy. The routine data recording system, however, included only statistics
from the Government sector, and only of patients whose diagnosis was
microscopically confirmed. In compiling data, the origin of a case of malaria is
attributed to the D.S. Division in which the institution (at which the patient was
treated) was located, rather than the area in which the patient was resident, which
was inaccurate because 90% of malaria patients sought health care at institutions
located closest to their residence, thus crossing administrative boundaries. It also
led to a loss of resolution of spatial data because patients' addresses recorded at
the Government HCCs to the village-level are replaced in the statistics by the D.S.
Division, which is a coarse spatial unit. Modifications to the system for malaria
case recording needed to correct these anomalies are defined here. If
implemented, these could result in major improvements to the quality of data, a
valuable resource for the future of malaria control. The paper reiterates the call for
the use of a standard spatial unit within a country to facilitate exchange of data
among health and other sectors for the control of tropical diseases.
Publication Types:
1758: Prehosp Disaster Med. 1998 Jan-Mar;13(1):29-34.
Hospital disaster management simulation system.
Levi L, Bregman D, Geva H, Revach M.
Trauma Research Unit, Rambam Medical Center, Haifa, Israel.

llevi@rambam.health.gov.il
INTRODUCTION: Theoretically, simulation of disastrous situations has many

advantages in that it prepares hospital staff to cope with the real scenario. It is a
challenge to create the database and custom-making a friendly software while still
keeping it representative of a real situation. This article describes experience with
developing and implementing the use of simulation software as a drilling
technique used by Israeli hospitals. METHODS: The application was developed
using SIMAN/ARENA software. Knowledge and a database for a basic multi-
casualty incident (MCI) were developed in the pilot phase. It contains detailed
descriptions of the casualties which can be compared with the real hospital
capabilities (staff and infrastructure). A consensus committee decided the crucial
model issues and established the thresholds for quality performance indicators.
Interfaces to the each hospital's information management systems (IMS) were
developed and the various output documents of each exercised step were updated.
Before drilling, the hospital managerial staff received notice and had to prepare
the data on the anticipated resources required. The simulation staff, as well as
representatives from the hospitals, then conducted the limited scale drill (LSD).
RESULTS: During the LSD, the trained hospital staff were given two types of
input: 1) copies of reports on patients entering the stations and had to enter them
into its IMS; and 2) timed telephone notifications of problems in each station.
During a 90 minutes drill, there were about 15 timely reports and 20 telephone
problems. The evaluation of the LSD were based mainly on the following: 1)
observing the staff solving various problems; 2) constructing a detailed picture of
the situation; and 3) measuring the effectiveness of the hospital IMS. The drill
ended with a discussion. Lessons are drawn from each drill in order to find
methods for optimizing the conduct of the hospital. An animation tool proved to
be useful in describing bottle necks in emergency room, diagnostic department,
and operating rooms. CONCLUSIONS: Simulation techniques and a preparatory
limited scale drill have advantages in evaluating and improving preparedness of
hospitals for managing an MCI before a full scale drill is carried out.
1759: J Health Serv Res Policy. 1998 Jan;3(1):39-43.
The importance of laboratory data for comparing outcomes and

detecting 'outlier' wards in the treatment of patients with
pneumonia.
Maor Y, Rubin HR, Gabbai U, Mozes B.
Gertner Institute for Health Services Research, Tel Aviv University, Sheba
Medical Center, Israel.
OBJECTIVES: To evaluate whether routine laboratory data can improve the

ability to compare risk-adjusted outcomes of different medical wards, and to
detect 'outlier' wards with significantly better or worse outcome. METHODS:
Patient data were taken from the Combined Patient Database Systematic
Management and Research Tool, a database created by merging different
computerized sources at a tertiary care hospital. All patients admitted to internal
wards with the diagnosis of pneumonia during the years 1991-1995 were included
(n = 2734). The outcome variable was mortality 30 days post-admission. We used
three comorbidity measures based on ICD-9-CM codes as possible predictors of
mortality: secondary diagnoses; the Health Care Financing Administration
severity index; and the Charlson comorbidity index. Models were created using
logistic regression. To each model, laboratory data gathered in the first 48 hours
after admission were added. To identify 'outlier' services we determined whether
the patients' ward was an independent predictor of mortality. The area under the
receiver operator curve (ROC) of the models was used for comparisons.
RESULTS: The area under the ROC was 0.65-0.72 for the models based on age
and comorbid diagnoses. The addition of laboratory data improved markedly the
discriminatory ability of each of the models, as reflected by an increase in the area
under the ROC to 0.83-0.84. An 'outlier' ward with a higher risk-adjusted
mortality rate was identified only by the models that included laboratory data.
CONCLUSION: Basic, automated, routinely gathered laboratory data added
significantly to the discriminatory power of risk models based on administrative
data with abstracted diagnoses. Addition of laboratory data improved the ability to
identify providers with possible exceptional quality of care.
1760: Med Device Technol. 1998 Jan-Feb;9(1):32-3, 36-7.
Marketing medical devices in Japan.
Ohashi J.
Menicon Co. Ltd., Research and Development Laboratories, Quality Assurance

Division, Aichi, Japan.
The control of medical devices in Japan has recently undergone significant

changes as the country brings its systems into line with those of the United States
and Europe. This article discusses pre-market approval, quality system
requirements and post-market surveillance. Many technical issues have been
harmonized but language is likely to continue to be a barrier to trade. Details of
information services that are available to foreign manufacturers and importers are
supplied.

1761: Midwifery. 1997 Sep;13(3):115-24.
Midwifery education for safe motherhood.
O'Heir JM.
OBJECTIVE: To determine the useability (relevance, clarity and quality of

content), applicability (ease of use) and accessibility (structure and form) of a
series of new safe motherhood midwifery education modules. DESIGN:
Questionnaire survey and focus group discussions, preceded by a two week
clinical skills course and an eight day orientation to using the modules.
SETTING: Nursing and midwifery education institutions, regional training
centres, acute-care hospital facilities and community settings in Ethiopia, Fiji,
Lesotho, Mozambique and Nepal. PARTICIPANTS: Thirty-six teachers, 82
midwives, nurse-midwives and auxiliary nurse-midwives from practice settings,
and 60 post basic midwifery students. KEY FINDINGS: Overall it was found that
the introductory information and the technical content of the modules were easy
to understand and use as were the instructions for both teachers and students. The
presentation of the material was orderly and easy to follow; the language was
comprehensible; and the illustrations were appropriate, clear and facilitated
teaching. The teachers found that they were able to use most of the
teaching/learning methods, teach most of the skills in the modules, and use the
guidelines for assessing competence. The main difficulties encountered included
adherence to the recommended time frame for some of the classroom sessions; the
limited availability of clinical cases for teaching the specific skills in the modules
and time limitations in the clinical area for practising the skills; and the provision
of transport for community visits, data to complete community profiles, and time
to complete other planned community activities. The students identified the need
for a set of learning materials which they could take with them for future
reference, and both teachers and students expressed concern about resources to
support, and legislation to cover, the application of the skills taught/learned. KEY
CONCLUSIONS: The modules have the potential to strengthen and support the
education of midwives in developing countries, enabling them to make
motherhood safer and contribute to a reduction in maternal mortality by providing
better midwifery care.
PIP: A series of new safe motherhood midwifery education modules was

evaluated in nursing and midwifery education institutions, regional training
centers, acute care hospitals, and community settings in Ethiopia, Fiji, Lesotho,
Mozambique, and Nepal in 1995. The series was developed by the World Health
Organization's Maternal Health and Safe Motherhood Program. A total of 36
teachers, 82 midwives or nurse-midwives, and 60 post-basic midwifery students
were enrolled in a 2-week clinical skills course and an 8-day training in module
use. In subsequent questionnaires and focus group discussions, participants
indicated the modules were understandable, relevant, easy to use, and of high
quality and the guidelines for assessing competence were adequate. Difficulties
encountered included insufficient recommended time frames for some of the
sessions, a limited availability of clinical cases for teaching the specific skills in
the modules, difficulties obtaining data for a community profile, and a lack of
resources to support application of skills learned. Participants indicated they
would benefit from having copies of the technical material used in the modules
for reference after the course. Overall, these findings indicate the modules have
the potential to strengthen the education of midwives in developing countries and
thereby to make motherhood safer. Weak health system infrastructures, including
regulatory measures, represent the major obstacle to successful program
application.
1762: Health Policy Plan. 1997 Dec;12(4):329-40.
Pharmaceutical regulation in context: the case of Lao People's

Democratic Republic.
Stenson B, Tomson G, Syhakhang L.
Karolinska Institutet, Stockholm, Sweden.
An explosive development of private pharmacies in the Lao People's Democratic

Republic (Lao P.D.R.) has led to 80% of pharmaceuticals being provided by the
private sector. In order to achieve the goal of access to good quality health care
for all citizens, the Lao government is making an effort to regulate the private
pharmaceutical sector using the emerging legal system of laws, decrees, and
regulations. The aim of this paper is to describe and analyze the system of drug
regulation in Lao P.D.R. in relation to the public social goals. Relevant official
documents at the central, provincial and district levels have been reviewed,
interviews were held with 30 key informants and 15 pharmacies were surveyed.
The public social goals have been expressed in terms of equity and quality of
care. However, total drug expenditure may be as low as US$1 per person per year
which is far below any minimum standard and does not make it possible to
achieve reasonable access to drugs for all. The regulatory system has so far been
focused on entry into the pharmaceutical retail market and dealing with basic
issues of product quality and conditions of sale. An enforcement system including
sanctions is being developed; other policy instruments such as information and
economic means are hardly being used at all. The government presently faces a
trade-off between quality of pharmaceutical services and geographical equity of
access. The study shows that regulation is strongly influenced by the general
socioeconomic context.
Publication Types:
Reform follows failure: II. Pressure for change in the Lebanese

health sector.
van Lerberghe W, Ammar W, el Rashidi R, Awar M, Sales A, Mechbal A.
Institute for Tropical Medicine, Antwerp, Belgium.
This paper describes how, against a background of growing financial crisis,

pressure for reform is building up in the Lebanese health care system. It describes
the various agendas and influences that played a role. The Ministry of Health,
backed by some international organizations, has started taking the lead in a reform
that addresses both the way care is delivered and the way it is financed. The paper
describes the interventions made to prepare reform. The experience in Lebanon
shows that this preparation is a process of muddling through, experimentation and
alliance building, rather than the marketing of an overall coherent blueprint.
Publication Types:
1764: Health Manag Technol. 1997 Dec;18(13):10.
Building cross-functional information systems is top health care IS

issue, CSC study says.
[No authors listed]
Publication Types:
• News
1765: J Formos Med Assoc. 1997 Oct;96(10):806-11.
Demographic characteristics and medical aspects of menopausal

women in Taiwan.
Chow SN, Huang CC, Lee YT.
Department of Obstetrics and Gynecology, National Taiwan University Hospital,

College of Medicine, Taipei, ROC.
This report describes the medical and demographic characteristics of menopausal

women in Taiwan in order to provide information for consideration during future
healthcare planning. The medical and demographic data analyzed were taken
from officially published materials of the Government of the Republic of China
on Taiwan, our own studies, and those of other researchers. In 1994, the average
lifespan of men in Taiwan was 71.8 years and that of women was 77.7 years. The
age of menarche was 13.6 years and the age of menopause was 49.5 years.
Women aged 50 and over accounted for 18.3% of the total female population and
8.9% of the total population in Taiwan. In 1994, 68.9% of women in Taiwan aged
50 and over were married. The most frequently occurring menopausal symptoms
in Taiwanese women were lumbago or low backpain (68%), fatigue (59%),
impairment of memory (55%), vaginal dryness (50%), and hot flushes and
sweating (49%). The spinal bone mineral density of women decreased markedly
after the age of 50 years. The prevalence of vertebral fracture in women 65 years
and over was 19.8%, which was higher than the 12.5% in men of the same age
group. The prevalence of hypertension and coronary heart disease in women 50
years or older was also higher than in men. The most frequent sites of cancer in
women in 1992 were the cervix uteri, breast, sigmoid colon and rectum, lungs,
liver, stomach, thyroid, ovaries, hemopoietic and reticuloendothelial systems, and
skin. There were 14,298 newly reported cases of malignant neoplasms in women
in 1992. About 60% of these occurred in women aged 50 years or more. The
median age of occurrence of cervix uteri, breast, and ovarian cancers was 48 to 49
years, which is very close to the menopause age. About 30% of menopausal
women in Taiwan are currently living without a husband. Although 18.3% of
women in Taiwan were at least 50 years old, approximately 60% of all malignant
neoplasms in the female population occurred in this group. There is an urgent
need for menopausal women in Taiwan to receive psychologic support and
comprehensive medical care.
PIP: To obtain information to guide future health care planning, data from
government and other sources on the demographic and medical characteristics of
menopausal Taiwanese women were reviewed. The average age at menopause,
according to a 1995-96 study of 386 menopausal women in Taipei, is 49.5 +or-
2.3 years. In 1994, women aged 50 years and over comprised 18.3% of Taiwan's
female population and 8.9% of the total population. 68% of menopausal women
in the 1995-96 study reported lower back pain; other common symptoms included
fatigue (59%), decreased memory (55%), vaginal dryness (50%), hot flashes
(49%), insomnia (46%), loss of libido (46%), dry skin (41%), and depression
(40%). After menopause, the prevalence of hypertension and coronary heart
disease becomes higher among women than men. In addition, bone mineral
density decreases markedly and 19.8% of women 65 years of age and over have
experienced vertebral fractures. About 60% of malignant neoplasms diagnosed in
1992 involved women aged 50 years and older. By age 60 years, women's risk of
cancer begins to increase substantially. An estimated 80% of Taiwanese women
initiate hormone replacement therapy for relief of menopausal symptoms,
prevention of cardiovascular disease, and prevention and treatment of
osteoporosis. Since 30% of menopausal women in Taiwan are currently widowed
or unmarried, there is a need to design programs that offer psychosocial support
as well as comprehensive medical care.
Publication Types:
• Review
1766: Top Health Inf Manage. 1997 Nov;18(2):39-45.
Copy management in a shared care environment using the Internet.
Guvenis A, Ayan Z, Serin O.
Biomedical Engineering Institute, Bogazici University, Istanbul, Turkey.

A new approach to sharing medical records using a demand-based database
replication method and the Internet e-mail facility is proposed. The underlying
model allows subscribed physicians to collect patient records from distant nodes
and have local access to these records when needed. A system called the Internet-
Based Distributed Medical Information System has been developed and
implemented in a shared care environment comprising outpatient clinics,
independent practitioners, and diagnostic laboratories. This tool may be highly
beneficial in improving coordination among health care professionals and
reducing unnecessary repeat investigations.
Publication Types:
1767: Health Inf Manag. 1997 Sep-Nov;27(3):124-7.
Health information management in Singapore.
Magennis T.
School of Health Information Management, University of Sydney, NSW.
This paper provides an overview of health information management practices in

Singapore, based on personal observation and interviews with health information
managers in five Singaporean hospitals. In Singapore borrowing a medical record
often requires a formal request and a permanent tracer is maintained for each
record. Medical officers generally have more responsibility than in Australia for
coding, which is completed within three days of discharge. A Singapore-wide
centralised patient database has been developed which is an important source of
information about patient drug allergies. Record design and assembly, release of
information and centralised registries are also described.
1768: Health Policy Plan. 1997 Sep;12(3):253-61.

Planning with PRA: HIV and STD in a Nepalese mountain
community.
Butcher K, Kievelitz U.
Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ), Pulchowk, Nepal.
The application of Participatory Rural Appraisal methods (PRA) to the topic of

sexual health enabled us to explore key factors concerning local people's
perceptions regarding HIV/AIDS and STDs and to plan collectively to address the
emerging issues. Conducting the process in a gender sensitive way enabled people
to feel safe enough to express their own opinions, and having gained confidence
in their peer groups, to share ideas later with the whole community in a joint
planning exercise. Nevertheless one group was identified as difficult to reach and
whose needs could not be met in a group for reasons of confidentiality. While the
methodology itself clearly has great potential in planning around specific health
issues, there are, nevertheless, limitations. Although the approach and the tools
used are simple and accessible, the skills needed to analyze the information are
more complex and demanding. The training given did not manage to equip
facilitators adequately with these analytical skills and in the future will be more
experience based and geared towards developing analysis and the ability to
formulate questions. In addition, since the project is not permanently resident in
the area, intensive support within the District is necessary to increase the chances
of sustainability.
PIP: The Primary Health Care Project (PHCP) in Nepal was established in 1994
as the German contribution to the government's ministry of health. One major
objective of the project is to strengthen the district health system. However, in
order to strengthen such a system, a clear picture must be obtained of what
already exists. A pilot participatory rural appraisal (PRA) exercise was done as a
first attempt to analyze the existing health system in anticipation of plan
development for future changes. The PRA method was applied to the issue of
sexual health in order to explore key factors concerning local people's perceptions
on HIV/AIDS and sexually transmitted diseases and to plan collectively to
address the emerging issues. The process was conducted in a gender sensitive
manner, helping participants to feel at ease expressing their opinions. Having
gained confidence in their peer groups, they were able later to share ideas with the
entire community in a joint planning exercise. One group was identified as
difficult to reach. The PRA method has great potential, but with limitations.
1769: Nurs BC. 1997 Aug-Sep;29(4):16-8.

Partners in health.
Bhagat R, Biring D, Pandher P, Quong E, Triolet K.
Vancouver/Richmond Health Board, South Unit.
1770: Clin Genet. 1997 Aug;52(2):100-9.
China's genetic services providers' attitudes towards several ethical

issues: a cross-cultural survey.
Mao X, Wertz DC.
Department of Psychiatry, West China University of Medical Sciences, Chengdu.

xin@icr.ac.uk
Attitudes towards ethical, legal and social issues in genetic research and practice
were investigated in 402 genetic services providers from 30 provinces and
autonomous regions in China. This was done using a Chinese version of an
international survey questionnaire on ethics and genetics that has been circulated
in 37 nations. In all, 255 study participants completed questionnaires (63%). The
majority of the respondents (89%) reported that they agreed with the current
Chinese laws and regulations on termination of pregnancy for genetic
abnormalities and non-medical indications, on the basis of considerations of
population control and family planning. More than half the respondents opposed
sex selection by prenatal diagnosis in the absence of an X-linked disorder.
However, most of them (86%) would prefer directive counseling. More than half
would agree to disclose genetic information to relatives at risk, and would permit
third parties such as law enforcement agencies, spouse/partner, blood relatives,
employers involving public safety, life and health insurers to access stored DNA
without consent. The majority (73%-98%) also thought that DNA fingerprinting
should be required for prisoners convicted of or charged with crimes, members of
armed forces and all newborns. Although these are only the first part of the results
of our international survey, they provide an initial basis for international
discussion on ethics and genetics in China.
Publication Types:
1771: Rinsho Byori. 1997 Aug;45(8):713-8.
[Establishment of a laboratory information office in response to the

expanding need for consultation--actual situation of the laboratory
information room, Clinical Laboratory Department, Kitasato
University Hospital]
Shimetani N, Ohtani H.
Kitasato University School of Medicine, Sagamihara.
Due to the advancement, segmentation and specialization of the medical care,

laboratory examinations covered by the National Health Insurance (NHI) tariff
have exceeded several hundred, and it is not possible for medical staff to be
familiar with all of these and to utilize them appropriately. There is an urgent
need for laboratory information for physicians, nurses, and other health
professionals. Accordingly, our Clinical Laboratory Department, Kitasato
University Hospital, established a "Laboratory Information (Consultation) Office"
in July 1995 to provide consultations on clinical laboratory tests to those engaged
in daily clinical practice and in medical research. The office is situated on the
second floor of the Laboratory Building of the Kitasato University Hospital. One
laboratory technician and one laboratory physician (clinical pathologist) are
stationed there. They are available for telephone consultations from 9:00 to 17:00
on weekdays, except for holidays, and from 9:00 to 13:00 on the first, third and
fifth Saturdays. In addition, since January 1997, this office also has been open to
members of medical associations in various cities in our area. To cope with
requests for laboratory information, including whether an examination is covered
the NHI tariff, selection of appropriate screening examinations and availability of
new laboratory tests, consultations by fax are accepted at any time, even after
regular working hours. As a post-graduate education program, the clinical
laboratory physicians study specimen handling analytical methods and
interpretation of results. At medical staff meeting, personnel from the Laboratory
Information Office provide clarification on the types of consultations offered,
address complex questions and find resolutions for rarely encountered and
difficult laboratory issues. At these meetings, a summary of new laboratory
examinations also is presented. This system of an information office where full-
time laboratory physicians and laboratory technicians are stationed is the first
such attempt in Japan. It may be considered a pilot project to determine if such a
system may be applied to other laboratory departments in the future.
Publication Types:
• Review
1772: Aust N Z J Psychiatry. 1997 Aug;31(4):532-42.
Aspects of psychiatric admissions of migrants to hospitals in Perth,

Western Australia.
Bruxner G, Burvill P, Fazio S, Febbo S.
Aspley Community Mental Health, Queensland, Australia.
OBJECTIVE: Recent Australian Government initiatives have emphasised

problems with service provision to the ethnic mentally ill. This study aims to
address the paucity of contemporary data describing the disposition of the ethnic
mentally ill in hospital settings. METHOD: Patterns of admissions for psychiatric
disorders to all hospitals in Perth, Western Australia, for the 3 years from 1990 to
1992, of migrants and the Australian born were compared using data from the
Western Australian Mental Health Information System. RESULTS: The overall
rates for European migrants showed a 'normalisation' towards those of the
Australian-born. There were high rates for the schizophrenic spectrum disorders
in Polish and Yugoslavian (old terminology) migrants. There were low admission
rates for South-East Asian migrants, predominantly those from Vietnam and
Malaysia. Rates for alcoholism were low in Italian and all Asian migrants. There
were high rates of organic psychosis, especially in those older than 75 years,
among the Italian and Dutch migrants. The relative risk of a first admission in the
3 years being an involuntary admission to a mental hospital was almost twice that
of the Australian-born for migrants from Poland, Yugoslavia, Malaysia and
Vietnam. CONCLUSIONS: The results imply the possibility of significant
untreated and/or undiagnosed psychiatric morbidity in the South-East Asian-born.
They also indicate a need for further exploration of the unexpectedly high levels
of psychiatric morbidity among some ethnic elderly groups, specifically the
Dutch- and Italian-born. The findings demonstrate the persistence of high rates of
presentation for psychotic disorders among Eastern European-born populations,
many years post migration.
1773: Nepal Popul Dev J. 1997 Jul;(Spec No):88-97.

Related Articles
Human resource development planning for sustainable health and

population programmes.
Adhikari SP.
PIP: This article identifies the need for human resource development planning
(HRDP) in population and health programs in Nepal. Sustainable development
depends upon balancing human numbers, resources, and quality of life.
Development strategies must be sensitive to health and population strategies.
Health and population strategies must reflect HRDP. Health and population fields
tend to intensively use human resources. Health and population manpower need to
be managed cost effectively yet meet the development goal of a more accessible,
more equitable, and more effective health care and family planning (FP) delivery
system. Manpower planning is affected by the type and quality of education, the
workplace, and the organization of health and FP manpower. FP entails three
processes: planning, production, and management. The former classical approach
of FP entailed institutions, sophisticated technology, and specialized manpower.
The classical approach did not work. Governments had difficulty finding
sufficient funds for investment. Human resources were an untapped source of
community and national development. Health and FP manpower should have a
variety of skills and knowledge that are complementary at the national and
community level. Manpower planning should be responsive to the needs of the
health system, the clients, and workers in an intersectoral system. FP workers
need to receive training in how to be sensitive to those in greatest need. A
functional information system is basic to manpower planning.
1774: Public Underst Sci. 1997 Jul;6(3):247-67.
Kaleidoscoping public understanding of science on hygiene, health

and plague: a survey in the aftermath of a plague epidemic in India.
Raza G, Dutt B, Singh S.

National Institute of Science, Technology and Development Studies, New Delhi,
India.
In September 1994 a plague epidemic hit a number of cities in India. Though the
spread of the disease was controlled within a short period of about one month, its
influences on various channels of information, on the functioning of government
departments (especially health and sanitation), on the scientific community and on
people's scientific information level were remarkable. This paper analyzes the
responses of 1127 individuals interviewed in December 1994. The data indicates
high levels of informedness about health, hygiene and plague, with little reference
to extra-scientific explanations of the causes of the epidemic. Respondents
expressed a high degree of confidence in the modern system of medicine. From
this analysis we also infer that the public could not be described as 'superstitious',
'unscientific' or 'unhygienic': only when denied access to information and civic
amenities did they show extra-scientific thinking or 'unhygienic' behaviour.
Publication Types:
1775: Indian J Pediatr. 1997 Jul-Aug;64(4):443-9.
Role and functions of Poisons Information Centre.
Lall SB, Peshin SS.
Department of Pharmacology, All India Institute of Medical Sciences, Ansari

Nagar, New Delhi.
The Poisons Information Centre (PIC) is a specialized unit providing information

on prevention, early diagnosis and treatment of poisoning and hazard
management. Most of the developed and many developing countries have well
established poison control centres with poisons information service, patient
management facility and analytical laboratory. In India, the National Poisons
Information Centre (NPIC) was established in February, 1995 in the Department
of Pharmacology at the All India Institute of Medical Sciences, New Delhi. The
centre provides toxicological information and advice on the management of
poisoned patients adopted to the level of the enquirer. The basis of this service are
the databases on poisoning, drug reactions and also the continuous and systematic
collection of data from the library. This information service is available round the
clock. The PIC has the training responsibility extending to medical and other
health professionals and community. The NPIC organized two successive training
courses for medical professionals and para professionals at all health levels.
Further, NPIC is a participant of INTOX project of IPCS/WHO, receiving regular
yearly training on the use of INTOX database. Laboratory service is an essential
component of a poisons control programme, providing analytical services on
emergency basis to help in diagnosis and management. The NPIC is developing
facilities for quick diagnosis of poisoning cases. Toxicovigilance and prevention
of poisoning is another major function of PIC. The Centre has prepared manuals
and leaflets on prevention and management cards on treatment of various
poisonings. Thus the Centre provides a service with considerable health benefits,
reducing morbidity and mortality from poisoning and gives significant financial
savings to the community.
1776: Taehan Kanho. 1997 Jul-Aug;36(3):49-69.
[Development in the National Hospice Care Service in Korea]
[Article in Korean]
Lee SW, Lee EO, Ahn HS, Heo DS, Kim DS, Kim HS, Lee HJ.
Seoul National University.
The urgent needs to establish hospice care systems in Korea arise from the
following reasons: (1) a drastic increase in chronically ill patients with the
increase of aged population: (2) rapid changes in living environment from the
traditional habitation (e.g., Many Koreans living in apartment complexes, which
is the most popular form of modern residence in recent years, prefer to die in the
hospital.): the overall increase in patients with advanced cancer: (4) recent trends
in early discharge of terminally ill patients from the limited hospital facilities to
accommodate other medical insurance beneficiaries: (5) easy acceptance of
euthanasia owing to the recent social atmosphere that belittles the dignity of
human life: (6) medical and nursing care of AIDS patient in terminal stage: (7)
and the problem associated with inhumane medical care system, overtreatment,
and groundless fears against narcotics. Terminally ill patients were used to be
treated in the hospital in the past. In these days, however, they are forced to have
home cares with little assistance from the qualified medical personnel because of
insufficient hospital facilities, which are even short for the need of emergency
patients and provide priority cares to medical insurance beneficiaries with other
acute problems. And yet, neither are there any administrative organizations nor
systematic medical studies that deal with the level of terminally ill patient's need,
their family's problems and resources of hospice care systems in Korea. Thus,
most patients are not able to get appropriate medical care at the terminal stage of
their lives. The objective of this study is to make comprehensive database for
various hospice care organization currently in operation, link them through
medical information system, and develop an easily accessible hospice care model
that meets the need of most Korean people. Our survey results may be
summarized as follows: Nationally there are 40 organizations that provide partial
or full hospice care. However, these organizations are not linked to any formal
medical service network. Furthermore, the objective of hospice care, care
principles, personnel with appropriate training, educational programs, standard for
care, costs, consulting service to patients' family members, the extent of medical
care from professional staff members, status of hospice facility, and management
of those institutions are neither clearly defined nor organized compared to the
international hospice care standards. The surveys on patients of terminal stage,
grouped in hospice and non-hospice care patients, reveal what they want visiting
nursing care to help their pain control, psychological, social and spiritual
demands. While the more than 90% of hospice care patients want to reduce their
pains, the non-hospice care patients, in addition to their desire for pain control,
demanded more psychological, social and spiritual helps as well. The results of
this research could be utilized to (1) define the standard of hospice care, (2)
provide the guidance for hospice medical care costs, (3) establish the database of
hospice care systems, (4) develop softwares, (5) build communication network
through Medinet, and (6) provide an organized visiting home nursing care system.
These information should be a valuable resource to many medical staffs who are
involved in cancer therapy, nursing care, and social welfare programs.
Publication Types:
1777: Med Inform (Lond). 1997 Jul-Sep;22(3):207-14.
Implementation of a patient-centred and physician-oriented

healthcare information system.
Young ST, Chang JS.
National Yang-Ming University, Department of Surgery, Veterans General

Hospital-Taipei, Taiwan, Republic of China.
Integration of information has enabled expeditious operation in air transfer,

banking, shopping, and stock brokerage, but not in healthcare. Existing health
information systems (HIS) are concerned too much with departmental
performance and charge billing, and neglect the end users--the patients and the
physicians. The resultant HIS then has divergent operation to antagonize the
physicians, and has fragmented data to the disadvantage of patients. Recognizing
the problems and the trend of HIS, this study proposed and implemented a
patient-centred and physician-oriented HIS in a Urology clinic. The proposed HIS
had patient care as its core, and accurately coded the patient's diagnoses and
therapy information. It also offered a friendly environment and complete function
for the physician to administrate medical records and to provide healthcare
services. The HIS had client/server structure and an open system to protect the
hardware investment and the software implementation. It will be the key to
success in complete hospital environments.
1778: Breast Cancer Res Treat. 1997 Jul;44(3):235-41.
Associations of alcohol, height, and reproductive factors with serum

hormone concentrations in postmenopausal Japanese women.
Steroid hormones in Japanese postmenopausal women.
Nagata C, Kabuto M, Takatsuka N, Shimizu H.
Department of Public Health, Gifu University School of Medicine, Japan.

chisato@cc.gifu-u.ac.jp
We measured serum levels of estradiol (E2), sex hormone-binding globulin

SHBG), progesterone, and dehydroepiandrosterone sulfate (DHEAS) in 61
postmenopausal women drawn from female residents in a community in Japan to
evaluate the relationships between these hormone levels and potential breast
cancer risk factors. The information on reproductive history, body size, alcohol
use, and physical activity was obtained by means of a self-administered
questionnaire. There was a significant trend in increasing E2 level with increasing
height after taking account of age and body mass index (BMI) (p for trend =
0.04). BMI was inversely associated with SHBG level after controlling age (p for
trend = 0.01). Decreasing progesterone with increasing BMI was observed after
controlling age and history of hysterectomy (P = 0.05). Alcohol consumption was
positively associated with E2 level and there was a strong linear trend after
controlling for age, height, and BMI (p for trend = 0.001). Trend for increasing
DHEAS with alcohol consumption was also statistically significant after
controlling for age and history of hysterectomy (p for trend = 0.01). Reproductive
factors as well as physical activity were not related to any of the hormone levels.
Publication Types:
1779: J Formos Med Assoc. 1997 Jul;96(7):535-41.
Factors affecting specialty and location of practice of government-

sponsored physicians in Taiwan.
Chie WC, Chang SH, Yang HF.
Department of Public Health, College of Public Health, National Taiwan

University, Taipei, ROC.
Geographic and specialty maldistribution have created problems of physician

supply in Taiwan. Previous small-scale government-sponsored physician (GSP)
programs in Taiwan have had only limited effects. To solve this problem, the
National Yang-Ming Medical College was established in 1975; it supplied its first
government-sponsored physician graduates in 1982. Obligatory service in
different specialties and geographic areas were assigned to graduates according to
their personal preference and school performance. In this study, we evaluated the
factors affecting the choice of specialty and location for these GSPs during the 6-
year obligatory service period. Data on Department of Health-regulated GSPs
who finished obligatory service prior to 1991 were obtained from the GSP files,
medical student files, and the National Medical Manpower Information System
for the years 1982 to 1985. Logistic regression was used to assess the effect of
year of entry, age, gender, rank in class, and hometown of the GSPs on specialty
choice upon entry into the obligatory service period. Both logistic regression and
generalized estimating equations were used to analyze the effects of these
parameters and location experiences during obligatory service on location
selection after the obligatory service period. We found that rural experience
during obligatory service was strongly associated with the choice of rural practice
after the completion of the obligatory service. Male gender, a later year of entry to
the program, and having a rural hometown were only moderately associated with
the choice of rural practice. A more comprehensive evaluation and review of the
effect of the GSP program on overall specialty and location distribution of
physicians is needed to provide guidelines for improvement of current GSP
program policies.
Publication Types:
1780: Soc Sci Med. 1997 Jul;45(1):159-69.
Dietary and lifestyle correlates of passive smoking in Hong Kong,

Japan, Sweden, and the U.S.A.
Koo LC, Kabat GC, Rylander R, Tominaga S, Kato I, Ho JH.
Department of Community Medicine, University of Hong Kong, Hong Kong.
From epidemiologic studies in several countries, passive smoking has been

associated with increased risk for lung cancer, respiratory diseases, and coronary
heart disease. Since the relative risks derived from those studies are weak, i.e.
relative risk less than two, we investigated whether poorer diets and less healthy
lifestyles might act as confounders and be correlated with having a smoking
husband on a cross-cultural basis. Characteristics of never-smoked wives with or
without smoking husbands were compared between 530 women from Hong
Kong, 13,047 from Japan, 87 from Sweden, and 144 from the U.S. In all four
sites, wives with smoking husbands generally ate less healthy diets. They had a
tendency to eat more fried food but less fruit than wives with nonsmoking
husbands. Other healthy traits, e.g. avoiding obesity, dietary cholesterol and
alcohol, or taking vitamins and participating in preventive screening were also
less prevalent among wives with smoking husbands. These patterns suggest that
never-smoked wives with smoking husbands tend to share the same less healthy
dietary traits characteristic of smokers, and to have dietary habits associated with
increased risk for lung cancer and heart disease in their societies. These results
emphasize the need to take into account the potential confounding effects of diet
and lifestyle in studies evaluating the health effects of passive smoking, especially
since it is known that the current prevalence rates of smoking among men is
indirectly associated with social class and education in affluent urban societies.
Publication Types:
• Meta-Analysis
1781: Sci Total Environ. 1997 Jun 20;199(1-2):197-204.
Large-scale biological monitoring in Japan.
Ogata M, Numano T, Hosokawa M, Michitsuji H.
Kawasaki Univ. Medical Welfare, Kurashiki, Japan.
Data from the large-scale biological monitoring program in Japan were assembled
and analyzed and the following results were obtained. All workers handling lead
and eight kinds of major organic solvents received physical examinations and
biological monitoring at the same time. Therefore, the number of workers
handling industrial chemicals and that received physical examinations and the
number of workers been examined by biological monitorings were similar to each
other. The total number of cases examined from 1989 to 1994 was about 661,000
for lead in the blood and about 4,173,000 for the urinary metabolites of eight
organic solvents. The results were classified into three categories and category 3
consists of workers having exposure concentrations above the 1988-1989
biological exposure indices of the ACGIH with the exception of lead
concentration in the blood where the limit in Japan was set at 40 micrograms/100
ml. The percentage of exposed workers in category 3 was 1.4% for blood lead and
0.2-2.4% for the urinary metabolites of the eight organic solvents. The percentage
of exposed workers in category 3 for blood lead, delta-aminolevulinic acid,
urinary mandelic acid, N-methylformamide and 2,5-hexanedione in the urine has
decreased with time. In ambient monitoring, the percentage of workplaces in
classification 3 for lead and styrene also has decreased with time.
1782: Southeast Asian J Trop Med Public Health. 1997 Jun;28(2):359-64.
Chikungunya in Thailand: a re-emerging disease?
Thaikruea L, Charearnsook O, Reanphumkarnkit S, Dissomboon P,

Phonjan R, Ratchbud S, Kounsang Y, Buranapiyawong D.
Division of Epidemiology, Ministry of Public Health, Nonthaburi, Thailand.
The first reported case of chikungunya virus diagnosed by serology in Thailand

was in 1960 and the last one was in 1991. The disease surveillance system does
not specifically include chikungunya cases and the signs and symptoms are
similar to these of dengue fever/dengue hemorrhagic fever (DF/DHF), rubella,
and fever of unknown origin (FUO); thus cases might often be reported under
those diagnoses. During the rainy season of 1995 (Jun-Aug), there were at least 2
reported chikungunya outbreaks which might indicate that it is a re-emerging
disease in Thailand. However, there is still limited information and knowledge on
some aspects of this disease such as clinical manifestations, subclinical cases,
duration of illness, complications, transmission, immunity, and reservoirs. Thus,
the objectives of this paper are to describe the epidemiology of chikungunya
infection based on outbreak investigations carried out in Khon Kaen (July 1991),
Nakorn Si Thammarat (July 1995), and Nong Khai Provinces (August 1995). All
three outbreaks occurred during the rainy season. The three most common clinical
manifestations were fever with severe althralgia with maculopapular rash. Both
sexes and all age groups were affected. Serological results were positive for IgM,
with four-fold rises in paired sera, and viral isolation in Nakorn Si Thammarat and
Nong Khai. Only in Nong Khai was hemagglutinin inhibition conducted and the
results were positive. No deaths were reported. The outbreaks occurred in rural
villages and all three larval indices (BI, HI, CI) were very high. The possible
vectors in these outbreaks were Aedes aegypti and Aedes albopictus. In the Nong
Khai outbreak, blood specimens were taken at the 3-5th day after onset and
therefore the proportion of positive results was low. IgM antibody of follow-up
cases declined within 3 months, villagers from all three areas with outbreaks
mentioned that they had no previous experience of this disease. This suggests that
chikungunya infection is a re-emerging disease.
1783: Nippon Koshu Eisei Zasshi. 1997 Jun;44(6):450-63.
[An analysis of telephone health counseling for Japanese employees

and their families abroad, "Japan health Care Line (overseas)"]
Kamoshita K, Kato M, Inamura H.
Hitotsubashi University.
In the past 6 years, the "Japan Health Care Line" has accumulated over 2,000
cases of telephone counseling calls, mainly on health problems, by Japanese
living abroad on business, and their families, in 55 countries. The characteristics
of these Japanese from medical aspects (physical and psychological), life style,
and education were determined; and factors that influence their life abroad as well
as some of their problems were analyzed. The role that telephone counseling can
play in alleviating their anxiety, in helping them adapt, and in maintaining their
health was also examined. The clients were Japanese employees and their families
whose health insurance associations had joined this service. Data were recorded
on a card for 14 items-the caller, the person needing the advice, age, sex, area of
residence, length of stay, hour of call, number of calls etc. The data and main
complaints were categorized in three ways: 1) by medical fields for business
reports; 2) by coding the complaints; and 3) by the ICD-10 classification. Of the
callers, 80% were in their 20's and 30's, meanwhile, as to the persons who need
the advice, 30% of them were under 10, and 30% were in their 30's. There were
many cases in obstetrics-gynecology, pediatrics, and general medical information.
In the contents of the counseling, conditions or symptoms of the client were
foremost, and together with advice on treatment, comprised half the calls. A study
was made on the correlation between the clients' length of stay/location and the
main complaints. Clients living abroad less than 1 year tended to call more,
especially for vaccination, translation, mental problems, and medical systems, but
did not call much in fields of obstetrics-gynecology, dentistry-oral surgery,
examination data and treatments. Location did not make much difference in the
fields of consultations, except for obstetrics-gynecology and dermatology. Middle
and Near East countries had special characteristics to their consultations. There
were differences in fields of counseling in calls from developing countries and
developed countries. In the former countries, calls on orthopedics, urology,
tropical diseases, and infectious diseases were numerous, while in the latter,
pediatrics and mental problems were.
Publication Types:
1784: J Psychosoc Nurs Ment Health Serv. 1997 Jun;35(6):19-27.
Forensic nursing in Pakistan. Bridging the gap between victimized

women and health care delivery systems.
Carbonu DM, Soares JM.
Diploma Program, School of Nursing, Aga Khan University, Karachi, Pakistan.

doramaria@akuc.edu
1. Women's issues tend to be more pronounced in developing countries, where

they include extreme limited resources, poor communication, vast distances,
individual and community poverty, and lack of education. 2. Empowerment of
victimized women depends on support, information, resources, creativity, and
positive self-concept. 3. Through support, understanding, effort, and
determination, the forensic nurse and Pakistani women can translate a vision into
reality by the integration of victimized women into all aspects of society.
Publication Types:
• Review
1785: Radiat Res. 1997 Jun;147(6):753-8.
Prevalence of uterine myoma detected by ultrasound examination in

the atomic bomb survivors.
Kawamura S, Kasagi F, Kodama K, Fujiwara S, Yamada M, Ohama K, Oto

K.
Departments of Clinical Studies, Radiation Effects Research Foundation,

Hiroshima, Japan.
Benign tumors of several organs have been demonstrated to occur as late effects
of atomic bomb exposure, and a recent addition to the list of affected organs is the
uterus. The increased incidence of uterine myoma noted in Radiation Effects
Research Foundation (RERF) Adult Health Study Report 7 (Wong et al., Radiat,
Res. 135, 418-430, 1993), however, was based on self-reported information,
optional gynecological examination and patient-requested ultrasound
examination. Thus the possibility of dose-related bias in case detection was a
serious concern. Therefore, the relationship between the prevalence of uterine
myoma and dose to the uterus was examined after excluding as much bias as
possible by asking all women who had undergone biennial examinations from
December 1991 through December 1993 to undergo ultrasound examinations.
Among 2506 female participants in Hiroshima, the uterus was visualized by
ultrasound examination in 1190, and 238 were found to have uterine nodules.
Multiple logistic analysis using Dosimetry System 1986 uterine doses revealed a
significant dose response for the prevalence of uterine nodules. The odds ratio at 1
Gy was 1.61 (95% confidence interval: 1.12-2.31). It is unlikely that the observed
relationship after adjusting for bladder filling, volume of the uterus, age and
menopause status was the result of dose-related bias. These results support
previous findings at RERF and provide further evidence that radiation exposure is
one of the factors associated with uterine myoma.
Publication Types:

1786: Health Policy Plan. 1997 Jun;12(2):146-60.
Challenges in implementing a budget-holding programme for

primary care clinics.
Nirel N, Gross R.
JDC-Brookdale Institute, Jerusalem, Israel.
In 1990, Kupat Holim Clalit (KHC), Israel's largest sick fund, initiated a
demonstration programme for transforming a number of primary care clinics in
the Negev district of southern Israel into autonomous budget-holding units. Four
programme components were implemented in the nine participating clinics:
allocation of a fixed budget; expansion of day-to-day decision-making authority;
establishment of a computerized information system to produce monthly reports
on expenditure; and provision of incentives for budgetary control. The research
findings are based on a four-year evaluation of the programme, which involved a
longitudinal case study conducted with multiple research tools: in-depth
interviews, a staff survey, and analysis of relevant documents. This article
analyzes the challenges involved in implementing the demonstration programme.
It examines clinic staff evaluation of the implementation process (e.g. overall staff
had a positive attitude toward it); assesses staff satisfaction with clinic
participation in the programme (while only 33% were satisfied, only 21% said
they would like the clinic to revert to the pre-programme model) and factors
influencing this satisfaction (among them intrinsic benefits, perception of the
programme as fair and age); and discusses the lessons to be learnt from the
programme regarding effective implementation of organizational change. The
main lessons indicate the importance of certain factors in implementing such
programmes: (a) long-term management commitment to the programme; (b)
appointment of agents of change/programme administrators; (c) establishment of
a formal agreement between the parties involved; (d) establishment of
communication channels between the parties involved; (e) intrinsic benefits for
staff, perceived as incentives to economize; (f) reliable data, perceived to be
reliable by the parties involved; (g) staff participation in the process of change;
and (h) involvement of the participating unit as a single entity.
1787: Can Nurse. 1997 May;93(5):32-4.
Pakistan's community health workers.
Majumdar B, Amarsi Y, Carpio B.
McMaster University Faculty of Health Sciences, Hamilton, Ontario.
Pakistan's health characteristics are worse than those of other Asian countries at
similar stages of development. Its mortality rate for children under five is 139 per
1,000, and its maternal mortality is 60 per 10,000. Malnutrition in women and
children is widespread; 50 per cent of children under five are stunted. Pakistan's
population growth rate of 3.1 per cent per year is among the highest in Asia. The
high population growth rate and poor health status of many people call for
extensive health care services, but, unfortunately, health services do not reach
most of the people of Pakistan. Partly because the training of doctors and nurses is
lengthy and expensive, there is an acute shortage of health care providers,
especially women. Although female health professionals are preferred for caring
for women, cultural constraints inhibit women from seeking education. Such is
the multifaceted dilemma in the provision of primary health care in Pakistan.
PIP: In Pakistan, the mortality rate for children under age 5 is 139/1000 live
births, and the maternal mortality rate is 60/10,000. 50% of the children under 5
are stunted as a result of malnutrition. There is an acute shortage of health care
providers; therefore, the Medical College and School of Nursing at Aga Khan
University, Karachi, developed a community health service model that proposes a
primary health care field team composed of community health nurses and doctors,
lady health visitors, and community health workers (CHWs). Most community
health nurses are graduates of a 3-year nursing program at the Aga Khan
University School of Nursing followed by 1 year of midwifery training. In
addition, graduates of the newly established BScN program are entering the
system as community health nurses. Community health doctors are medical
graduates whose education has emphasized clinical and theoretical knowledge of
primary health care. Lady health visitors are the mid-level health care providers
who deliver health care to mothers and children under age 5. They are high school
graduates whose 2-year training includes midwifery, covering prenatal care,
delivery care, postnatal care, and newborn care. CHWs have attended the CHW
Training Program at Aga Khan University in order to provide preventive and
promotive maternal and child care in their communities. The role of the CHW is
to be an essential and permanent member of the health care system. The CHW
encourages collection, storage, and use of clean water and garbage disposal;
offers information about prenatal and postnatal care; refers women with
pregnancy complications; encourages breast feeding; demonstrates food
preparation for infants and toddlers; explains the management of diarrhea and
vomiting; instructs about adequate prenatal nutrition; encourages immunization of
pregnant women and children; and monitors the growth of children under age 5.
Publication Types:
• Review
1788: Demography. 1997 May;34(2):171-87.
Geographic information systems, spatial network analysis, and

contraceptive choice.
Entwisle B, Rindfuss RR, Walsh SJ, Evans TP, Curran SR.
Carolina Population Center, University of North Carolina, Chapel Hill 27516-

3997, USA. entwisle.cpc@mhs.unc.edu
How does family planning accessibility affect contraceptive choice? In this paper
we use techniques of spatial analysis to develop measures of family planning
accessibility, and evaluate the effects of these geographically derived measures in
a multilevel statistical model of temporary method choice in Nang Rong,
Thailand. In our analyses we combine spatial data obtained from maps and Global
Positioning System (GPS) readings with sociodemographic data from surveys and
administrative records. The new measures reveal (1) important travel time effects
even when family planning outlets are close by; (2) independent effects of road
composition; (3) the relevance of alternative sources of family planning supply;
and (4) the importance of the local history of program placement.
Publication Types:

1789: J Biosoc Sci. 1997 Apr;29(2):219-33.
Costs of family planning programmes in fourteen developing

countries by method of service delivery.
Barberis M, Harvey PD.
DKT International, Washington, DC 20036, USA.
The cost effectiveness of several modes of family planning service delivery based
on the cost per couple-year of protection (CYP), including commodity costs, is
assessed for 1991-92 using programme and project data from fourteen developing
countries (five in Africa, four in Asia, three in Latin America and two in the
Middle East). More than 100 million CYP were provided through these family
planning services during the 12 months studied. Sterilisation services provided
both the highest volume (over 60% of total) and the lowest cost per CYP ($1.85).
Social marketing programmes (CSM), delivering almost 9 million CYPs, had the
next lowest cost per CYP on average ($2.14). Clinic-based services excluding
sterilisation had an average cost of $6.10. The highest costs were for community-
based distribution projects (0.7 million CYPs), which averaged $9.93, and clinic-
based services with a community-based distribution component (almost 6 million
CYPs), at a cost of $14.00 per CYP. Based on a weighted average, costs were
lowest in the Middle East ($3.37 per CYP for all modes of delivery combined)
and highest in Africa ($11.20).
PIP: This study of cost effectiveness of family planning programs is important in

light of declining donor support. The study examines cost per couple years of
protection (CYP) for family planning programs in 14 developing countries. Cost
effectiveness is evaluated by mode of service delivery. Modes of service delivery
include sterilization, clinic-based services (CBS) excluding sterilization,
community-based distribution (CBD) excluding sterilization, and contraceptive
social marketing (CSM). Costs are determined by a variety of methods: actual
expenditures, budget allocations, or estimation. Costs include donor and
government support related to service delivery. Omitted costs include, for
example, nonspecific health care training, research and evaluation, data
collection, and general IEC (information, education, and communication). In
combined family planning and maternal/child health services, estimates are used
to distinguish between the separate functions. CSM costs do not include revenues
from inside the CSM sale system. Findings indicate that service volume includes
about 60% or more of total services provided by organized family planning
programs in 1991, excluding China. 55% of services provided in study countries
were devoted to sterilization, 31% were devoted to CBS, and 9% were devoted to
CSM. In 1991, almost 57 million CYP were provided by sterilization. The least
expensive mode of service delivery was sterilization, based on data from India
and Colombia. The next most cost-effective delivery mode was contraceptive
social marketing, except in African countries where programs are new and small
in scale. The most expensive service was CBS, which includes CBD. Costs were
lowest in the Middle East and highest in Africa. Except for Africa, CSM within
countries showed the lowest costs. The authors recommend that programs meet
country and AIDS prevention needs.
1790: Soc Biol. 1997 Spring-Summer;44(1-2):111-23.
Unmet need for contraception in Vietnam: who needs what and

when.
Ross JA, Pham SB.
Futures Group International, Glastonbury, Connecticut 06057, USA.
The Vietnam 1988 survey established the first national estimates for reproductive
preferences and behavior. It created a unique baseline for levels and differentials,
both for the marked differences between North and South, and for various social
and demographic categories. It also provided the first national data for program
guidance, including information on unmet need. Unmet need for contraception
has been extensively documented for much of the developing world, but its
structure is not yet well understood. This study differentiates unmet-need couples
by several demographic characteristics, by time since the last birth, and by
features identified through a computer search program. Past investigations have
emphasized the per cent with unmet need within various population subgroups,
but some of those subgroups are small, whereas the national family planning
program must be oriented to subgroups with large absolute numbers of unmet
need couples. Unmet-need couples are selective, whether by reference to the
married population or by reference to other couples who also wish to avoid
pregnancy but are using a method. Most unmet-need couples are younger than
users, have fewer children and, especially, are closer to their last birth.
Surprisingly, most have never used a contraceptive method before, even though
Vietnam has had a vigorous family planning program and 49 per cent of all
couples in the survey reported some experience with a modern contraceptive
method. In terms of sheer numbers, those in need are distributed very widely
throughout the country. The most disadvantaged segments of the population have
both high percentages and large numbers in need, but the concentration of the
national program upon a single contraceptive method restricts their options.
PIP: The 1988 National Viet Nam Survey of 3890 married or cohabiting women
15-49 years of age documented an overall unmet need for contraception of 29%.
For each sociodemographic category, the analysis distinguished between the
distribution of unmet need for women in absolute terms and the percent of all
married women of reproductive age having unmet need. Unmet need according to
the latter classification system was especially high among women with 1 child
(34%), those with a 0-15 month open birth interval (49%), rural women from
South Viet Nam (37%), and illiterate women (48%). The greatest unmet need
existed among women in the early childbearing stage. Despite the widespread
availability of menstrual regulation and induced abortion in Viet Nam, between
one-seventh and one-half of women older than 30 had more children than they
desired. The most disadvantaged segments of the population had both high
percentages and large numbers in need, but the emphasis of the national family
planning program on a single contraceptive method restricts their options. A
wider method mix would likely reduce the unmet need for contraception among
Vietnamese couples.
1791: Int J Med Inform. 1997 Apr;44(2):117-25.
Bhorugram (India): revisited. A 4 year follow-up of a computer-

based information system for distributed MCH services.
Singh AK, Kohli M, Trell E, Wigertz O, Kohli S.
Department of Primary Health Care and General Practice, University of

Linköping, Sweden.
Impact of a health informatics research project on the management and delivery

of primary health care, focusing on maternal and child health care (MCH), was
reported earlier in 1992, with encouraging results in terms of increased antenatal
care coverage and decrease in Immunisation drop-outs. The software (MCHS)
was based on essential data sets (EDS) to assist the care providers in information
management for MCH care. The site was revisited after four years to evaluate the
status of the project and to ascertain whether computers were still in use and was
the dispensary staff using the MCHS package or not? The results are presented in
this paper to demonstrate that 'information is a difference that makes a difference'.
Information generated by the MCHS acted as a catalyst for behavioural change in
the community from indifferent users to active users of the health care services.
This is reflected by the increased acceptance of antenatal care, 80% fully
immunised child (FIC) and participation in other primary health care activities.
Publication Types:
1792: J Intellect Disabil Res. 1997 Apr;41 ( Pt 2):180-92.
Classification, prevalence, prevention and rehabilitation of

intellectual disability: an overview of research in the People's
Republic of China.
Sonnander K, Claesson M.
Centre for Disability Research, Uppsala University, Sweden.
The People's Republic of China is a developing country with all the problems and
challenges that face such countries all over the world. Progress has been
hampered by scarcity of resources, and a lack of relevant information and
appropriate skills, as well as by the stigma traditionally attached to people with
intellectual disability. The present rapid economic development has made possible
further improvement and expansion of educational opportunities, and health and
rehabilitation services. According to a recent census and sample surveys
conducted in the People's Republic of China, the overall prevalence rate of people
with disabilities was estimated to 4.9%. Thus, China has more individuals with
disabilities than any other country in the world. According to these figures, the
prevalence of intellectual disability in the population is approximately 1%. For
children younger than 14 years of age, the prevalence is around 2%, which
accounts for 66% of all handicapped children, making it the most frequent
childhood disability. Today, the existing medical facilities, and educational and
social welfare organizations cannot meet the tremendous need of care and
services. The problems of the large number of disabled children and adults are a
major challenge for contemporary Chinese society. This paper is devoted to
research pertinent to intellectual disability in China. With a few exceptions, only
publications in the English language were included in this review, which makes
the overview selective rather than comprehensive. Publications on classification
systems and diagnostic criteria, screening methods and assessment instruments,
prevalence rates, aetiology and risk factors, prevention and intervention efforts,
special education, and families with children with intellectual disability are
presented.
Publication Types:

• Review
1793: Rinsho Byori. 1997 Apr;45(4):350-6.
[Cost effectiveness of image diagnosis]
Inamura K, Kimura M, Ito A, Umeda T, Kozuka T.
School of Allied Health Sciences, Faculty of Medicine, Osaka University, Suita.
First, annual cost of electronic filing of medical images were calculated and
compared with that of film storage in two hospitals under different conditions.
Storage of medical images using a pixel size of 100 microns x 100 microns and 2-
byte depth on the 130 mm, 650 MB magneto-optical disks costs with four times
as much as the cost for film storage. However, 175 microns x 175 microns 12 bits
combined with implementation of lossless compression would reduce the cost to a
level equal to that for films storage. Doubled or tripled densities of MOD will
improve the cost ever further. Second, the effectiveness of Hospital Information
System/Radiological Information System (HIS/RIS) was evaluated. Examination
time, film delivery time and the total turn-around time was markedly shortened by
more than 23 hours on average. Our measurement method employing IC cards in
pre-post HIS/RIS/PACS procedures is generally applicable to other hospitals.
Third, to determine the optimal method of maximizing the efficacy of diagnostic
imaging, 260 questionnaires were sent to the staff of 13 university hospitals.
Every situation was described by both a radiologist and the physician who ordered
the examination and received the reports and images. The level of technical
efficacy and diagnostic accuracy of radiology strongly influenced the diagnostic
thought processes of the physician.
Publication Types:
1794: Crit Care Clin. 1997 Apr;13(2):389-407.
International comparisons of critical care outcome and resource

consumption.
Angus DC, Sirio CA, Clermont G, Bion J.
Health Delivery & Systems Evaluation Team (HeDSET), Department of

Anesthesiology, University of Pittsburgh, PA, USA.
Though there are reasonable data to suggest that certain countries, such as the
United States, spend considerably more money on the provision of critical care
services than others, there is little information regarding the added benefits
accrued with this additional expense. Studies to date have suggested little if no
difference in outcome but have been limited in their size, design, and choice of
outcome measures. Furthermore, significant underlying societal priorities and
philosophy may dictate that the optimal critical care delivery system is different
for different countries. With the increasing availability of large patient databases,
however, it will be more feasible in the future to design and conduct assessments
of critical care delivery systems between countries taking appropriate account of
the choice of study design, definition of at-risk populations, and choice of
valuable measures of output and cost. The results of such assessments will
hopefully drive wiser decision making in the design and management of critical
care delivery systems worldwide.
Publication Types:
• Review

1795: Crit Care Clin. 1997 Apr;13(2):331-46.
Evolution of neonatal and pediatric critical care in India.
Vidyasagar D, Singh M, Bhakoo ON, Paul VK, Narang A, Bhutani V,

Beligere N, Deorari A.
Department of Pediatrics, University of Illinois at Chicago Medical Center, USA.
During the last decade, the disciplines of neonatal and pediatric critical care have
rapidly progressed in India. The growth of Neonatal Intensive Care has paced the
growth of Pediatric Critical Care. The substantial growth of discipline and the
positive improvements in neonatal outcomes are the results of the concerted
efforts of the National Neonatal Forum and commitment of expatriate physicians
residing in the United States. This article provides the background information
regarding perinatal, neonatal, and infant mortalities in India. It also describes the
maternal child health care delivery system in the Indian subcontinent.
Publication Types:
• Review
1796: Am J Clin Nutr. 1997 Apr;65(4 Suppl):1198S-1202S.
Food and nutrition surveillance: an international overview.
Jerome NW, Ricci JA.
Department of Preventive Medicine, University of Kansas School of Medicine,

Kansas City 66160-7313, USA.
Systems providing routine food and nutrition surveillance (FNS) in local and
national populations are essential to the understanding of relations between
nutrition and health and the implementation of appropriate actions to promote the
well-being of those populations. The purpose of an FNS program is to gather,
interpret, and disseminate information about nutrition. Functions of FNS systems
include national and regional planning, monitoring and evaluation of food and
nutrition programs, provision of timely warnings of food shortages, problem
identification, advocacy support, and monitoring food and nutrition effects of
structural-adjustment policies. The characteristics of an FNS system are
determined by its function. Successful FNS systems are community based and
action oriented. We reviewed FNS systems throughout the world, with special
emphasis on those in developing countries.
Publication Types:
• Review
1797: Vet Hum Toxicol. 1997 Apr;39(2):106-14. The difficulty in

handling poisonings associated with Chinese traditional medicine: a
poison control center experience for 1991-1993.
Deng JF, Lin TJ, Kao WF, Chen SS.
Department of Medicine, Veterans General Hospital-Taipei, Faculty of Medicine,

National Yang-Ming University, Taiwan, Republic of China.
The purpose of this prospective case series was to outline the characteristics of
Chinese traditional medicine poisonings and develop essential information for
poison prevention and management. All phone inquiries made to the Poison
Center related to Chinese traditional medicines from January 1, 1991 to December
31, 1993 were included. Standardized questionnaires were used to capture
relevant information. Among the 318 phone inquiries about Chinese traditional
medicines, 273 cases were classified as poisonings; and 22 mortalities occurred
(6.9%). All of the poisonings occurred because of suicide attempts, accidents, or
erroneous or improper use or processing. In our study, 47% of the potential toxic
effects of Chinese traditional medicines were either unknown or could not be
found in the literature. There existed undefinable uncertainty in attributing the
clinical effects to the exposures to Chinese traditional medicines. We recommend
that the strategy in handling Chinese traditional medicine poisonings to decrease
mortality should be comprised of confirmation of the generic name of the
substances and the specific part of the plant used, awareness of improper
processing methods, maintenance of records on a broad review of systems and
laboratory data, identification of active principles and potential interactions
among the individual active agents; verification of histopathologic effects of the
toxins; development of information on toxicodynamics and toxicokinetics;
intensive supportive care for poisoned patients, and investigation of potential
antidotes. There are several regulatory options available to health authorities to
control the unrestricted use of these potentially toxic medicines and to help
safeguard the public.
Publication Types:
• Case Reports
• Review
1798: Popul Headl. 1997 Mar-Apr;(257):1-2.
"Population" theme of keynote address by Dr. Sadik.
Sadik N.
PIP: Dr. Nafis Sadik, executive director of the United Nations Population Fund
(UNFPA), gave the keynote address to the 53rd session of the Economic and
Social Commission for Asia and the Pacific (ESCAP). She stated that UNFPA
programs in Asia were the largest the United Nations group had in the world;
almost one-third of UNFPA program resources went to Asia. Asia is also the
center of the Partners Programme, a new program in which developed nations
share their experience and expertise in population and development with
developing nations. Under a new European Commission initiative the Asia-
Pacific region will receive, through UNFPA, US $31 million for population
programs. According to Dr. Sadik, UNFPA collaborates with the Population and
Statistics Divisions of ESCAP on projects including: 1) information technology
for gathering and disseminating population data; 2) systems to monitor and
evaluate reproductive health and family planning programs; 3) research on the
family and the elderly in Asia's future; and 4) demographic analysis of female
migration, employment, and poverty. A follow-up conference on the 1992 Fourth
Asian and Pacific Population Conference and on the 1994 International
Conference on Population and Development will be organized by ESCAP and
supported by UNFPA to assess implementation of the Bali declaration and the
ICPD Programme of Action.
1799: J Perinatol. 1997 Mar-Apr;17(2):161-3.
Maternal-child health system and perinatal mortality in the United

Arab Emirates.
Sedaghatian MR, Noor AM.

Neonatal Department, Mafraq Hospital, Abu Dhabi, United Arab Emirates.
The United Arab Emirates has witnessed extensive social and economic
development during the past 2 decades. Significant demographic changes have
also taken place mainly as a result of the continuous flow of expatriates. The
development of the health care delivery system resulted in the reduction of the
infant mortality rate by 25% (10.93 per thousand live births by 1992), but the
perinatal mortality rate has remained almost unchanged. Although maternal and
child health care has improved dramatically, its limited impact on perinatal
mortality can be attributed to underutilization of maternal health centers, absence
of screening programs for mothers at high risk, absence of regionalization of
perinatal care centers, poor maternal and neonatal transport facilities, absence of
effective referral and cooperation and interaction between hospitals and health
centers, the limited number of nursing and medical staff, and, finally,
underutilization of available information to support and enhance research. The
national perinatal mortality survey may address and seek appropriate solutions to
such problems.
PIP: The United Arab Emirates has enjoyed considerable social and economic
development over the past 2 decades. Improvements to and expansion of the
country's health care delivery system resulted in a 25% reduction in the level of
infant mortality, but the perinatal mortality rate has remained almost unchanged.
The limited impact of improved maternal and child health care services upon
perinatal mortality can be attributed to the underutilization of maternal health
centers, an absence of screening programs for high-risk mothers, the absence of
regionalization of perinatal care centers, poor maternal and neonatal transport
facilities, the absence of effective referral and coordination between hospitals and
health centers, the limited number of nursing and medical staff, and
underutilization of available information to support and enhance research. These
findings are based upon data from Federal Ministry of Health facilities and
industry and other private sector sources.
1800: Biomed Environ Sci. 1997 Mar;10(1):1-13.
National public health surveillance in China: implications for public

health in China and the United States.
Yang GH, Stroup DF, Thacker SB.
Institute of Epidemiology and Microbiology, Chinese Academy of Preventive

Medicine, Beijing, China.
STUDY OBJECTIVE: Throughout the world, political developments have
brought new demands to communities to prevent and intervene in the incidence of
infectious and noninfectious conditions. Historically, these developments have
required new and more effective public health surveillance activities. This report
describes public health surveillance practice in the People's Republic of China,
making comparisons with selected aspects of surveillance in the United States
with respect to collection, analysis, dissemination, and use of data. MAIN
RESULTS: In both the People's Republic of China and the United States, political
change has affected health, and multiple surveillance system are used in public
health practice. Surveillance of acute infectious diseases based on the reporting of
legally notifiable diseases and the use of vital records for surveillance have the
longest established history in both countries. In both countries, data from the
surveillance systems have been used to affect public health policy.
CONCLUSIONS: In comparing surveillance practices in these countries, we find
similarities in conditions reported and in the dissemination of the data. At the
same time, legal, social, cultural, and economic differences between the nations
have affected the practice of surveillance in analysis and evaluation. We make
explicit recommendations for improvement and evaluation of systems in both
countries, including sentinel surveillance system and data quality measures in
China and computer networking and data analysis in the United States.
Publication Types:
PMID: 9099422
1801: Ann N Y Acad Sci. 1997 Feb 20;809:309-16.
Communicating with cancer patients in Saudi Arabia.
Younge D, Moreau P, Ezzat A, Gray A.
Department of Orthopedics, King Faisal Specialist Hospital and Research Centre,

Riyadh, Saudi Arabia.
The following factors are relevant to the communication problems that exist in
this country: 1. CULTURAL ASPECTS: The impression is that patients here cope
better with terminal illness at home than do patients elsewhere. The extended
family, with its strong ties, and the strong Islamic faith that encourages its
members to provide for parents and children in case of need mean that any input
by health professionals is magnified by the family in the care of the patient. At
first, it was uncertain if foreign health professionals would be accepted into Saudi
homes (which are intensely private and protected for the family) for the purpose
of caring for patients. This has proved unfounded. Hospitality is a very important
part of Saudi society; nurses and doctors are welcomed and respected. Much of
this success is due to the use of Saudi men as drivers and translators. These people
provide 24-hour service, act as social workers assessing the needs of the family,
and are the link between the patient and family, the nurse, and the doctor. 2.
"CURE" OR "PALLIATION": The emphasis for cancer patients in Saudi Arabia
is still on "curative treatment," even after any realistic hope of a cure is gone. The
problem this causes is compounded by many patients being excluded from the
decision-making process. Decisions made by the family may not always reflect
the patient's wishes. Greater communication is needed to guide treatment
decisions. 3. TRUTH-TELLING: Denying information of the patient's illness is
probably more a historical than a cultural phenomenon. Similar attitudes prevailed
until very recently in practically all other countries. In this very conservative
country, people are committed to preserving Islamic culture in the face of
Western technology. As medicine continues to demonstrate its effectiveness as
well as its limitations, people will come to realize that the right of patients to
know and understand their illness allows them to cope much better, and is
compatible with the responsibility of the family to care for them. 4. WORK
FORCE: The government employs 14,500 doctors, but only 12% are Saudi
nationals. Nearly all the 33,000 nursing work force are expatriates. There is a
constant turnover of expatriate staff. The commitment to continuing care with
proper communication that is required for the whole of medicine is likely to be
fully realized only when the majority of the workforce are Saudi nationals. 5.
PRIMARY, SECONDARY, AND TERTIARY CARE SERVICES: The
Kingdom is well served by a system of 174 public hospitals and numerous private
clinics. However, for a patient with a chronic or terminal illness, continuing care,
even in the community, tends to be provided by the hospital service; whereas the
polyclinics and health centers seem to provide mainly crisis management. The
aim should be to develop community care for chronic illness as part of the
primary health care system. The impact of Western medicine on Saudi society has
been dramatic and sudden, as evidenced by the high growth rate of the population.
There is now widespread interest in matching the culture to the technology. Much
of the drive to change the attitudes of both patients and health professionals
comes from young Western-trained Saudi doctors, who are in the best position to
merge the strengths of both cultures in this sensitive area.
1802: China Popul Today. 1997 Feb;14(1):8.
National Conference on Urban Family Planning Programme.
Zhang G.
PIP: This news insert relays information on the Second National Conference on
China's Urban Family Planning Program held in Nanjing, Jiangsu province,
during December 1996. Conference participants included Mme. Peng Peiyun as
Minister of the State Family Planning Commission and 200 participants from 30
provinces and State Council departments. The conference aimed to discuss the
family planning system in relation to the socialist market economy, improvements
in delivery of more and better services to reproductive age couples, and more
scientific and reasonable family planning management. The conference was
sponsored by the State Family Planning Commission. The program offered the
opportunity to exchange experiences in implementing urban family planning
programs. The first conference was held in Shanghai in 1992. Significant changes
have taken place over the past 10 years. There is now a low birth rate, a low rate
of natural increase, and changes in attitudes toward fertility. Family planning is a
voluntary practice. The urban population has experienced improvements in the
quality of life. People demand more and better services and services for maternal
and child health and reproductive health. The process of urbanization is
accelerating as more people move to cities and towns and new towns are formed.
An increasing number of workers are engaged in joint-venture businesses and in
the private sector.
1803: Isr J Med Sci. 1997 Feb;33(2):103-11.
Compliance with mammography screening in Israeli women: the

impact of a pre-scheduled appointment and of the letter-style.
Ore L, Hagoel L, Shifroni G, Rennert G.
Department of Community Medicine and Epidemiology, Carnel Medical Center,

Haifa, Israel.
The objectives of this study were to determine the impact of different personal
invitations on screening mammography attendance and to clarify the influence of
personal characteristics and health-related attitudes and behaviors on compliance.
One thousand and five hundred women, aged 50-74 years, were randomly
selected in the city of Haifa. Four letters of invitation were used. Actual
mammography performance was validated by a national computerized database.
All other data was collected via a telephone interview following the
mammography. The overall compliance rate amounted to 45%. The major
predictors of compliance were having had a clinical breast examination within the
previous year (p = 0.0008), having a health professional recommend routine
mammography (p = 0.01) and perceiving mammography as efficient in early
detection of breast cancer (p = 0.02). Aggressiveness of message details, or a
family physician's or higher authority's signature on the letter had no impact on
compliance. A letter of invitation for a routine mammogram at a specific time
resulted in an overall rate of compliance 3-fold higher than the baseline. Based on
the results of this study. Kupat Holim Clalit decided to implement use of personal
invitations for screening mammography to israeli women on a regular basis.
Publication Types:
• Clinical Trial
• Controlled Clinical Trial
1804: J Infect Dis. 1997 Feb;175 Suppl 1:S122-34.
Surveillance for polio eradication in the People's Republic of China.
Zhang J, Zhang LB, Otten MW Jr, Jiang T, Zhang XL, Zhang RZ, Wang
KA.
Chinese Academy of Preventive Medicine and World Health Organization,

Beijing, People's Republic of China.
A case-based virus surveillance system for wild poliovirus in China was

developed. By 1993, all 30 provincial immunization units and, by 1994, all 29
provincial laboratories were sending computerized data to the national level. In
1993, a county-level, computerized map was operationalized that permitted visual
monitoring of the progress of the polio eradication program every month by
county. In 1993, wild poliovirus type 1 was detected in 8 provinces. Wild
poliovirus mainly caused clusters of polio cases identified by a surveillance
system that detected primarily clinical polio in children <5 years old (1 stool
sample was collected on approximately 50% of reported cases). By 1995, the
surveillance system had reached certification-like levels (80% of acute flaccid
paralysis [AFP] patients with 2 stool specimens and AFP case rate of 1/100,000
children <15 years old). No indigenous wild poliovirus was detected in 1995. This
general case-based model can be applied to measles and other important diseases,
and may then lead to a more rapid decrease in adverse health outcomes.
1805: Sociol Methodol. 1997;27:355-92.

The neighborhood history calendar: a data collection method
designed for dynamic multilevel modeling.
Axinn WG, Barber JS, Ghimire DJ.
"This paper presents a new data collection method, called the Neighborhood
History Calendar, designed to collect event histories of community-level changes
over time. We discuss the need for and the uses of this method. We describe
issues related to the design of instruments, collection of data, and data entry. We
provide detailed examples from an application of this method to the study of
marriage, contraception, and fertility in rural Nepal. The paper addresses
applications of this same technique to other settings and research problems. We
also extend the technique to collection of other forms of contextual-history data,
including school histories and health service histories. Finally, we discuss how
Geographic Information System (GIS) technology can be used to link together
multiple sources of contextual-history data." excerpt
1806: Plan Parent Chall. 1997;(1-2):31-3.
An integrated approach to help Nepal's rural poor.
Thapa M.
PIP: Nepal is a densely populated country, and 90% of its population lives in rural
areas marked by deprivation. The gender gap that keeps women at a disadvantage
can be seen in educational, food access, and life expectancy figures. About half
the population exists below the poverty level, and total health expenditure is about
US$7 per capita. Many rural areas are served only by traditional healers. Maternal
mortality and fertility rates are high, and the fertility rate in rural areas is almost
double that in urban areas. The government has developed an new integrated
policy to improve the health of the population, especially of its most vulnerable
members, that includes 1) gender-sensitive community participation; 2)
decentralization and delegation of power to the local level; 3) an emphasis on
disease prevention and health promotion; 4) development and dissemination of
locally-acceptable information, education, and communication materials; 5)
mobilization of existing local community-based groups; 6) development and
expansion of the competency of local health and development workers; 7)
promotion and improvement of existing traditional health care practices; 8)
creation of outreach clinics; 9) improvement of follow-up health care; 10)
empowerment of rural poor, especially women, in the areas of literacy, legal
rights, health promotion, and health protection; 11) provision of credit and
markets for self-sustainable income generation; and 12) development of a
functional referral system at each level.
1807: Kokuritsu Iyakuhin Shokuhin Eisei Kenkyusho Hokoku. 1997;(115):155-60.
[Development of a geographical information system and its

application to Escherichia coli O-157 patient distribution]
Kaminuma T, Kabuyama N, Ishikawa K.
kaminuma@nihs.go.jp
The so called Geographical Information System (GIS) is one of the basic tools for
wide range of public health applications. We had developed a general purpose
GIS and applied it to represent geographical distribution of patients of the
bacterium E. coli O-157 which bursted out in Japan last early summer particularly
at Sakai City in Osaka Prefecture. The patient record have been supplied from the
Food Safety Office of the Ministry of Health and Welfare. These records were
handled by EXCEL. The basic geographical data was constructed from the map
data provided by Japan Geographical Survey Institute, and ArcView 2 was used
as the map system. The maps were converted to Graphics Interchange Format
(GIF) files and put on our Web server.
Publication Types:
1808: Int Arch Occup Environ Health. 1997;70(6):385-92.
Types of organic solvents used in small- to medium-scale industries

in Japan; a nationwide field survey.
Ukai H, Inui S, Takada S, Dendo J, Ogawa J, Isobe K, Ashida T, Tamura M,

Tabuki K, Ikeda M.
Kyoto Industrial Health Association, Japan.

OBJECTIVE: The aim of the present survey is to identify organic solvents
commonly used in various workplaces in Japan. METHODS: A total of 24
occupational health service institutions (OHSI) distributed nationwide in Japan
offered data on types of solvent workplaces, types of solvents used therein, and
the solvent concentrations surveyed in a 2-month period between April and May
1996 to form a data base (OHSI data base, consisting of 1597 cases). Separately,
Kyoto Industrial Health Association (KIHA) offered information on 948 cases
studied during a 1-year period ranging from April 1995 to March 1996 (KIHA
data base). The two data bases were treated in parallel to examine the
reproducibility of the results. RESULTS: Detection prevalence was very low (0-
1%) for almost half of the 47 legally regulated solvents. Among the solvents in
use, toluene was most frequently detected, although the prevalence appeared to be
reduced as compared with that recorded for the early 1980s. The most frequently
observed solvent combinations comprised toluene, xylenes, and ethyl acetate in
the OHSI data base and toluene, xylenes, and methanol in the KIHA data base.
Contrary to the case in the 1980s, dichloromethane was used more often than
trichloroethylene as a degreasing agent in the present survey. No use was detected
for carbon tetrachloride, chloroform, 1,2-dichloroethane, 1,2-dichloroethylene, or
1,1,2,2-tetrachloroethane except for research purposes. CONCLUSIONS: Toluene
remained the most common solvent and was used in combination with xylenes,
ethyl acetate, and methanol. There was an increase in the use of dichloromethane
as a degreasing agent.
1809: Int Arch Occup Environ Health. 1997;69(6):386-91.
The epidemiology and surveillance of blood lead in Taiwan (ROC):

a report on the PRESS-BLL project.
Wu TN, Shen CY, Liou SH, Yang GY, Ko KN, Chao SL, Hsu CC, Chang PY.
Disease Surveillance and Quarantine Service, Ministry of Health, Taipei, Taiwan,

ROC.
To monitor the lead hazards in industries and to investigate the prevalence of

elevated blood lead levels (BLLs) in lead-exposed workers, a lead surveillance
system (PRESS-BLLs) has been established and operated in Taiwan, Republic of
China, since July 1993. A cohort of lead-exposed workers who received a
periodic annual health examination at 55 accredited hospital laboratories was
constructed. A total of 9807 separate BLL measurements were reported to the
system in 1994. The mean BLL was 15.8 micrograms/dl in male workers and 11.6
micrograms/dl in female workers. The mean BLL of lead-exposed workers was
significantly (P < 0.05, z-test) higher than that of the general Taiwanese
population (8.6 micrograms/dl for males and 6.7 micrograms/dl for females). In
addition, the BLLs of 983 (10.0%) workers exceeded the regulatory action level
(40 micrograms/dl for males; 30 micrograms/dl for females). The workplaces and
homes of 57% of the workers with elevated BLLs were thoroughly investigated to
determine the sources of lead contamination. These actions identified the causes
of elevated BLLs and set up strategies to reduce workers' lead exposure. The
establishment of this occupational lead surveillance system represents a method
for monitoring of lead hazards from occupational and environmental settings to
prevent lead poisoning. The information acquired from the system can help in the
setting up of a priority of prevention and the development of control measures. It
is also useful for further monitoring of changes in the BLLs of the lead-exposed
cohort. The Health Department of Taiwan can use this information to evaluate the
effectiveness of current industrial hygiene practice. Subjects with elevated BLLs
have been medically treated and placed on long-term follow-up for sequelae.
1810: J Telemed Telecare. 1997;3(2):71-7.
Urban teleradiology in Hong Kong.
Sheng OR, Hu PJ, Au G, Higa K, Wei CP.
Department of Information and Systems Management, School of Business and

Management, Hong Kong University of Science and Technology, Hong Kong.
olivia@usthk.ust.hk
We investigated four major teleradiology programmes in Hong Kong. We

analysed the overall organizational background of each programme, the context of
its implementation, the choice of technology and the decision-making process,
and the subsequent dissemination of the technology. Our review suggests that the
success of a telemedicine programme is contingent not only on good technology
but also on effective management of issues pertaining to human and
organizational factors. At the departmental level, the context of the
implementation of telemedicine is crucial. At the institutional level, success
depends on planning and management. At the professional level, continued
education, periodic meetings and seminars are all effective means of promoting
telemedicine among health-care professionals and administrators. At the national
level, the Hong Kong experience suggests that telemedicine can be effectively
developed by starting with urban-based programmes.
Publication Types:

• Review
1811: Milbank Q. 1997;75(2):235-60.
Ambulatory mental health treatment under universal coverage:

policy insights from Israel.
Feinson MC, Lerner Y, Levinson D, Popper M.
Department of Information and Evaluation, Mental Health Services, Ministry of

Health, Jerusalem, Israel.
Untested assumptions concerning ambulatory treatment have shaped mental

health policies for decades. Three opinions prevail: (1) all use is alike; (2) any use
leads to high use; and (3) all high use is discretionary and therefore excessive.
These assumptions were tested, using data from a nationwide survey of
ambulatory utilizers in Israel, a country that has universal coverage. The findings,
based on detailed clinical and treatment records, challenge all three assumptions.
Moreover, they document a diversity of clinical needs while also verifying
substantial variations in the type, frequency, and duration of treatment provided to
meet those needs. In brief, Israeli data do not confirm continuing concerns by
policy makers about uncontrollable use of services with expanded mental health
coverage. Special policy limitations on mental health treatment should be
reconsidered in light of empirical evidence from a system without the restrictions
that exist in the United States.
Publication Types:
1812: Natl Med J India. 1997 Jan-Feb;10(1):31-5.
Informatics technology in health care in India.

Chawla R, Bansal AK, Indrayan A.
University College of Medical Sciences, New Delhi, India.
1813: J Perinatol. 1997 Jan-Feb;17(1):65-9.
Maternal and child health services in India with special focus on

perinatal services.
Singh M, Paul VK.
Department of Pediatrics, All India Institute of Medical Sciences, New Delhi,

India.
India has an excellent infrastructural layout for the delivery of MCH services in
the community through a network of subcenters, primary health centers,
community health centers, district hospitals, state medical college hospitals, and
other hospitals in the public and private sectors. However, the health pyramid
does not function effectively because of limited resources, communication delays,
a lack of commitment on the part of health professionals, and, above all, a lack of
managerial skills, supervision, and political will. The allocation of financial
resources for the delivery of health care continues to be meager. Nevertheless, in
spite of obvious constraints, the country has made laudable progress in reducing
post-neonatal mortality in recent years. Indeed, the focus has shifted to the young
infants and the perinates. Under the CSSM program, a massive expansion of
MCH services has occurred at the sub-district and the district levels. The RCH
program, to be launched shortly, aims at effective utilization of these facilities to
ensure delivery of integrated services of assured quality through decentralized
planning. Simultaneously, as a result of the ongoing economic liberalization, the
MCH care in the private sector will also expand rapidly. Indeed, India is on the
threshold of an extraordinary improvement in the status of its neonatal-perinatal
health.
PIP: The infant mortality rate (IMR) in India dropped from about 140/1000 live
births in the early 1970s to 73/1000 in 1994. The IMR is highest in Orissa state
(103/1000) and lowest in Kerala state (16/1000). Neonatal/perinatal data
collection in the country is carried out by means of the Sample Registration
System generating vital statistics; the Survey of Causes of Death by lay reporting;
and the Data on Causes of Death from the Urban Hospitals. The health
infrastructure comprises subcenters for a population of 5000, primary health
centers (PHCs) for a population of 30,000, and a community health center for
every 3-4 PHCs. There is a district hospital in each district capital. The most
comprehensive among maternal and child health programs is the Child Survival
and Safe Motherhood Program, under which maternal-child health services have
been integrated since 1992 in order to achieve substantial improvements by the
year 2000. The child survival component consists of newborn care, immunization,
management of acute diarrhea and respiratory infections, prevention of
hypothermia and infections, promotion of exclusive breast feeding, and referral of
sick newborns. In mid-1997 the maternal-child health services will become part of
the Reproductive and Child Health (RCH) Package of the National Family
Welfare Program. The RCH Package consists of prevention and management of
unwanted pregnancy; antenatal, delivery, and postpartum services; child survival
services for newborns and infants; and management of reproductive tract
infections and sexually transmitted diseases. The Integrated Child Development
Services program was launched in 1975 and covers 70% of the country's
community development blocks and 260 urban slum pockets. Its beneficiaries are
children under 6 years of age, expectant and lactating mothers, and adolescent
girls. The All India Hospitals Postpartum Program, with every hospital including
an outreach program for 50,000 people, seeks to provide family planning during
the post-delivery period. The National Neonatology Forum was created in 1980
and has trained over 15,000 specialists.
Publication Types:
• Review
1814: Gan To Kagaku Ryoho. 1997 Jan;24(2):229-37.
[Our policy and future tasks related to ICH in anti-cancer drug

development--a discussion from the viewpoint of an enterprise]
Ekimoto H.
Anticancer Drugs Dept, Nippon Kayaku Co., Ltd.
International harmonization of data to be submitted in order to receive

governmental authorization for the release of new medicines (ICH) has been
promoted by Japan, the USA and European countries. Because of this trend, the
Japanese drug authority, the medical institutions which perform clinical trials of
not yet authorized new drugs and the pharmaceutical companies which contract
these trials to medical institutions, are now required to change greatly their
conventional views concerning drug development. The trend towards ICH has
also been having a great impact on the development of anti-cancer agents in
Japan. The greatest impact of ICH is that it requires pharmaceutical companies to
take responsibility for the planning, pursuit and management of clinical trials of
new drugs. To meet this requirement, it is urgent that pharmaceutical companies
educate and train staff members involved in drug development, so that they attain
high levels of medical proficiency in the field concerned. It is also necessary for
these companies to organize in house groups of specialists in making clinical
trials, who can evaluate clinical data and make decisions about outcomes by
themselves. At the same time, medical institutions are required to establish a
system which supports the clinical trials carried out within the hospital, while
meeting the appropriate guidelines. Thus, medical institutions are required to
make greater efforts to ensure adequate disclosure of diagnosis of cancer to a
patient, obtain informed consent from patients and develop a hospital system
capable of conducting excellent clinical trials. The governmental authority related
to drugs is required to improve drug administration, including streamlining
regulations and providing consultation services concerning the appropriate
strategy for particular clinical trials. If the relevant governmental authority,
medical institutions, pharmaceutical companies and mass media cooperate with
the goal of improving the environment and systems related to clinical trials, the
current system of clinical trials will be improved significantly, allowing more
scientific and ethical clinical trials. This, in turn, will promote the smoother
development of anti cancer agents in this country. At present, both the views on
and the manner of conducting clinical trials (especially phase I clinical trials)
differ in Japan and Western countries. These differences cause differences in the
scheduling of preclinical studies, possibly leading to delayed commencement of
phase I clinical trials in Japan. Among these issues, the procedures for preclinical
studies of safety and pharmacokinetics studies (absorption, distribution,
metabolism and elimination of drugs) need to be internationally standardized as
soon as possible.
Publication Types:
1815: Paediatr Perinat Epidemiol. 1997 Jan;11 Suppl 1:23-30.

The Israeli Maternal Perinatal Database: methods and preliminary
evaluation.
Zadka P, Barell V.
Central Bureau of Statistics, Health Division, Jerusalem, Israel.
The Israel Maternal Perinatal Database (IMPD) includes the 1980-92 birth cohorts
and was created using deterministic linkage, based on a unique identity number.
This number is assigned at birth for Israeli-born infants and upon acquiring
permanent or temporary residential status for immigrants and is used widely. The
IMPD includes approximately 1.3 million births and about 400,000 mothers with
more than one birth, 40,000 mothers with more than three births and 20,000 grand
multipara mothers with four births or more. The pretest-based estimates of
incorrectly matched births are 2%. The expected percentage of underlinkage is 5-
10% for births occurring before 1985. Since 1985, incorrect maternal
underlinkages result only when a birth occurs out of Israel to an Israeli resident.
One of the advantages of the IMPD is the ability to estimate linkage reliability,
validity and censoring effects by comparison with an external data sources, the
National Population Register, which groups each mother with all her living
children under the age of 18 years. One of the potential analysis pitfalls is the
effect of censoring at entry as a result of influx of immigrants from the former
Soviet Union and Ethiopia.
1816: Public Health Rep. 1997 Jan-Feb;112(1):7-8.
Better records needed for Gulf veterans' health research.
[No authors listed]
Publication Types:
• News
1817: Stud Health Technol Inform. 1997;43 Pt B:884-8.

Primary care informatics: Bhorugram, India: revisited.
Singh AK, Kohli M, Trell E, Kohli S, Wigertz O.
Dept of Primary Health Care & General Practice, Health Faculty, Linköping
University, Sweden.
A Primary Health Care Informatics project was initiated in 1990 at Bhorugram,

Rajasthan, India. It was reported in MIE91 with initial, encouraging results. The
evaluation of the information system has been successful in all operational terms,
and the Fully Immunised Child (FIC) could be used as a local cardinal index to
monitor and evaluate the quality of care, cost-effectiveness and community
participation. Health Systems and Health Economy Research alike have long
searched for apt quality and performance markers that in themselves could
embrace and express a number of aspects and factors. The FIC index is shown to
well meet the criteria of such a cardinal measure in the MCHC services. We, also,
demonstrate an implementation strategy for establishing Information Systems in
Primary Health Care Centres in Developing countries.
1818: Stud Health Technol Inform. 1997;46:508-11.
Development of a computerized patient classification and staffing

system.
Park HA, Park JH.
College of Nursing, Seoul National University, Korea.
Korean health care agencies are trying to find ways to survive amid strong
competition within the health care industry and pressure to open health care
market from abroad. One way to survive is to improve health care quality at
present or reduced expenditure. Nursing is the largest manpower in health care
agencies and plays an important role in determining quality of care through direct
interaction with patients., thus, nursing manpower management is an essential
part of survival strategies. If the nursing department can adapt to dynamic
changes in the health care environment in terms of quality and quantity of service
needed, health care agencies' quality and efficient management will be achieved at
the same time. A computerized prototype patient classification and nursing
staffing system was developed using Microsoft Visual Basic 3.0. This system
allows a user to use GUI(Graphic User Interface) with an icon and a mouse. By
applying this computerized system to clinical practice, nursing managers will
receive accurate information regarding nursing manpower management at nursing
unit level as well as departmental levels. Then nursing managers can achieve
effective nursing manpower management, which will improve nursing care by
allocating more nursing staff time to direct patient care.
Training strategy for nursing staff in using computers in hospitals--a

Malaysian viewpoint.
Mohamad SB, Coote L, Lane V.
Medical Development Division, Ministry of Health Malaysia, Kuala Lumpur,

Malaysia.
The ability of hospitals to fulfil their roles--of information processing and

dissemination, and of quality patient care provider--is influenced by the
availability of supporting information systems. Using computers in wards, which
is a change process, introduces new working practices accompanied by attitudinal
and knowledge alterations in the users. This paper suggests that as a practical
approach users need to be consulted and assessed prior to the introduction of
computers in their work places. A questionnaire survey, the main purpose of
which was to determine the potential users' responses and to measure their
computer competencies, was sent to 183 nursing staff in several hospitals. Results
show that the respondents have slightly positive attitudes towards computers even
though 85% of them were computer illiterate. A training strategy is needed to
increase competencies and to develop more favourable attitudes, which can be
monitored using four training indicators.
A conception of a support system for optimising the organisation of

nursing staff from the viewpoint of the nursing care needs structure.
Tsuru S, Shindob S, Takatanic Y, Seod A.
Institute of Health Sciences, Hiroshima University School of Medicine, Japan.
Methods of allocating nursing staff in hospitals should be established that

improve the "sufficiency rate" of existing care needs for nursing in patients. The
conception of a support system for the optimisation of organising nursing staff
was proposed so that the degree of meeting care needs could be maximised. In
this study, the structure of care needs was defined by sampling information
related to eight factors. A basic framework was developed for a support system
for the optimisation of organising nursing staff by using data based on (1) rate of
satisfying eight selected criteria, (2) condition factors that can affect this rate, and
(3) organising nursing. The possible usage of this support system is also discussed
in this paper.
Publication Types:
1821: World Hosp Health Serv. 1997;33(2):28-34.
Health care's quality improvement imperative.
Parker SS, Vitelli T.
Intermountain Health Care, Salt Lake City, UT, USA.
In health care, as quality improves, costs tend to decline. The goals of excellent
care and affordable costs are not mutually exclusive. Borrowing quality
improvement techniques from manufacturing industries, physicians and other
health care professionals are achieving breakthroughs in improving the quality
and reducing the cost of care. Quality improvement continues the tradition of
scientific inquiry in medicine and places new emphasis on accountability to the
customers of health care: patients and payers. By examining processes, clinicians
look at the delivery of care across different treatment modalities and rely on the
insights of employees involved at every stage of the processes. Intermountain
Health Care is one American health care organization that has experienced
significant success in improving quality and reducing cost through the use of
quality improvement methods.
1822: Health Millions. 1996 Nov-Dec;22(6):14-7.
Integrating HIV / AIDS care in family welfare services: the PSS

experience.
Sharma UG.
PIP: In India, participants of a consultative meeting in early February 1994 in

Haryana State on STD (sexually transmitted disease) and AIDS prevention in
family welfare programs and those at a December 1994 workshop in Jaipur State
on integration of RTI (reproductive tract infections)/STD/HIV prevention
activities into family welfare programs agreed on the need to broaden the scope of
family welfare programs to include RTI/STD/HIV prevention and control. The
meeting participants examined 4 case studies on the issue of RTI and STDs in the
context of family welfare programs. One case study reviewed activities of the
New Delhi-based Parivar Seva Sanstha (PSS), which provides comprehensive
reproductive health services. All PSS staff have received training in HIV
prevention. In Madras, PSS initiated a pilot project to integrate RTI/STD services
into its mainstream family planning services. It tailored experiences of the
Colombian Family Welfare Association (PROFAMILIA) to fit PSS project
objectives. Formative research revealed that both men and women seek STD
diagnosis and treatment services from the private sector despite the high costs and
poor quality of care. Based on these findings and the PROFAMILIA experiences,
PSS developed a model for integrated services for implementation, evaluation,
and eventual replication. PSS has increased its focus on the use of condoms for
contraception and HIV/STD prevention. All female clients now have access to
standard screening, diagnosis, and treatment. PSS will create a new clinic offering
reproductive health services for males. It will also develop systems for partner
referral and community-based programs to provide education and motivation for
family planning and RTI/STD/HIV prevention. Operational research will provide
insight into the needs and perceptions of the population, process evaluation of the
project, and RTI/STD/HIV control. Based on the case studies, certain ideas for
future actions emerged (e.g., a major advocacy drive) as well as ideas for training,
education, counseling, and social marketing and research and evaluation.
1823: Nippon Koshu Eisei Zasshi. 1996 Nov;43(11):946-53.

[International trends in influenza control: preparing for the next

pandemic and vaccination]
Hirota Y.
Department of Public Health, Faculty of Medicine, Kyushu University.
The prevention of influenza continues to be a major public health concern, and a

program of vaccination has been promoted, especially to high-risk individuals
such as the elderly. In addition, concerted efforts are being expended in many
developed countries in order to better cope with the next influenza pandemic.
These efforts include enhancing influenza virus surveillance, improving vaccine
production and its delivery systems, centralizing vaccine distribution and
establishing priorities, etc. In Japan, on the other hand, influenza is only
considered a minor illness, and thus little attention has been give to measures
against influenza. To disseminate information on recent international trends in
influenza control to Japanese public health specialists, I herein outline the
recommendations made at two recent international meetings: "Pandemic
Influenza: Confronting a Reemergent Threat" held in the u.s., at Bethesda,
Maryland, in December 1995; and "The 7th European Meeting of Influenza and
Its Prevention" held in Berlin. Germany, in September 1993. Since a routine
system capable of responding adequately to annual epidemics is considered to be
the best defense against a pandemic, I also describe the present state of influenza
control in other countries to contrast it with that in Japan: the target groups for
special vaccination programs recommended by the U.S. Advisory Committee on
Immunization Practices; the recommendations for influenza vaccination and
reimbursement for the vaccination of recommended groups in developed
countries: and influenza vaccine distribution in Japan and the U.S., 1980-1994. At
present in Japan, the efficacy of the currently used inactivated vaccine is regarded
as either very low or none at all. There is also no official national
recommendations as to what groups should be targeted for active immunization,
nor any system for vaccination reimbursement. Public health specialists in Japan,
therefore need to fully understand Japan's peculiar situation and, as a result, better
recognize the importance of influenza and its prevention.
Publication Types:

1824: Sangyo Eiseigaku Zasshi. 1996 Nov;38(6):262-6.
[A questionnaire study on health administration in small enterprises

in a rural region]
Futatsuka M, Nagano M, Minami R.
Department of Public Health, Kumamoto University School of Medicine, Japan.
A questionnaire study on the health administration of industrial workers was

performed on 230 enterprises in city A in a rural region. Responding subjects
numbered 140 and the response rate was 60.9%. Subjects by scale were: 16%
with more than 50 workers, 48% with from 10 to 49 workers and 36% with less
than 10 workers, and the proportions by industry were: 32% manufacturing, 22%
wholesale-retail trade and 14% construction. The subject proportions classified
according to the health insurance scheme were: 59% government-managed health
insurance, 15% national health insurance and 11% society-managed health
insurance. The rate of periodic health examination was 100% in enterprises with
more than 50 workers, 67.2% in those with from 10 to 49 workers and 51.0% in
those with less than 10 workers. The main reasons why then did not receive health
examinations were: 40% had no time available to conduct examinations, 21%
believed such examinations were not necessary, and 19% did not know of such an
examination system. They encountered some difficulties in promoting health; for
example, the advanced age of workers, and no time or money to spare for health
administration. They desired provision of facilities close at hand for health
examination, health consultation and health information. The results of this study
show the difficulty of promoting health administration in small scale enterprises
and also that it is difficult to obtain accurate information on actUal conditions
including health administration in small enterprises.
Publication Types:
1825: Rinsho Byori. 1996 Nov;44(11):1043-9.

[Standardization of serum lipid examination: an attempt in Oita]
Magari Y, Sato M, Toshimitu S, Toujinbara M, Kumagaya Y, Taguchi I,

Iwasaki Y, Migita Y, Housaka M, Maeda H, Kiyose T, Ito M.
Lipid Unit, Oita Medical Association.
There is an obvious difference in currently available clinical laboratory data

between hospitals. With the advent of information systems, the clinical laboratory
information in the future must be standardized so that it can be used in medical
treatment and health control throughout the life patients time. Establishing
publicly acknowledged standards is essential for standardization to be translated
into practice. The standards for clinical laboratory examination in Japan are
approved by consensus in the Japanese Committee for Clinical Laboratory
Standards (JCCLS). However, standards have yet to be established for most
laboratory examinations. This poses is a major obstacle in promoting the
standardization. Standardization should be implemented carefully with
consideration of the worldwide trend. That is probably the reason why the
consultation and approval at JCCLS have been delayed, but it is hoped that
standards will be established as soon as possible. The committee for quality
control survey in Oita Medical Association organized a Lipid Unit of the
Sectional Committee for Standardization in 1994 and has since implemented
standardization according to the lipid standardization program of the U.S. Centers
for Disease Control and Prevention (CDC) with some modifications. Measures for
improvement have been adopted for a trial period in parallel with four surveys,
and in September, 1995 all 9 hospitals passed the standardization test performed
on the basis of the CDC provisions for certification. The Oita Medical
Association plans to expand the lipid standardization to all parts of the prefecture
using the trial of standardization by the Lipid Unit as a model.
Publication Types:
1826: J Occup Environ Med. 1996 Nov;38(11):1151-60.
Recording, notification, compilation, and classification of statistics of

occupational accidents and diseases: the Thai experience.
Choi BC.
Laboratory Centre for Disease Control, Health Canada, Canada.
An International Labour Organization (ILO) project was conducted in July and

August 1995 in Thailand to assist with the development of an information system
on occupational accidents and diseases for the Workmen's Compensation Fund
(WCF). The WCF provides cash benefits and medical care to insured workers
who suffer employment injuries. The project included literature research based on
the facilities of the ILO in Bangkok, and those of the Thai government, and a
thorough review of the ILO Code of Practice (the Code) on recording and
notification of occupational accidents and diseases, and of other international
recommendations on statistics of occupational accidents and diseases. A
comparative study of various notification systems of occupational accidents and
diseases in Australia, Canada, the Philippines, Sweden, Thailand, and the United
States was conducted. The project also included fact-finding sessions among
various information suppliers and users in Thailand. The Thai notification form
for collecting data for the database was redesigned and pretested. Results of the
project indicated that the Code is appropriate for the recording and notification of
occupational accidents and diseases in Thailand. In addition, a number of
information requirements, which were included in the notification systems in the
countries studied but not listed in the Code, were found to be useful for the
database. A list of the baseline variables to be included in the proposed database
was developed, the notification form was redesigned, and coding schemes for the
information collected on the redesigned form were constructed on the basis of
international standard classification systems for economic activity, employment
status, occupation, nature of injury, occupational disease, body part, type of
accident, and agency. A number of mechanisms were suggested for cross-
checking the accuracy of data in the database. Based on the review of the Code
and other international recommendations on statistical reporting, a list of baseline
statistics was formulated for inclusion in the WCF annual report. Lastly, some
suggestions for future statistical analysis of the database were given.
Publication Types:
1827: Prev Med. 1996 Nov-Dec;25(6):725-9.

Establishment of a work-related diseases surveillance system in
Taiwan, Republic of China.
Wu TN, Liou SH, Wang JD, Shen CY, Ko KN, Yang GY, Lai JS, Ho CK,
Chao SL, Hsu CC, Guo YL, Lai MS, Chang PY.
Disease Surveillance and Quarantine Service, Department of Health, Taipei,

Taiwan, Republic of China.
BACKGROUND: The occurrence of occupational illness and injury has been

seriously underestimated in Taiwan, which subsequently contributes to difficulties
in performing effective control of occupational hazards and implementing
intervention programs for protecting workers. METHODS: Based on the
successful experience of the nationwide blood lead level surveillance program,
the Department of Health, the Executive Yuan, Taiwan, Republic of China, has
established a work-related diseases surveillance system. This government-
administered system requests practicing physicians to report the suspected cases
suffering from six categories of work-related disorders. RESULTS: An
occupational illness and injury surveillance program in Taiwan has been in
operation since June of 1995. CONCLUSION: Background information of work-
related diseases obtained from this surveillance system will be useful for
providing better management of available resources for occupational medicine,
for preventing hazards, and for enforcing occupational diseases prevention
programs. Our experience in establishing this surveillance system will be used in
other countries and settings.
1828: Hum Reprod. 1996 Oct;11 Suppl 2:45-50.
Endometrial vasculature in Norplant users.
Rogers PA.
Department of Obstetrics and Gynaecology, Monash University, Monash Medical

Centre, Clayton, Victoria, Australia.
Disrupted, prolonged and irregular endometrial bleeding are major unwanted side-
effects of progestin-only contraceptives. The aim of this paper is to review current
information on steroid control of the microvasculature, microvascular
heterogeneity and microvascular fragility, with emphasis on the relevance of these
issues to the endometrial microvasculature in women receiving Norplant implant
contraception. Subjects were either Indonesian women with between 3 and 12
months exposure to Norplant (n = 191) or Caucasian controls recruited in
Melbourne, Australia. Norplant endometrium was always thinner than control
endometrium, with a varied histology that usually included a basalis-type
appearance, signs of haemorrhage and some dilated and congested subepithelial
vessels. Thin-walled vessels were seen which could have been either blood
vascular or lymphatics. Steroid control of the vasculature can operate through
numerous direct and indirect mechanisms, with up to 30 genes relevant to
vascular function having consensus oestrogen response elements in their promoter
regions. The vasoactive effects of progesterone are less well documented.
However, experimental data for direct effects on the endometrial vasculature are
mounting. Progestin-induced endometrial breakthrough bleeding is often focal,
suggesting that microvascular heterogeneity may be an important factor in
understanding this phenomenon. Increased susceptibility to bleeding may result
from increased microvascular fragility, possibly as a consequence of progestins
altering the balance of angiogenic promoters and inhibitors in the endometrium,
thus leaving the vessels in a permanently weakened state.
PIP: Enhanced understanding of steroid control of the endometrial

microvasculature, microvascular heterogeneity, and microvascular fragility is
essential to controlling the disrupted, prolonged, and irregular vaginal bleeding
associated with progestin-only contraceptives. A World Health Organization
study involving 191 Indonesian women with 3-12 months of exposure to Norplant
implants yielded important information on these aspects. The endometrium was
consistently thinner (0.4 mm) in Norplant users compared with Australian
controls (5.8 mm). Other histologic features characteristic of the endometrium in
Norplant users included a basalis-type appearance and minimal functionalis, signs
of hemorrhage, dilatation and congestion of subepithelial vessels, spindle-shaped
periglandular cells, and breaks and signs of re-epithelialization in the surface
epithelium. Steroid control of the vasculature can operate through numerous
direct and indirect mechanisms, with up to 30 genes relevant to vascular function
having consensus estrogen response elements in their promoter regions. The
vasoactive effects of progestins are less well documented, but appear to be
independent of their effects on the other tissue compartments. The vasculature
varies considerably from vessel to vessel, and localized rupture of vessels appears
responsible for breakthrough bleeding. It is hypothesized that exogenous
progestin administration perturbs one or more steps of the normal angiogenic
process, producing a situation in which parameters such as basement membrane
breakdown or endothelial cell adhesion molecule expression are altered, leaving
the vessels in a permanently weakened state.
Publication Types:

1829: AIDS Educ Prev. 1996 Oct;8(5):381-93.
Organizing Asian Pacific Islanders in an urban community to

reduce HIV risk: a case study.
Loue S, Lloyd LS, Phoombour E.
Department of Epidemiology and Biostatistics, School of Medicine, Case Western

Reserve University, Cleveland, OH 44106-4945, USA.
We present a case study of community organization efforts within the Asian

Pacific Islander communities of San Diego County to reduce the risk of HIV
transmission. We utilized a five-phase process to implement the strategies of
locality development, social planning, and social action: community analysis,
program design and initiation, program implementation, program maintenance
and consolidation, and program reassessment. An evaluation of the process
indicates that there were increases over time in the project's activities as well as in
the levels of interagency connectedness. This is one of the few reported efforts to
organize Asian Pacific Islander groups to address HIV transmission. Key
elements that led to the successful organization of the original project into a tax-
exempt nonprofit entity (the Asian Pacific Islander Community AIDS Project)
were emphasis on community ownership, reliance on group consensus, use of
"gatekeepers" to access communities, simultaneous multilevel programming, and
service to the community as a "coordinating" entity.
PIP: This case study describes a project begun in March 1993 which sought to
reduce the risk of HIV transmission among the Asian Pacific Islander
communities of San Diego County, California. The project involved the
community organization strategies of locality development, social planning, and
social action which were implemented through five phases: community analysis,
program design and initiation, program implementation, program maintenance
and consolidation, and program reassessment. This report describes each stage in
depth and includes figures which illustrate 1) the time line of organizational,
funding, and programmatic development from March 1993 to February 1995; 2) a
schematic representing organizational efforts within the Asian Pacific Islander
communities to reduce HIV risk and to provide HIV education; and 3) the
percentage of agencies engaging in cooperative activities at baseline, 12 months,
and 18 months. A table summarizes the organizational activities which took place
within the community during the first year of the project. The success of the
project in increasing both its activities and the levels of interagency cooperation
over time is attributed to the accuracy of the initial community assessment and to
a reliance on the basic principles of community organization with an emphasis on
Asian Pacific Islander ownership of the initial project and the nonprofit program
into which it evolved. Other key elements in the strategy were reliance on group
consensus as the basis for decision-making, collection of data from the
community as the basis for program planning, use of "gatekeepers" to access
linguistically and culturally insular communities, simultaneous multilevel
programming, and service to the community as a "coordinating" entity. To date,
no assessment has been made of any changes in HIV seroprevalence rates in the
target community.
Publication Types:
1830: Southeast Asian J Trop Med Public Health. 1996 Sep;27(3):512-21.
Sustainability of a successful malaria surveillance and treatment

program in a Runggus community in Sabah, east Malaysia.
Hii JL, Chee KC, Vun YS, Awang J, Chin KH, Kan SK.
Department of Medical Services, Kudat and Kota Kinabalu, Sabah, Malaysia.
The district of Kudat has one of the highest and most persistent malaria
transmission levels in Sabah, Malaysia, with annual parasite incidence of 102 per
1,000 inhabitants per year. Due to this situation and the failure of DDT spraying
to control malaria, a community participation health program (Sukarelawan
Penjagaan Kesihatan Primer or SPKP) was developed as an adjunct to current
anti-malarial measures during 1987-1991. SPKP is made up of unpaid community
workers known as village health volunteers (VHVs). VHVs are selected by a
village development and security committees training and supervision a member
of the Vector-Borne Diseases Control Program (VBDCP). The beneficiaries of
SPKP consisted primarily of Runggus people and other remote, and mobile
populations who visit the home of a VHV for diagnosis and treatment. This group
of febrile patients and their children who attend a participating school submit
finger prick blood and personal details to the VHV. and receive a presumptive
treatment for malaria. Thick and thin blood smears are examined by a VBDCP
microscopist who then prepare and forward a radical or curative treatment to the
VHV so that it can be administered to the microscopically-positive patient free of
charge. Between June 1987 to June 1991, VHVs from 32 kampungs (villages) and
22 schools collected 56,245 slides representing 24.7% of total slide collection
compared to 74.9% collected by passive case detection (PCD) posts in health
centers and district hospital. The average volunteer treated 11.8 (range 10.4-13.4)
and 31.4 (range 26-49) patients per month in kampungs and schools respectively.
In contrast, non-SPKP posts in a district hospital, health centers and flying doctor
service treated an average of 616.3 patients per month (range 134.8-1032.8). The
slide positivity rate of blood smears taken by VHVs was 8.43% compared with
7.37% for non-SPKP posts. Average slide collection and slide positivity rates
varied considerably from one community to another, despite their close
geographic proximity. The monthly number of VHV-diagnosed patients from the
school and kampungs communities and the monthly number of true malaria
patients in the two groups were significantly correlated. Sustainability of SPKP
was linked to an ongoing process of social change which involved co-operative
networking between the government health sector and the community. This in
turn provided a stimulus for malaria abatement efforts. When Runggus people
themselves control and maintain ownership of community-based malaria
programs, the function of SPKP as a malaria surveillance system and an
antimalarial drug distribution network is vastly improved.
1831: Med Educ. 1996 Sep;30(5):378-84.
Specialty choice and understanding of primary care among

Japanese medical students.
Ohtaki J, Fujisaki K, Terasaki H, Fukui T, Okamoto Y, Iwasaki S, Tsuda T.
Division of Postgraduate Education, Institute of Clinical Medicine, University of

Tsukuba, Japan.
To assess specialty choice and understanding of primary care among Japanese

medical students, all students from seven Japanese medical schools (three public
and four private) were surveyed, using a written questionnaire. A total of 3377
students provided data for the study. Of the students surveyed, 89.8% wanted to
become clinicians, and 79.3% wanted to have general clinical ability. About half
of the respondents, 54.9%, replied that they had some, or great, interest in primary
care, but it was found that their understanding of primary care was inadequate.
Almost half (56.3%) of the students answered that they had some idea of what a
general practitioner did. This proportion was nearly the same through all years of
medical school. While 1245 (36.9%) students (most of them in the fifth or sixth
year) replied that they had received some clinical training while working in
hospitals, only 203 (6.0%) students had worked in private clinics (the sites where
most primary care is still provided), and 129 (3.8%) students had experience in
providing home visits and home care. An even greater number, 64.3%, replied
that they had inadequate information about the career options available to them.
The study found that although many Japanese medical students want to obtain
broad clinical competence, their understanding of primary care is insufficient. In
order to increase the number of primary care providers the system of medical
education in Japan must provide primary care doctors to act as role models, and
must make available information about postgraduate primary care programmes.
These programmes need to be increased, as do rewarding positions for
programme graduates.
Publication Types:
1832: JOICFP News. 1996 Aug;(266):5.

Related Articles
Embracing the reproductive health approach. Global perspective.
Gardiner C.
PIP: Dr. Charlotte Gardiner, technical officer of the Reproductive Health Branch,
Technical and Evaluation Division, United Nations Population Fund (UNFPA),
was interviewed on June 6 concerning the focus of UNFPA on reproductive
health following the International Conference on Population and Development
(ICPD) and the role foreseen for JOICFP in implementing the Program of Action.
Her remarks include the following information. UNFPA has high regard for the
JOICFP program in family planning (FP) because of its community-based
approach. The perceptions of the community dictate the way the project is
fashioned; local needs are met; services are acceptable; and the quality of care is
ensured. JOICFP's approach has always been integrated (controlling intestinal
parasites; nutrition; family planning). It has operated one of the earliest
reproductive health (RH) programs, an approach to FP that would better fit
Africa's local needs and that has been successful in Asia and Latin America. Over
the years UNFPA has increasingly supported the RH approach, one that integrates
the vertical type of FP program in a maternal and child health (MCH) framework.
The ICPD has moved further into a RH approach where FP becomes a changing
concern over the lifespan of a woman and more attention is paid to the
relationship between contraception and health. The ICPD has focused on the
needs of adolescents for FP information and services. UNFPA will support
programs that incorporate information and services for prevention, early
detection, and management of sexually transmitted diseases, especially human
immunodeficiency virus (HIV) infections. Another goal of the ICPD is to reduce
the high maternal mortality rates that exist in most of the developing world, so
UNFPA will continue to advocate the integration of FP in maternity care
programs and to support integration of obstetric care interventions in the public
health care system. UNFPA sees FP programs as an important means of
preventing abortion and reducing the impact that abortion has on maternal health.
1833: J Med Syst. 1996 Aug;20(4):197-205.
Implementation of HL7 to client-server hospital information system

(HIS) in the University of Tokyo Hospital.
Ohe K, Kaihara S.
Hospital Computer Center, University of Tokyo Hospital, Japan.
In developing a large-scale Hospital Information System (HIS), a client-server

architecture has been gaining in popularity. It is important to introduce a standard
message protocol that is independent both on the database structure and on the
vender's proprietary platform. We introduced Health Level Seven (HL7) to our
hospital information system. From our experiences, although we had to modify
the original HL7 specifications in order to introduce the protocol to a client-server
HIS especially in the area of order entry and record-oriented query, it was found
that HL7 can be adopted in a client-server HIS.
1834: J Epidemiol. 1996 Aug;6(3 Suppl):S147-57.
Health information system.
Minowa M, Hayashi M, Kitai A, Koyama A, Otani Y.
Department of Epidemiology, National Institute of Public Health, Tokyo, Japan.

Outline of selected ones among a number of nationwide surveys related to health
and welfare services (90 surveys as of 1995) conducted mainly by the Ministry of
Health and Welfare periodically in Japan is described. That is, history, purpose,
coverage, date, contents, data collection procedure, tabulation and publication
were explained in regard to : (1) Population Census, (2) Vital Statistics, (3)
Patient Survey, (4) Infectious Disease Surveillance System, (5) Comprehensive
Survey of Living Conditions of People on Health and Welfare, (6) Census on
Medical Care Institutions, (7) Hospital Report, (8) Survey on Physicians, Dentists
and Pharmacists, (9) Statistical Report on Public Health Administration Services,
(10) Survey on Social Welfare Institutions, and (11) National Nutrition Survey.
On-line data service system of the Ministry of Health and Welfare is also briefly
mentioned.
1835: J Epidemiol. 1996 Aug;6(3 Suppl):S81-5.
Surveillance system of infectious diseases in Japan.
Ohshiro H, Kawamoto K, Nose T.
Department of Public Health Faculty of Medicine, Tottori University, Yonago,

Japan.
The surveillance system of infectious disease in Japan started in 1981 and has
been providing useful epidemiological information on 27 communicable diseases.
The system consists of medical institutions (fixed monitoring stations),
institutions of hygienic sciences, health centers, local governments and the
ministry of health and welfare. There are two types of information about
infectious diseases. One is clinical reports of incidence cases from medical
institutions, and the other is laboratory information about etiologic agents.
Between health centers, local governments and the department of statistics and
information in the ministry of health and welfare, information is transmitted
through the on-line network. Collected information is analyzed and submitted by
both local and central committees of analysis. From the epidemiological point of
view, quality control of the data and integration of other sources of data would be
the next goal of the system.
1836: Toxicol Lett. 1996 Aug;86(2-3):131-42.

Exposure to environmental chemicals relevant for respiratory
hypersensitivity: global aspects.
Schwela D.
World Health Organization, Geneva, Switzerland.
Trends of air pollutant concentrations that influence the incidence of respiratory

diseases and might be influential for respiratory hypersensitivity are presented and
discussed. Data for these trends are collected in UNEP/WHO's Global
Environmental Monitoring System GEMS/Air which recently has been revitalized
and redirected to become a tool for providing the information necessary for
rational air quality management. Data are interpreted with respect to WHO's most
recent air quality guidelines, which are an update of the air quality guidelines for
Europe published in 1987. A WHO study on the global disease burden and the
contribution of air pollution to it is discussed and global estimates of mortality
resulting from air pollution through sulphur dioxide and suspended particulate
matter, by different economic regions, are given. Starting from the air quality
guidelines still valid at the time of publication of the update, about 460,000 excess
deaths globally are due to suspended particulate matter and about 370,000 to
sulphur dioxide.
Publication Types:
• Review
1837: MMWR Morb Mortal Wkly Rep. 1996 Jul 5;45(26):565-8.
Progress toward global eradication of poliomyelitis, 1995.
Centers for Disease Control and Prevention (CDC).
In 1988, the World Health Assembly established a target to eradicate

poliomyelitis worldwide by the year 2000. To achieve this goal, the World Health
Organization (WHO) recommends four strategies: 1) achievement and
maintenance of high routine vaccination coverage levels among children with at
least three doses of oral poliovirus vaccine (OPV); 2) development of sensitive
systems of epidemiologic and laboratory surveillance, including the use of the
standard WHO case definition; 3) administration of supplementary doses of OPV
to all young children (usually those aged < 5 years) during National Immunization
Days (NIDs) to rapidly interrupt poliovirus transmission; and 4) "mopping-up"
vaccination campaigns--localized campaigns targeted at high-risk areas where
poliovirus transmission is most likely to persist at low levels. This report updates
progress toward global polio eradication based on information submitted to WHO
as of April 15, 1996.
1838: AVSC News. 1996 Summer;34(2):7.

Related Articles
Orienting Egyptian service providers to the needs of high-risk

women.
Neamatalla G, Guimei M.
PIP: Since 1993, the AVSC has been collaborating with three university hospitals
in Egypt to pilot-test a service model aimed at increasing contraceptive access and
reducing the number of high-risk pregnancies. The Safe Reproductive Health
Program offers screening, referral, and counseling for Egyptian women at high
risk of maternal and infant morbidity and mortality. The program is part of a
broader strategy to expand the national family planning program's method mix
and increase the use and availability of postpartum contraception. Central to the
program have been one-day training workshops (for hospital doctors, nurses,
social workers, and administrators from the departments of obstetrics,
gynecology, and pediatrics) aimed at increasing awareness of the nature and
magnitude of Egypt's maternity risk and fostering a client-oriented service
approach. The multidisciplinary nature of these orientations has facilitated
emergence of a team approach to services. Postpartum IUD services have been
initiated at the three hospitals, and there is increased support for tubal ligation
services for high-risk women. A client information system is being introduced to
strengthen and monitor referral links. The government of Egypt has requested
AVSC assistance in expanding this program to other university hospitals and to
the national public sector program over the next two years.
1839: Popul Headl. 1996 Jul-Aug;(253):4.

ESCAP helps Bangladesh develop population information network.
[No authors listed]
PIP: The Economic and Social Commission for Asia and the Pacific (ESCAP)
provided technical support to a July 1996 workshop on strengthening the Asia-
Pacific POPIN model for building a decentralized system of national and local
population information service providers for Bangladesh. Population information
is vital to Bangladesh's ability to sustain family planning (FP) program gains, and
an improved system is necessary to improve delivery of data and information to a
variety of users working in the areas of reproductive health and FP, population
and development, and population program advocacy.
1840: Indian J Matern Child Health. 1996 Jul-Sep;7(3):63-8.

Related Articles
Health education at PHC level -- status and strategies.
Lal S, Jain RB, Khanna P, Malik JS.
PIP: The Government of India's National Health Policy emphasizes the

importance of health education programs to primary health care. Implementation
of this strategy was evaluated through both quantitative and qualitative methods
among 32 multipurpose health workers, 5 health supervisors, 60 anganwadi
workers, 32 adult education instructors, 73 school teachers, and 10 women's
groups in Haryana, India. Despite the official emphasis on health education, this
function is not included in the job descriptions of health workers, training is not
provided, and locally relevant IEC materials are not available or distributed.
Home visits focus mainly on family planning, deliveries, and malaria and rarely
include a health education component. Management of health education is the
responsibility of the Block Extension Educator, who failed to distribute many IEC
materials or conduct training activities. 62.5% of health workers indicated they
used IEC materials only once a month. Moreover, monitoring of health education
activities was sporadic and incomplete. Work plans emphasize physical targets
(i.e., number of meetings) rather than the quality of educational interventions. No
operations research studies were conducted. Overall, these findings suggest a need
for integration of health care delivery and communication activities, training of
health workers in health education techniques, field evaluation of IEC materials,
establishment of a system to provide field workers with feedback on their work,
and greater use of mothers' groups and school-based programs for interpersonal
communication.
1841: Ann Acad Med Singapore. 1996 Jul;25(4):487-91.
Review of published clinical trials conducted in Singapore from 1959

to 1994.
Lee HP, Chia SE.
Department of Community, Occupational, Family Medicine National University

of Singapore.
Trials are increasingly being used to evaluate the effectiveness of health care
interventions. As has been recognised by those active in these activities, there is a
need, not only to search for all published materials, but also to evaluate their
quality and usefulness. This paper is an attempt to provide information and to
examine the areas of focus and quality of information on all published clinical
trials conducted in Singapore from 1959 to 1994. The searches were conducted
using the MEDLINE CD-ROM for the period from 1966 to 1994 and manual
search for the period before 1966. All published studies involving drugs or
procedures (surgical techniques or instrumentation) on human subjects performed
in Singapore were included in the study. Out of a total of 136 papers obtained, 90
fulfilled our criteria. There is an increase in the number of publications over the
years especially in the last 10 years; with the biggest surge in the last 5 years.
Most of the clinical trials were pharmacological intervention studies (57.8%)
although there is a steady rise in non-pharmacological studies recently. As the
number of clinical trials increases, coupled with the rising cost, it would be useful
for the relevant authorities to consider setting up a registry to co-ordinate the trials
that are being conducted.
Publication Types:
• Review
1842: Stud Fam Plann. 1996 Jul-Aug;27(4):179-87.

Why did maternal mortality decline in Matlab?
Maine D, Akalin MZ, Chakraborty J, de Francisco A, Strong M.
Prevention of Maternal Mortality Program, Columbia University School of Public

Health, New York, NY 10032, USA.
In 1991, an article on the Maternity Care Program in Matlab, Bangladesh,

reported a substantial decline in direct obstetric deaths in the intervention area,
but not in the control area. The decline was attributed primarily to the posting of
midwives at the village level. In this article, data are presented from the same
period and area on a variety of intermediate events. They indicate that the decline
in deaths was probably due to the combined efforts of community midwives and
the physicians at the Matlab maternity clinic. Their ability to refer patients to
higher levels of care was important. The data further indicate that the decline in
deaths depended upon the functioning of the government hospital in Chandpur,
where cesarean sections and blood transfusions were available. Midwives might
also have made a special contribution by providing early termination of
pregnancy, which is legal in Bangladesh.
PIP: Data were collected during 1993 from the Matlab Demographic Surveillance
System, midwives' cards, the Matlab maternity clinic record book, and records at
the government's district hospital. This study analyzed these data in order to
determine why maternal mortality declined in the intervention area. Direct
obstetric deaths declined from 20 deaths during the 3 years before the Maternity
Care Program was implemented to 6 deaths during the 3 years after program
implementation. In the control area, mortality remained stable at 20 deaths during
the same time period. The declines were apparent among diagnoses for induced
abortion, eclampsia and pre-eclampsia, and prolonged obstructed labor. There
were few changes in causes of death in the control area. During the intervention
period, midwives in villages administered services to 49 women with
preeclampsia, of whom 6 later developed eclampsia. There were 20 referrals to
the maternity clinic for a variety of complications including eclampsia. The
Matlab clinic received 54 patients during the intervention period with a primary
diagnosis of pre-eclampsia or eclampsia. Midwives provided care for 77 women
with prolonged labor. Matlab clinic received 116 patients due to prolonged labor.
4% of the 2364 midwives' cards indicated referral. 83% of referrals were to the
Matlab clinic. The Matlab maternity clinic had 300 admissions during the study
period, of which 65% (194 women) were from the intervention area. Women from
the intervention area were 2.3 times more likely to be treated at the Matlab clinic
than women from the control area. 69% of admissions at Chandpur District
Hospital were from the Matlab intervention area. Case fatality rates in the hospital
did not differ among intervention and control populations. The authors conclude
that greater use of midwives, referrals and proper transport, and better service
conditions significantly contributed to maternal mortality decline.
1843: Sangyo Eiseigaku Zasshi. 1996 Jul;38(4):156-7.
[A study of industrial poisoning from official reports of accident

investigations]
Katoh K, Sawatari K.
National Institute of Industrial Health, Japan.
1844: Soc Sci Med. 1996 Jul;43(2):173-86.
The influence of budget-holding on cost containment and work

procedures in primary care clinics.
Gross R, Nirel N, Boussidan S, Zmora I, Elhayany A, Regev S.
JDC-Brookdale Institute of Gerontology and Human Development, J.D.C. Hill,

Jerusalem, Israel.
In 1990, Kupat Holim Clalit (KHC), Israel's largest health insurance fund,
initiated a demonstration program for transforming primary care clinics in the
Negev district of southern Israel into autonomous budget-holding units. Four
program components were implemented in nine clinics: allocation of a fixed
budget; expansion of day-to-day decision-making authority; establishment of a
computerized information system for producing monthly reports on expenditure;
and provision of incentives for budgetary responsibility (returning part of a
clinic's savings for use at its discretion). The demonstration program had three
objectives: budgetary control and cost containment; improvement of services and
increased client satisfaction; and improvement in the motivation, initiative,
responsibility, and satisfaction of clinic staff. This report presents interim findings
from an evaluation study of the budget-holding program conducted in 1991-1992.
The report considers three questions: How was the demonstration program
implemented? Did work procedures in the clinics change following
implementation of the program? How did budget-holding influence levels of
expenditure in the clinics? The program components were implemented gradually
in the nine clinics during 1991-1992. Not all, however, were fully implemented.
The staff survey conducted after implementation of the program identified a
number of changes in the work procedures of the clinics: heightened cost
consciousness, discussion of the monthly expenditure reports, emphasis on the
need to economize, and attempts to economize. Data on expenditure in the
budget-holding clinics were analyzed and compared to data on expenditure in
primary care clinics in the Negev district as a whole. It was found that while the
average quarterly per capita expenses in the district increased in real terms from
1991-1992, expenses in the budget-holding clinics remained stable or, in some
cases, actually decreased. While we cannot conclude categorically from the
existing data that the budget-holding program is responsible for the unique
patterns of expenditure in the nine clinics, we can confidently state that work
procedures in the nine clinics changed following implementation of the program
and that the clinics achieved cost containment relative to the district as a whole.
Findings from the various research tools support one another, and reinforce the
conclusion that budget-holding can potentially promote cost containment.
1845: Pacing Clin Electrophysiol. 1996 Jul;19(7):1117-21.
The health insurance system in Japan.
Watanabe Y.
Toyota Regional Medical Center, Japan.
The steadily increasing cost of medical care associated with advancing medical
technology as well as the rapid progression of generalized aging of the society has
become a major socioeconomical issue confronting most developed countries.
Although Japan is no exception in this regard, and a drastic modification of the
health care system is now being discussed, it is also clear that its postwar health
insurance system has played a major role for the Japanese achieving the longest
life expectancy in the world (over 82 years for female and 76 years for male) in
the past decade. It is thus my understanding that the invitation for this brief
review reflects the need for reference information regarding the current debate in
the North American continent.

1846: MMWR Morb Mortal Wkly Rep. 1996 Jun 21;45(24):513-6.
Epidemic malaria--Tadjikistan, 1995.
Centers for Disease Control and Prevention (CDC).
In June 1995, the Tadjikistan Ministry of Health (MOH) and CDC, with support
of the U.S. Agency for International Development, began collaborative efforts to
strengthen the health information and disease surveillance systems in Tadjikistan
(1995 population: 5.7 million). As part of an initial evaluation in Tadjikistan, the
Republican Sanitary and Epidemiologic Service (RSES) and the Parasitology
Laboratory of the Institute for Preventive Medicine in the MOH reported a
substantial increase in the incidence of malaria since 1991. This report
summarizes malaria surveillance data for 1995 in Tadjikistan and describes
barriers to implementing effective measures for controlling and preventing
malaria in Tadjikistan.
1847: J Acad Hosp Adm. 1996 Jul-1997 Jan;8-9(2-1):17-9.
Automated microbiology culture system for upgradation of the

emergency microbiology services for better patient care.
Singh S.
Department of Laboratory Medicine, All India Institute of Medical Sciences, New

Delhi.
1848: Health Libr Rev. 1996 Jun;13(2):69-80.
The 'market' for medical and health information in transition: the

case of the Hong Kong Hospital Authority libraries.
Cheng G.
Hong Kong Hospital Authority.
The last few years have been a period of transition not only for hospitals and their
governance but also for post-graduate medical education in Hong Kong. Both
trends have a direct impact on the information market place. This article starts by
studying the provision of medical and health-related information in Hong Kong.
The two university medical and dental libraries, together with the hospital and
health sciences libraries in government hospitals and the Department of Health,
house the major collections on medicine and health care. The demand for medical
and health care information is increasingly felt with the takeover of 39 hospitals
by the statutory Hong Kong Hospital Authority in 1991. The major problems and
issues in planning for library information services are the historically uneven
development of libraries, discrepancies in funding, the changes in organizational
and management structure, and the competition with higher development
priorities within the organization. In view of current technology and the
availability of rich external resources, the adopted strategies tend towards the
formation of 10 library service networks, development of integrated library
information systems on the Health Authority-wide area network, and the
devolution of management responsibilities. The future challenges in store for the
information professional are examined.
1849: Indian Pediatr. 1996 May;33(5):367-72.
Community based estimation of perinatal mortality through record

linkage.
Singh A, Kaur A.
Department of Community Medicine, Post Graduate Institute of Medical

Education and Research, Chandigarh.
OBJECTIVE: To estimate perinatal mortality through record linkage of Health

Workers (HW) and Anganwadi Workers (AWW) in rural Haryana. DESIGN:
Retrospective analysis of records (1991-92) of HW and AWW. Enquiry and home
visits were made for tracing the fate of pregnancy in cases with incomplete
records. SETTING: In 1993-95 in 45 villages selected purposively in Raipur Rani
block, Ambala. MAIN OUTCOME MEASURE: Enlisting of perinatal deaths as
the main outcome measure through scrutiny of records of HW and AWW.
RESULTS: Perinatal mortality rate (PMR) was 42.25 and 45.78 per thousand
births as per the record of HW and AWW, respectively for the 23 villages for
whom records of both were available. Support by enquiry or home visit yielded a
PMR of 59.42 for combined HW and AWW sources and 51.66 per 1000 births for
AWW source alone. Concordance between AWW and HW records for fate of
pregnancy was moderate (K = 0.46; 95% CI 0.35-0.57). CONCLUSIONS: There
is a lack of a system of record linkage between and within the records of HW and
AWW at primary health care level. AWW data was more accurate and up-to-date
as compared to HW. Reasonably accurate estimates of perinatal mortality rate can
be made through record linkage.
PIP: In India, October 1991-September 1992 data were abstracted from records on
pregnant women, postpartum cases, and infants' immunization status procured
from health workers (HWs) and Anganwadi workers (AWWs) working in 23
villages of Raipur Rani block, Ambala, in Haryana State. Home visits and enquiry
were conducted to learn pregnancy outcomes in cases with incomplete records.
The purpose was to determine whether the record linkage approach is a feasible
means to estimate the perinatal mortality rate (PMR). Among the 1954
pregnancies registered by either an AWW or HW, both AWWs and HWs had
information available on only 510 (26%) cases. HW and AWW records agreed on
outcome of 431 (84.5%) of the 510 pregnancies (Kappa = 0.46 for agreement [i.e.,
moderate agreement]). Among the remaining pregnancies, AWWs had more
information than HWs (46% vs. 28%). The PMR estimated from AWW records
alone or from combined HW and AWW sources was higher than that estimated
from HW records alone (51.66 and 49.18, respectively vs. 10.9/1000 births), but
the difference was not statistically significant. For both AWWs and HWs, live
birth outcomes were more likely to be recorded than still births or early neonatal
deaths (97.8% vs. 72%) and less likely to be determined via enquiry or home
visits (2.2% vs. 28%) (p 0.001). The same pattern was true for AWWs alone
(95.6% vs. 57% and 2.4% vs. 43%, respectively; p 0.001). HWs were more likely
not to record pregnancy outcomes than AWWs (16-17% vs. 8-9%). These
findings indicate no record linkage system between the records of HWs and
AWWs at the primary health care level and that AWW data were more accurate
and up-to-date than HW data.
Publication Types:
1850: Toxicol Ind Health. 1996 May-Aug;12(3-4):427-34.

Fish consumption advisories and outreach programs for Southeast
Asian immigrants.
Shubat PJ, Raatz KA, Olson RA.
Division of Environmental Health, Minnesota Department of Health, St. Paul

55164-0975, USA.
Southeast Asian immigrants and refugees, in particular the Hmong people of

Laos, have settled in large numbers in metropolitan areas of Minnesota. These
communities, accustomed to hunting and fishing for food in Laos, now fish in
some of the most contaminated waters of Minnesota. Fishing and fish-preparation
customs of their homeland emphasize using all fish caught and discarding very
little waste. These practices result in a potentially high exposure to PCBs and
mercury. Educational outreach efforts to inform this population of the potential
health hazards from consuming the fish are hindered by language and cultural
barriers. While most Hmong anglers welcome information about contaminants
and fishing, the typical press releases and mailings that convey fish advisory
information to the public do not reach this community. The Minnesota
Department of Health and the Minnesota Department of Natural Resources
collaborated to determine the health messages and communication methods that
would best meet the needs of these communities. Using the results of interviews
and a behavioral survey, the Minnesota Department of Health has tailored fish
consumption advisories to meet the unique needs of Southeast Asian anglers.
Over the past four years, educational programs involving specialized advisories,
translations, signs, a Hmong language video, and workshops have been used to
inform Hmong anglers and other Southeast Asians about fish contaminants.
1851: Orthop Nurs. 1996 May-Jun;15(3):39-47.
Health care Chinese style.
Wienke K.
Marquette University College of Nursing, Milwaukee, Wisconsin, USA.
This article presents observations from an October 1993 visit to the People's
Republic of China with a delegation of orthopaedic nurses who toured hospitals
throughout the nation. The author provides information that allows the reader to
compare the health care system of the United States with that of the People's
Republic of China, outlining the effects of political rule, population, pollution,
and economics on the development of the Chinese health care system. The
historical and current state of medical theory and medical and nursing education
are described along with personal observations and experiences from the author's
tour.
1852: Natl Med J India. 1996 May-Jun;9(3):113-7.
Effect of indoor air pollution on the respiratory system of women

using different fuels for cooking in an urban slum of Pondicherry.
Dutt D, Srinivasa DK, Rotti SB, Sahai A, Konar D.
Jawaharlal Institute of Postgraduate Medical Education and Research,

Pondicherry, India.
BACKGROUND. Some of the highest exposures to air pollutants in developing

countries occur inside homes where biofuels are used for daily cooking.
Inhalation of these pollutants may cause deleterious effects on health. We studied
the effects of exposure to indoor air pollution from the use of cooking fuels on
lung functions and respiratory symptoms in women aged 15-60 years.
METHODS. The study was conducted in Kuruchikuppam, an urban slum in
Pondicherry. The study participants were 105 women using biofuels, 105 using
kerosene and 105 using liquid petroleum gas (LPG), selected from among 1117
women aged 15-60 years, by a stratified random sampling technique. These
women were interviewed at home to collect information about exposure to fuel
smoke and presence of respiratory symptoms. Lung functions were assessed by
measuring forced vital capacity (FVC), forced expiratory volume in the first
second (FEV1) and peak expiratory flow rate (PEFR). Occurrence of respiratory
symptoms over six months was noted by making monthly follow up visits.
RESULTS. Women using biofuels experienced more respiratory symptoms (23%)
than those using kerosene (13%;p > 0.05) or LPG (8%; p < 0.05). Lung functions-
FVC, FEV1, FEV1% and PEFR-were significantly lower in biofuel users
compared with both kerosene (p < 0.01) and LPG users (p < 0.001). Lung
functions in kerosene users also were significantly poorer when compared with
LPG users (p < 0.01). Predicted pulmonary functions using multiple regression
equations, derived from the data set of the present study, indicated that women
using biofuels were more liable to have reduced pulmonary functions than women
using kerosene or LPG. CONCLUSION. Women exposed to biofuel smoke suffer
more from respiratory illnesses and have decreased pulmonary functions
compared with women exposed to kerosene or LPG smoke. To reduce pollutant
exposures we recommend the use of smokeless chullas or cleaner fuels such as
charcoal, biogas and kerosene.
1853: Neurology. 1996 May;46(5):1287-91.
Risk factors for Creutzfeldt-Jakob disease: a reanalysis of case-

control studies.
Wientjens DP, Davanipour Z, Hofman A, Kondo K, Matthews WB, Will RG,

van Duijn CM.
Department of Epidemiology & Biostatistics, Erasmus University Medical

School, Rotterdam, The Netherlands.
To review the evidence for risk factors of Creutzfeldt-Jakob disease (CJD), we

pooled and reanalyzed the raw data of three case-control studies. The pooled data
set comprised 178 patients and 333 control subjects. The strength of association
between CJD and putative risk factors was assessed by computing the odds ratio
as estimate of the relative risk. The risk of CJD was statistically significantly
increased for subjects with a family history of CJD (odds ratio = 19.1; 95% CI 1.1
to 348.0). Further, there was a significant association between the risk of CJD and
a history of psychotic disease (odds ratio = 9.9; 95% CI 1.1 to 86.1). Although not
significantly increased, there was an elevated risk of CJD for subjects with a
family history of dementia, a history of poliomyelitis, subjects employed as health
professionals, and subjects ever exposed to cows and sheep. No association could
be shown with organ meat consumption, including brain. The negative results of
this reanalysis reassures the absence of a common risk factor in all CJD patients.
However, the ongoing epidemiologic surveillance of CJD in several European
countries may provide more evidence to exclude any environmental exposure
early in childhood.
Publication Types:

• Review
1854: Harefuah. 1996 Apr 15;130(8):561-6.

[National policy in the fight against cancer]
[Article in Hebrew]
Robinson E.
1855: Harefuah. 1996 Apr 15;130(8):521-3, 583.
[Coping with AIDS in a support group--an encounter with the

health system]
[Article in Hebrew]
Weishut DJ.
Israel AIDS Task Force, Tel Aviv.
We present the first documentation of a short-term support group for the HIV-
infected and those with AIDS in Israel. The group enabled its members to cope
with existential issues and with the psychological, social and medical hardships of
these conditions, thus becoming an essential support factor in their lives.
Participation in the group resulted in better compliance with medical treatment
and helped improve psychological symptoms. It is important to stress the
contribution such a support group can offer these people. The image of the health
system in their eyes is presented. The 4 main areas of hardship in the encounter
between the HIV-infected and those with AIDS with the health system are:
ensuring privacy, consistency in procedures and in providing information,
sensitivity to the emotional state of the individuals, and communication between
physician and patient. It is important to bring the distress of these people to the
attention of physicians so that they can show a sensitive and empathetic attitude
and facilitate dialogue with the patient. It is important for medical teams to be
both consistent in procedures involving the HIV-infected and patients with AIDS
and in providing information, as well as ensuring privacy.
Publication Types:
• Case Reports
1856: China Popul Today. 1996 Apr;13(2):9-10.
Population and family planning in Tibet.
China. China Population Information and Research Centre. Tibetan

Population Study Team.
PIP: This article summarizes findings from a summary report produced by a six-
member team sent by the China Population Information and Research Center to
Tibet Autonomous Region. The study project aimed to develop a five-year
population plan for 1996-2000. Project members toured eight counties and cities
in Shannan, Lhasa, Hyingchi, and Xigaze prefectures in 1995. Tibet's total
population was an estimated 2.43 million in 1995. 1990 Census findings indicate
that 95.5% were Tibetans, 3.7% were Han, and 0.8% were other ethnic groups.
The total fertility rate (TFR) in 1989 was 4.2 children/woman. TFR is expected to
decline to 3.0 in the year 2000. It is generally accepted that Tibet should maintain
a growth rate of around 16.7/1000. Tibet's family planning program began in
1980 with the promotion of the one-child family norm among officials, workers,
and urban residents of Han nationality living in Tibet. Urban Tibetans were
allowed to have two children with a birth interval of 3 years and a third birth with
government approval. Family planning was also promoted among farmers and
herdsmen (88% of the total population). Family planning, at present, is practiced
predominantly by urban residents (12% of the total population). A study of family
planning in Dixin Township revealed that 44% of married reproductive-age
women practice family planning. Family planning is under the authority of the
Regional Family Planning Office and is affiliated with the Bureau of Public
Health. There are 43 full-time family planning officials in all 7 prefectures and 74
counties. Most family planning services are handled by part-time medical and
health staff in the public health system. The family planning program has resulted
in 150,000 averted births. TFR declined from 5.8 children/woman in 1980 to 3.5
at present. This decline is attributed to women's desire for family planning and the
fertility policy. The preferred methods include the IUD and Norplant. Unmet need
is great.
1857: China Popul Today. 1996 Apr;13(2):6.

Jiangsu aims at quality services.
[No authors listed]
PIP: This news brief discusses population growth and achievements in family
planning in one of China's most economically developed provinces, Jiangsu.
During the Five-Year Plan of 1991-95, population growth was controlled
sufficiently to result in 300,000 births averted due to improvement in family
planning. Provincial leaders and family planning workers agree that
modernization may be achieved by the year 2000 by shifting the emphasis of
family planning to economic development. The provincial government plans to
offer a comprehensive package of contraceptive and reproductive health services
to women of childbearing age. An information management system is planned for
Taicang City. The aim is to show underdeveloped areas of the province the
successful family planning experiences in Yancheng City. The Jiangsu
government has a standardized management system that allows for the delivery of
information and technical services and an improved supply of contraceptives.
Over 95% of towns and service rooms had family planning service stations and
population schools in 1995. Over 60% of villages had branch schools that
provided family planning information and services. A public media campaign is
planned that would spread information on childbirth, contraception, and
reproductive health. This system would link IEC between the province, counties,
and townships and facilitate delivery of services. Each county must establish an
information management system for population and family planning.
1858: China Popul Today. 1996 Apr;13(2):5.

Related Articles
Henan intensifies family planning implementation.
[No authors listed]
PIP: This news brief describes some measures taken by the Henan Provincial
Government to strengthen family planning. Henan, which is centrally located in
an agricultural area of China, loosened its family planning implementation during
1986-90. The result was increased population. During 1991-95, and with effective
measures to improve family planning, the birth rate declined from 24.92/1000 in
1990 to 14.70/1000 in 1995. The rate of natural increase declined to 8.13/1000.
Henan has a population target management responsibility system that is managed
by the provincial Party Secretary and Governor. During the early 1990s the
provincial government strictly implemented the family planning regulations and
improved service delivery at centers and stations. Officials and Party members
were urged to be examples in the practice of family planning. Population schools
are now being set up at the township level. These schools will use audiovisual
teaching aids and other curricula to increase awareness of the population issues.
At the village level, information on population and family planning will be
distributed.
1859: Control Clin Trials. 1996 Apr;17(2):99-110.
Japanese and American reports of randomized trials: differences in

the reporting of adverse effects.
Hayashi K, Walker AM.
Department of Population and International Health, Harvard School of Public

Health, Boston, Massachusetts, USA.
We sought to identify differences in the description of adverse drug experiences

in reports of randomized clinical trials (RCTs) from the United States and Japan,
using diclofenac and simvastatin as test drugs. Reports were identified in Medline
(Index Medicus 1966-1990), EMBASE (Excerpta Medica 1974-1990),
JAPICDOC (1979-1990), and JOIS-III (JMEDICINE 1980-1990). In each search
keywords describing study design were paired with the drugs' generic names,
chemical names, and development numbers. Twenty-seven U.S. reports (18 for
diclofenac and 9 for simvastatin) and 22 Japanese reports (17 for diclofenac and 5
for simvastatin) identified in these four databases were selected for review. For
each paper we identified the relation of the article to the data (preliminary,
primary, and secondary reports, reviews), the means of identifying adverse
reactions, the principal outcomes of the trials, and a variety of descriptive
measures relating to study design, authorship, and elements of presentation. With
few exceptions, Japanese reports were not indexed in English-language databases,
and studies from the United States were not carried out in the Japanese databases.
The Japanese literature consisted exclusively of primary reports of clinical trials,
whereas the U.S. literature was dominated by review articles and secondary
reports of data from trials not fully published elsewhere. Japanese reports
contained more detail on adverse experiences but reported principally those
attributed to the drugs by attending clinicians. U.S. reports by contrast offered
little detail but tended to include all adverse experiences, whether or not clinically
attributed to drugs. A preponderance of U.S. articles reported significant
differences between drugs in safety or treatment efficacy, whereas only one third
of the Japanese articles did so for the same agents. Reports from both countries
offered few details of the methods used to gather information on adverse drug
experiences, and as a result the reported absolute frequencies of such events are
difficult to compare between trials or to generalize to other settings. In
conclusion, the reporting of adverse reactions in clinical trials is inadequate in
both the United States and Japanese literature. The shortcomings are
complementary in that reports of U.S. trials contain insufficient detail and
Japanese reports do not interpret or synthesize experience. Clinical research into
drug safety in both countries could be improved through the adoption of simple
standards of clarity and consistency in the monitoring and reporting of drug
adverse effects.
Publication Types:
1860: Eur J Pediatr. 1996 Apr;155(4):303-7.
A case-control study of recurrent Kawasaki disease using the

database of the nationwide surveys in Japan.
Nakamura Y, Yanagawa H.
Department of Public Health, Jichi Medical School, Tochigi, Japan.
In spite of many reports of recurrent Kawasaki disease, little information about

the risk factors associated with recurrence is available. We conducted a case-
control study on 150 cases of recurrent Kawasaki disease and 1173 pair-matched
controls selected from the database of nationwide surveys of the same disease in
Japan. Items observed were: sex, age, use of intravenous gamma globulin, and
cardiac sequelae at the first episode. Sex and cardiac sequelae did not affect the
risk of recurrence. One- to 2-year-old children were more likely to be affected
again than infants (odds ratio [OR] = 1.42; 95% confidence interval [CI], 0.94-
2.13), and children who were 3 years of age or older were less likely to
experience a recurrence than infants (OR = 0.59; 95% CI, 0.34-1.02). Intravenous
gamma globulin therapy at the first episode increased the risk for recurrence of
Kawasaki disease within 12 months (OR = 2.66, 95% CI, 1.06-6.66). However, it
did not affect recurrences 12 months after the first episode (OR = 1.02; 95% CI,
0.53-1.97). CONCLUSION: Patients with Kawasaki disease treated with
intravenous gamma globulin are 2.66 times as likely to be affected by the disease
again within 12 months as those treated without intravenous gamma globulin.
1861: Chin Med J (Engl). 1996 Apr;109(4):276-81.
Serotype epidemiology and patterns of antibiotic susceptibilities of

salmonellae isolated in Hong Kong 1983-93.
Kam KM.
Institute of Pathology, Sai Ying Pun Polyclinic, Hong Kong.
OBJECTIVE. To study the serotype epidemiology and patterns of antibiotic

susceptibilities of salmonellae isolated in Hong Kong over an eleven-year period.
METHODS. The laboratory information of 22 733 strains of salmonellae isolated
from diarrhea stool samples of 7 public hospitals, 5 out-patient clinics and 2
public health laboratories and reported to the Salmonella surveillance system in
Hong Kong from 1983 to 1993 were analysed. RESULTS. The yearly total
number of isolates has remained steady, while an increasing proportion of cases
occurred in the > 25 years age group with a substantial decline in the < 1 age
group. Males were significantly more affected than females, particularly in those
< 15 years old. S. typhimurium and S. derby were the two most commonly
isolated serotypes throughout the period. An outbreak of S. portsmouth occurred
which accounted for 15.3% of total isolates in that year. S. enteritidis has doubled
in the last 2 years, while S. typhi has more than halved over the 11-year period.
The S. enteritidis increase was seen mostly in the > 25 age groups, with those < 5
years little affected. Antibiotic susceptibility tests showed the typhoid and
paratyphoid bacilli remained fully antibiotic sensitive, while non-typhoid non-
paratyphoid isolates showed increasing resistance to ampicillin, chloramphenicol,
tetracycline, and cotrimoxazole. CONCLUSIONS. Laboratory monitoring of
salmonella serotypes causing diarrhea and their antibiotic susceptibilities is
essential as population movements and industrial activities increase in the
southern parts of China.
1862: Soc Sci Med. 1996 Apr;42(8):1163-8.

Erratum in:
• Soc Sci Med 1996 Jul;43(1):I.
Small group intervention vs formal seminar for improving

appropriate drug use.
Santoso B, Suryawati S, Prawaitasari JE.
Department of Clinical Pharmacology, Faculty of Medicine, Gadjah Mada

University, Yogyakarta, Indonesia.
In an attempt to evaluate the efficacy of different methods of interventions to

improve the appropriate use of drugs for acute diarrhoea, a controlled study has
been carried out in 6 districts in Yogyakarta and Central Java provinces,
Indonesia. This study was designed to investigate the impacts of two different
methods of educational intervention, i.e. a small group face-to-face intervention
and a formal seminar for prescribers, on prescribing practice in acute diarrhoea.
The districts were randomly assigned into 3 groups and 15 health centers were
selected from each district. Prescribers in Group 1 underwent a small group face-
to-face intervention conducted in the respective health center. Those in Group 2
attended a formal seminar conducted at the district level. Prescribers in Group 3
served as the control group. Both interventions were given on a single occasion
without follow-up supervision or monitoring. Written information materials on
the appropriate management of acute diarrhoea were developed and were
provided to all prescribers in the intervention groups. Focus group discussions
(FGDs) involving prescribers and consumers in the 6 districts were carried out to
identify various underlying motivations of drug use in acute diarrhoea. The
findings of the FGDs were used as part of the intervention materials. To evaluate
the impacts of these interventions on prescribing practice, a prescribing survey for
patients under five years old with acute diarrhoea was carried out in health centers
covering 3-month periods before and after the intervention. The results showed
that both interventions were equally effective in improving the levels of
knowledge of prescribers about the appropriate management of acute diarrhoea.
They were also partially effective in improving the appropriate use of drugs,
reducing the use of non-rehydration medications. There was a highly significant
reduction of antimicrobial usage either after small-group face-to-face intervention
(77.4 +/- 2.7% to 60.4 +/- 2.9%; P < 0.001) or formal seminar (82.3 +/- 3.0% to
72.3 +/- 3.6%; P < 0.001), and the former caused significantly (P < 0.001) greater
reduction than the latter. There was also a significant (P < 0.01) reduction in the
usage of antidiarrhoeals after both interventions, i.e. from 20.3 +/- 3.7% to 12.5
+/- 3.3% (P < 0.01) after face-to-face intervention and from 48.5 +/- 4.1% to 27.0
+/- 4.3% (P < 0.01) after seminar. However, the formal seminar had a
significantly (P < 0.01) greater impact than the small group face-to-face
intervention. There was also a trend toward increased oral rehydration solution
(ORS) usage after both interventions, but this did not achieve the level of
statistical significance (P > 0.05). No changes were observed in the control group.
Although the small group face-to-face intervention did not appear to offer greater
impacts over large seminars in improving the appropriate use of drugs in acute
diarrhoea, since the unit cost of training is far less costly than the seminar, it
might be feasibly implemented in the existing supervisory structure of the health
system.
Publication Types:
• Clinical Trial
• Randomized Controlled Trial
1863: Nippon Koshu Eisei Zasshi. 1996 Apr;43(4):276-85.
[Questionnaire survey of AIDS examination recipients at

government-run public health center regarding AIDS awareness
promotion and HIV examinations]
Hasegawa S, Sawa H, Shimizu K, Fujioka M, Tsushio M, Fujihara N,

Ishikawa N, Shimizu M, Kato K, Denpo K, Yoshikawa I, Kanou E,
Miyamoto H, Agematsu R, Sunagawa K, Tajima K.
Department of Health, Aichi Prefecture, Japan.
An anonymous questionnaire survey was conducted among persons who had

undergone screening for AIDS at public health centers under the auspices of 7
local government bodies (Hokkaido, Metropolitan Tokyo, Aichi Prefecture,
Osaka Prefecture, Kobe City, Saga Prefecture, Okinawa Prefecture). There were
1,230 replies, for a response rate of 46.8%. Questions in the survey pertained to
general knowledge of AIDS, information desired by the recipients, desired ways
to foster awareness, and a desirable examination system. A comparison was made
in terms of gender, marriage status (married, single) and age (less than 40 years of
age, more than 40 years of age), respectively. The survey results were as follows.
1. Concerning the infection route, accurate response rate was low with regard to
the mother-child infection, mosquito transmission, and use of contaminated
needles. 2. Desired methods to promote AIDS awareness expressed among replies
were given in the following order or frequency: "information via radio and TV,"
"spread of knowledge through telephone consultation," and "holding an AIDS
Week or similar kinds of campaigns." 3. Information sought by respondents
frequently included AIDS treatment, pathology, and spread. This trend was most
obvious among those under 40 years of age. 4. As for the AIDS examination
system, replies most often reflected the hope that the examination site would be
the Public Health Center, the charge would be gratis, and that one could be
examined at night during the week, and on days off. 5. For those undergoing
examination where there was no actual concern of possibility of HIV infection,
single persons, accounted for around 80% of the overall. 6. More than half of
those who had been examined mentioned having experienced concerns about
maintaining confidentiality at the time they were examined.
Publication Types:
1864: Occup Environ Med. 1996 Apr;53(4):281-6.
An analysis of the Vietnamese system of occupational safety and

health and setting priorities with the analytical hierarchy process.
Matsuda S.
Department of Preventive Medicine and Community Health, University of

Occupational and Environmental Health, Japan.
OBJECTIVE: There were two objectives. The first was to describe the
Vietnamese system of occupational safety and health (OSH) and its problems.
The second was to evaluate priorities among future OSH policies by the analytical
hierarchy process (AHP). METHODS: The Vietnamese OSH system was
analysed in detail mainly based on various official documents. After the OSH
problems in Vietnam were identified through discussions with Vietnamese OSH
specialists they were given priorities in five different OSH policies, which were
evaluated by the AHP. RESULTS AND CONCLUSION: The OSH system in
Vietnam is in theory well organised: the government has established fundamental
laws and has organised the OSH administrative system from the central to the
grassroots level. However, this system does not work sufficiently well to improve
working conditions. According to discussions with Vietnamese OSH specialists,
four factors associated with OSH problems in Vietnam were evaluated: shortage
of materials and manpower, inadequate OSH information system, inappropriate
OSH administrative system, and poor awareness of workers and employers about
the OSH problems. Considering the relative importance of these four factors, the
priorities within five policies were evaluated by the AHP technique. The results
showed that the most important change needed was reorganisation of the OSH
administrative system, followed by OSH education for workers and employers,
training of personnel in OSH services, improvement of OSH research activity,
and the establishment of an adequate OSH information system. It is expected that
developed countries will help the Vietnamese government to implement these
programmes.
Publication Types:
PMCID: PMC1128464
1865: Health Transit Rev. 1996 Apr;6(1):25-48.
Health and development: knowledge systems and local practice in

rural Thailand.
Lyttleton C.
Anthropology Department, University of Sydney, Australia.
The specific framing of health within a development context has implications for
constructions of wellness and illness and how people react in times of ill health.
In Thailand, recent national HIV/AIDS education-prevention campaigns
commonly use topdown relay of public health information. This pattern replicates
numerous development projects that aim to bring useful and beneficial knowledge
to rural villagers. How villagers integrate this information depends, in part, on
previous experiences with development programs in general and public health
programs in particular. This paper considers the political economy of medical
knowledge and multiple local health strategies in rural Northeast Thailand as a
background to the contingent response to public health directives.
1866: Clin Perform Qual Health Care. 1996 Apr-Jun;4(2):110-2.
Cyberspace Hospital: growing from a simple idea to a global health

information resource.
Lun K.
National University Hospital, Singapore.
1867: Sociol Bull. 1996 Mar;45(1):87-95.
State sponsored health care in rural Uttar Pradesh: grassroots

encounters of a survey researcher.
Balakrishnan R.
PIP: This paper reports on impressions gained by the author while gathering data
for a baseline survey on the delivery and quality of health and family planning
(FP) services in rural Uttar Pradesh in India. Data were collected from FP staff
and acceptors. The author found that the public health service staff were often
derelict in their duties and failed to maintain proper records. Staff positions were
secured and kept through the payment of bribes. Bribes are also used to secure or
prevent transfers to other districts. Staff morale was further demoralized by
harassment in the form of delaying payment of salaries or travel allowances and
by the creation of factions loyal to the Medical Officer-in-Charge and the
immediately subordinate Medical Officer. In order to reform this system, it must
be held accountable to the people it serves and must regain their confidence. The
presence of a privately-operated clinic in the area indicates that affordable
services can be delivered. FP staff also require a means of transportation, such as
mopeds, to allow them to increase their effectiveness. Despite this climate of
derelict service provision, it must be noted that some personnel were performing
an exemplary service to their districts.
1868: China Popul Today. 1996 Feb;13(1):18-9.

Related Articles
The progress of human rights in China. Protecting the legitimate

rights and interests of women and children.
China. State Council. Information Office.
PIP: In 1992 China enacted the Law on the Protection of Women's Rights and
Interests stipulating their rights in politics, culture and education, property, labor,
person, marriage, and family. The legal system has adopted 10 similar
legislations, more than 40 administrative laws and regulations, and over 80 local
laws and regulations guaranteeing women's rights. The Program for Chinese
Women's Development for 1995-2000, issued in August 1995, strives to improve
the quality of life. In 1993, 95% of women voted in local elections. 21.03% of the
deputies in the Eighth National People's Congress are women, and the proportion
of women in local people's congresses is even higher. The number of women
employed by the government increased from 10.04 million in 1991 to 12.371
million in 1994. In 1994 there were 16 female ministers or vice ministers, 18
female provincial vice governors, more than 300 female mayors or vice mayors,
and 21,012 female judges. 38% of the work force are women, and 50% of the
labor force in the countryside is comprised of women. Approximately 8 million
(35%) of the country's scientists and technicians are women. Women receive
social benefits and care during menstruation, pregnancy, maternity, and breast
feeding. They are entitled to 3 months of maternity leave with pay. 80% of girls
aged 7-11 attended school in 1990 vs. 97.7% in 1994. During the same period the
proportion of female students in secondary schools and universities increased
from 42.2% and 33.7%, respectively, to 44.3% and 34.5%, respectively. There is
a state-sponsored family planning policy in place. As a result, the contraceptive
prevalence of married women rose from 75% in 1990 to 83% in 1994; the birth
rate dropped from 21.06/1000 in 1990 to 17.7/1000 in 1994; and the total fertility
rate dropped from 2.31 to 2.0 per woman. Around 98% of urban women and 79%
of rural women get prenatal care; and maternal mortality declined from
94.7/100,000 in 1989 to 67.3/100,000 in 1993. In 1994 the proportion of children
inoculated against pertussis, diphtheria, tetanus, BCG, measles, and polio reached
over 90%. There are 3164 health care institutions for women and children in
China.
1869: JOICFP News. 1996 Feb;(260):4.

Project on track in Nepal.
[No authors listed]
PIP: This article describes the workshops held in December 1995 in Nepal under
the sponsorship of the regional UNFPA Sustainable Community-based Family
Planning and Maternal and Child Health Project and the Special Focus on
Women. Workshops focused on evaluations of the fee-charging system in the four
year project areas, the use of health check-ups between pregnancies, and
successful IEC. A major recommendation at the workshop was that the opinions
of the target group must be incorporated into IEC materials. The IEC workshop
was the first of its kind, and recommendations were integrated into the Tokyo
workshop on IEC Evaluation. Pretesting of materials is viewed as necessary in
order to meet the actual needs and realities at the grass roots level. IEC is viewed
by participants as aiming for increased awareness and for increased evidence of
practical use of the information. The concept of family planning is viewed as
requiring complete understanding. The workshops were found to be helpful as an
exchange of information about the range of IEC materials possible. Participants
requested a national coordinating body for coordinating IEC materials on
reproductive health and networking with government and privately sponsored
groups. Fee systems were found to be successfully introduced even in the poorest
areas with few government services. Project areas in Panchkhal and Sunsari
successfully exchanged information. In Panchkhal there was a need to involve
women more in women's groups. In Sunsari sustainability needed to be promoted.
The Nepal national workshops involved about 70 participants, who came from
village health committees, field staff, and mothers' clubs in Sunsari, Morang, and
Panchkhal districts. Attendance increased over the preceding year. The IEC
workshop was attended by about 40 participants from government and private
groups and agencies that produced IEC materials.
1870: Nature. 1996 Feb 1;379(6564):381-2.
Comment in:
• Nature. 1996 Apr 25;380(6576):664.

• Nature. 1996 Apr 25;380(6576):664.
• Nature. 1996 Apr 25;380(6576):664.
Indian researchers press for stricter rules to regulate 'gene-hunting'.
Jayaraman KS.
Publication Types:
• News
1871: Reflections. 1996;22(2):12-3.
Korea's hospitals. Shedding light on patients' needs.
Park HA.
1872: J Egypt Public Health Assoc. 1996;71(5-6):369-83.
Epidemiology of anemia among attendants of primary health care,

Jeddah.
Badawood A, Salem KA.
Arab Board of Community Medicine, Jeddah.
This study was carried out to find the prevalence of anemia, as well as associated
factors in the studied group. The material of this study included all reports of
diseases that were sent from all PHC, Jeddah city, to the Health Information
Systems Unit at the Directorate of PHC, Jeddah during the year of 1415 Hegrian.
Data about anemia were collected and analyzed. Results of the study showed that
the prevalence of anemia was found to be 1.82% in the studied group, among
Saudi population it was found to be 1.84%. The prevalence of anemia among
females was found to be 2.39% which was significantly higher than that among
males (1.25%). Also, the prevalence of anemia was found to be significantly
higher among different age groups compared to those aged 1-4 years. The
prevalence of anemia was found also to be affected by geographic distribution of
the population.
1873: MARHIA. 1996 Jan-Jun;9(1):10-1.
Motherhood: making it safer for Filipino women.
Baylon MC.
PIP: In November 1995, in the Philippines, the Department of Health

implemented the Women's Health and Safe Motherhood Project. Its target
audience is poor women in remote and underserved provinces. It addresses
maternal health, reproductive tract infections (RTIs), sexually transmitted diseases
(STDs), cervical cancer, domestic violence, and the desire to space births. It aims
to improve the quality of women's health services through training of health
providers, providing women with information to help them make informed
choices, providing regular supplies and drugs, privacy and infection control at
service delivery points, providing follow-up care, and improved cost-effective and
technically-sound referral systems. The project also aims to ensure accessible
service delivery points, well-equipped and maintained facilities, client and
community feedback in managing service delivery, and information provision in
order to increase acceptability of health services. The major components of the
project include service delivery, institutional strengthening (via information,
education, and communication; training of health providers; and improvement of
the logistics system), community partnership for women's health development,
and policy and operations research. The service delivery component will adopt a
life-cycle approach to service delivery in Region 8 (urban and rural communities).
It will pilot the syndromic approach in the management and detection of RTIs and
STDs in 10 provinces. The biggest tasks of the project are upgrading referral
networks from provincial and district hospitals to rural health units and barangay
health stations and upgrading primary hospitals.
1874: Media Asia. 1996;23(3):163-72.
A paradigm shift in communication strategies for health and family

welfare programmes.
Trakroo PL, Bamezai G.
PIP: This paper analyzes the implications of the interface mechanisms used in
India to help people relate to their health care system. The analysis begins by
explaining why Indian social structure resisted most development initiatives in the
first 25 years after independence, describing the pressure upon traditional forms
of communication exerted by technology-based media, and noting that newer
development processes have attempted to facilitate informed decision-making and
active participation by the rural population by stimulating social changes to
empower underprivileged groups. The paper continues by discussing the
postindependence phases (cooperative, participation, and involvement) of the
empowerment process. Next, the use of communication inputs in the Five Year
Development Plans beginning in 1952 is reviewed. The paper then considers
newer responses to the challenge of inspiring the rural population to use the health
system, the current status of communication research, the mobilization of media
personnel, the expected impact of technological innovations, the necessity of
reducing gender imbalances, and the availability of community-based structures
that could facilitate development. It is concluded that the communication lag
among India's development framework, social structure, and health-promoting
communication inputs may be overcome by providing appropriate, viable, and
cost-effective programs; fully exploiting pressure groups to bridge the people and
the health system; and achieving consensus on goals and mechanisms.
1875: IDRC Rep. 1996 Jan;23(4):15.
Moving Asia from grassroots to cyberspace.
Wheeler C.
PIP: Through International Development Research Center's Pan Asia Networking

program (PAN), some of the least developing countries in Asia are acquiring the
means to access information residing on the Internet. Most importantly, the
program helps Asian nations share their information resources among them and
the world electronically for the first time via the Internet. The PAN program will
carry a number of content-based subnetworks which addresses biodiversity,
natural resource management, social and economic policy, environmental
technology, human health, and information and communication technology. The
broad range of development-related issues provided by PAN will benefit
researchers, development workers, academics, teachers, students, decision-
makers, and people interested in Asian development. As PAN grows and matures,
many more people in developing countries of Asia will have the opportunity to
tap into the accumulated wisdom in the Internet.
1876: Prog Hum Reprod Res. 1996;(39):2-3.
Oral contraceptive pills and the risk of venous thromboembolism.
[No authors listed]
PIP: Information on the association between combined oral contraceptives (OCs)

and cardiovascular disease risks has been derived almost exclusively from studies
in developed countries. To assess this relationship in developing countries, where
the risk factors for cardiovascular disease may be different, a case-control study
of venous thromboembolism, stroke, and myocardial infarction was carried out in
21 centers in 17 countries in Africa, Asia, Europe, and Latin America. The World
Health Organization Collaborative Study of Cardiovascular Disease and Steroid
Hormone Contraception enrolled 3800 cases of stroke, venous thromboembolism,
and myocardial infarction and 11,200 matched controls. Studies in the UK had
suggested that OCs containing desogestrel and gestodene doubled the risk of
venous thromboembolism compared with levonorgestrel and norethindrone-
containing OCs. The multi-center study identified an overall risk of venous
thromboembolism in the lower range of that reported in developed countries, an
increased risk soon after starting OC use but elimination of such risk within a few
months after pill discontinuation, and slightly increased risk among obese women
and those with a history of high blood pressure during pregnancy. Unexpected
was the finding that women who use OCs containing desogestrel or gestodene
may be at double the risk of blood clotting in the veins compared with users of
OCs containing levonorgestrel or norethindrone. Although these findings remain
controversial, several countries have modified OC prescribing practices to
eliminate women at high risk of cardiovascular disease.
1877: Ann Demogr Hist (Paris). 1996:119-36.
[Public health and medical corps in transition: the case of Crete at

the beginning of the 20th century]
[Article in French]
Bournova E.
Université d'Athènes.
This article deals with the transformation of the public health system in Crete at
the turn of the century, when the island was placed under the protection of the
European Powers. Cretan archives, especially those from the town of Rethimno,
provide a wealth of information on this subject. They show that the new ruling
powers, with the declared objective of safeguarding their soldiers, required local
authorities to keep a close watch over epidemics, indeed to lock up populations
considered dangerous for public health, such as lepers and prostitutes--who did
not fail to put up a strong resistance. While providing equipment for hospital
facilities, which were still primitive, the Powers also introduced legislation
concerning the practice of medicine, from which Muslim Cretans were gradually
excluded. The rate at which medical care was provided increased markedly at the
beginning of the twentieth century, in particular in the principal towns. The
Rethimno notarial archives reveal that this new and well qualified medical corps
belonged to the world of prominent citizens, and while ministering to the town's
health needs, they held considerable political and economic power.
Publication Types:
1878: Oncologist. 1996;1(5):324-325.
In Response To: Professor Cassileth's manuscript on "Alternative

and Complementary Cancer Treatments," Featured in The
Oncologist 1996;1:173-179.
Quah TC.
Department of Pediatrics, National University Hospital, Singapore.
COMMENTS FOR PROFESSOR BARRIE R. CASSILETH: I have enjoyed

reading the two issues of The Oncologist I've received so far. I would like to
make some comments on Dr. Cassileth's article. I'm a pediatric oncologist at the
National University Hospital in Singapore. Singapore is an interesting place to
study people, as ours is a multi-racial country, with 75% Chinese, 16% Malays
and 7% Indians, plus a significant expatriate population (Americans, British,
Australians, etc.). I've been very interested in the influence of different ethnic and
social backgrounds on how our patients cope with their diseases, especially
families of children with cancer. We did a survey of 20 patients and found that
nine of the children are given bird's nest, nine are given ginseng, and five had
been given Chinese medicinal herbs. I've been doing a bit of literature search, and
found that there's some evidence that Chinese medicine may help to "boost the
immune system," enhancing the ability of the patients to undergo conventional
cancer therapy. However, most traditional Chinese medicine practitioners would
recommend that these patients continue with their "Western treatment." I have no
objection to patients availing themselves of these complementary approaches,
though we do not encourage it either. We are in the unenviable situation of trying
to help and give advice to our patients about things about which we know little, as
there is so little hard evidence. Of all the literature I've gone through so far, I find
the recent Choices in Healing by Michael Lerner (MIT Press) the most helpful.
PROFESSOR CASSILETH'S RESPONSE: Dr. Quah raises a number of
important issues. I share his interest in the influence of culture and ethnicity on
how patients and families cope with cancer. The cultural meaning of malignant
disease, in fact, has long shaped not only individual reactions, but also how
societies have approached research, treatment, and communication. In the United
States, for example, the word "cancer" literally was banned from public print until
the mid-1920s [1], and only now are physicians beginning to discuss cancer with
their patients in Russia [2]. The survey of 20 patients conducted by Dr. Quah
represents a substantial portion of the literature on the subject of alternative
therapy use for children with cancer. During the decade of laetrile popularity in
the United States, a study at a major pediatric oncology center found that 17 of
106 patients (16%) received alternative therapy, although eight different types of
alternative therapies were known by 50% of parents. That study was conducted in
1977-1978 [3]. An Australian study published in 1994 [4] found that
approximately 46% of children had been given alternative treatments; like Dr.
Quah's patients and those in the Australian study, they remained simultaneously
under mainstream care. One suspects that by now, close to 100% of parents as
well as adult patients could name at least eight different types of alternative
cancer therapies. I concur with Dr. Quah's assessment of Choices in Healing. It
differs strikingly from other publications about alternative cancer medicine,
almost all of which are proponent books that extoll unproven or discredited
methods and decry a government/pharmaceutical industry conspiracy to withhold
cancer cures (read "alternative, unproven methods") from the public. A visit to the
health and medicine section of any large bookstore provides an eye-opening
display of books on dozens of methods promoted as cancer cures. Can Chinese
medicine "boost the immune system?" Claims for the mechanisms by which
alternatives of the past were said to work typically reflected mainstream science
of the day. The most common claim across the variety of today's popular
alternative cancer therapies is that they enhance immune function. Many herbal
remedies, including those from China, are sold for this purpose in America.
Several Chinese medicines, such as polysaccharide from a root used in traditional
Chinese medicine, Six Flavor Tea and Golden Book Tea used in conjunction with
chemotherapy and radiation therapy, and Mylabris - dried Chinese beetle - have
been studied for their utility against cancer in recent years. Because studies such
as these are reported almost exclusively in Chinese journals, and because they
tend to be preliminary, they are not well known in other countries. Dr. Quah's
own professional home, the National University of Singapore (NUS), is one of the
first medical schools in Asia to use the World Wide Web to distribute health
information. NUS has the major cancer databases from the United States and
many other important international databases. It intends to become a global health
information hub on the Internet. Hopefully this resource will help fill in some of
the information gaps. But most oncologists, like Dr. Quah, indeed are faced with
trying to advise patients about therapies for which there is little hard evidence.
The best guiding principles at this point are to discourage remedies that promise
cancer cure or are promoted for use instead of mainstream treatment, encourage
non-invasive, comforting, complementary (adjunctive) therapies such as massage,
green tea and qi gong, and check medical journals and newspapers for warnings
such as those issued recently for Ma Huang (ephedrine), a still-common
ingredient in herbal remedies widely available through catalogs and in health food
stores.
PMID: 10388010 [PubMed - as supplied by publisher]
1879: Eisei Shikenjo Hokoku. 1996;(114):76-83.
[An international exchange and dissemination of chemical safety

information on the Internet]
Ohtake C, Yamamoto M, Nakano T, Nakata K, Ishikawa K, Kaminuma T.
An information system for chemical safety has been developed on the National
Institute of Health Sciences (NIHS) Information and Computing Infrastructure.
The system is based on client server systems on the local area network (LAN)
connected to the Internet. A wide range of safety information for chemicals
including foods, food additives, household goods, industrial chemicals and
environmental pollutants were collected and put on the World Wide Web
(WWW) server and the database management system, Sybase. In addition to
original information contents, the System has links to many useful Web sites so
that it functions as a global hub for chemical safety information.
Publication Types:
• Review
1880: Eisei Shikenjo Hokoku. 1996;(114):53-61.
[NIHS information and computing infrastructure (NICI)]
Nakata K, Nakano T, Kaminuma T.
We describe the information and computing infrastructure in National Institute of

Health Sciences, which were constructed until May, 1996. The in house computer
network and computing facilities for common usage in NIHS have been
developed under the initiative of Division of Chem-Bio Informatics since 1989.
The present LAN (Local Area Network) consists of coaxial cables and optic fibers
which are connected by a LAN Switch. The LAN is connected to the Internet via
IMnet, the inter ministry network back bone of the Science and Technology
Agency. Various types of workstations and personal computers such as SUN WS,
Silicon Graphics WS, IBM WS & PC, Macintosh, and NEC PC are connected to
the LAN. This computing network environment which we named NICI (NIHS
Information and Computing Infrastructure) not only provides network
communications but also facilitates advanced computating systems for chemical
safety research at NIHS as a COE.
Publication Types:
• Review
1881: Emerg Infect Dis. 1996 Jan-Mar;2(1):30-6.

Surveillance for pneumonic plague in the United States during an
international emergency: a model for control of imported emerging
diseases.
Fritz CL, Dennis DT, Tipple MA, Campbell GL, McCance CR, Gubler DJ.
Centers for Disease Control and Prevention, Fort Collins, Colorado, USA.
In September 1994, in response to a reported epidemic of plague in India, the

Centers for Disease Control and Prevention (CDC) enhanced surveillance in the
United States for imported pneumonic plague. Plague information materials were
rapidly developed and distributed to U.S. public health officials by electronic
mail, facsimile, and expedited publication. Information was also provided to
medical practitioners and the public by recorded telephone messages and
facsimile transmission. Existing quarantine protocols were modified to effect
active surveillance for imported plague cases at U.S. airports. Private physicians
and state and local health departments were relied on in a passive surveillance
system to identify travelers with suspected plague not detected at airports. From
September 27 to October 27, the surveillance system identified 13 persons with
suspected plague; no case was confirmed. This coordinated response to an
international health emergency may serve as a model for detecting other emerging
diseases and preventing their importation.
1882: Bull Med Libr Assoc. 1996 Jan;84(1):32-40.
Information-seeking behavior of health professionals in Hong Kong:

a survey of thirty-seven hospitals.
Cheng GY, Lam LM.
Hospital Authority Head Office Library, Causeway Bay, Hong Kong.
Shortly after the establishment of Hong Kong's Hospital Authority (HA) in 1990,
ten library service networks supported by the Library Information Systems
(HALIS) were established to pool resources. A survey was undertaken to
investigate the information-seeking behavior of health professionals working in
thirty-seven public hospitals, examine their information needs, assess user
satisfaction with and the impact of library services (including HALIS), and
examine why hospital libraries sometimes fail to meet user needs. The findings
revealed disparate use patterns among different groups of health professionals and
confirmed that medical staff were most satisfied with the library collections and
services. The nurses and hospital executives were found to be underserved. They
needed information not only for work-related reasons but also to support self-
study and development. The new HALIS service was neither well known nor
widely used, especially among nurses. The findings provided valuable measures
of performance for comparing different hospitals and assessing changes over
time. Survey results also highlighted areas in which improvements are needed,
such as collection enhancement, promotion and user training, and assessment of
the impact of library service on patient care. Subsequent developments in these
directions have led to increased awareness and use of library services and
confirmed the direction of strategic plans for growth.
Publication Types:
• Multicenter Study
PMCID: PMC226122
1883: Neuroepidemiology. 1996;15(6):313-20.
Neuro-epidemiological pilot survey of an urban population in a

developing country. A study in Bangalore, south India.
Gourie-Devi M, Gururaj G, Satishchandra P, Subbakrishna DK.
Department of Neurology, National Institute of Mental Health and Neuro-

Sciences, Bangalore, India.
A feasibility study was conducted in an urban population of 3,040 in Bangalore,

South India, to understand the baseline characteristics, evaluate screening
questionnaires, identify potential problems and determine the magnitude of the
problems. The target population was selected by a random method, from four
census enumeration blocks of a specific urban area. A two-phase study design
was adopted consisting of screening by trained field investigators in the initial
stage and clinical examination by a neurologist in the second stage. The
information was collected by an interview method on a house-to-house basis.
Evaluation of the screening instruments yielded high sensitivity and specificity
rates, and it became clear that there is a need to reduce false-positive results in the
screening questionnaire for individuals above 7 years of age. The prevalence of
neurological disorders was 32.8 per 1,000 population (with a rate of 7.8/1,000 for
epilepsy). It appears feasible to detect a wide range of neurological disorders
using the methods described.
Publication Types:
1884: Med Inform (Lond). 1996 Jan-Mar;21(1):69-79.
Health and welfare data on optical memory cards in Isehara city.
Sakashita Y, Ogushi Y, Okada Y, Horie M, Ohta Y, Hayashi Y, Suzuki S,

Haruki Y, Takahashi T.
Tokai University, School of Medicine, Kanagawa, Japan.
An off-line network system of health and welfare for elderly people using optical
memory cards has been established in Isehara city (Japan) since 1991. 2775
citizens have the cards and 24 offices have the terminals. It covers almost one
third of people aged over 65 in Isehara city and almost all of the offices concerned
with their health and welfare. About a half of holders use optical memory cards
every time they visit these offices. The optical memory card holds data including
basic data for health and welfare, health check data over 5 years, medical images
with scripts and history of welfare services. All the data are used for medical care,
health consultation and management of health and welfare services. A card can
hold health and welfare data for a lifetime, and it is easy to expand the system. It
has been a good experience for us, because the optical memory card system needs
co-operation among citizens, medical association and local government, and the
experience will help us to expand the system in the future.
1885: J Pediatr Health Care. 1996 Jan-Feb;10(1):2-9.

Cultural considerations in Cambodian childrearing.
Kelley BR.
INTRODUCTION: The purpose of this study was to explore childrearing

practices and beliefs of Cambodian refugees. Cambodians, a culturally distinct
group, are increasing in number in the United States. They are in need of health
care and childrearing advice, but Cambodian childrearing practices and beliefs are
not well documented. METHOD: A descriptive study was conducted to
investigate Cambodian families' cultural childrearing practices and beliefs.
Participant-observation techniques were used, and interviews were conducted
with a convenience sample of 28 Cambodians. RESULTS: Three themes
emerged: Buddhism is deeply embedded in Cambodian culture; the family is the
basic, most important structure in the life and identity of a Cambodian; and life is
set and ordered within a hierarchical structure. Childrearing practices are set up to
teach and reinforce these beliefs. DISCUSSION: Nurses offering advice regarding
childrearing practices must respect the client's value system. Nurses must
continue to ask and share cultural information while developing mutually
acceptable guidelines for care.
1886: J Manag Med. 1996;10(1):67-80.
Decentralization in a sick fund: lessons from an evaluation.
Gross R, Rosen B.
JDC-Brookdale Institute, Jerusalem, Israel.
In 1988, Israel's largest sick fund embarked on a process of decentralization,

which consisted of the delegation of authority from central management to two
regions that were chosen as demonstration sites. Aims to examine the extent to
which the decentralization plan was implemented, to identify the major
difficulties in implementation and to evaluate the process of implementing
organizational change. Contends that the demonstration programme was
implemented in part only, and that difficulties did arise during implementation.
Our evaluation of the decentralization process led us to develop conceptual
diagnoses of the various problems that might arise during decentralization and
derive lessons for successful implementation. Evaluation taught us that when
implementing a plan of decentralization, it is beneficial to make a clear division of
responsibilities; develop control instruments and an information infrastructure;
improve the skills of managers; appoint a team responsible for implementing
decentralization, and establish a joint forum for working out problems between
central management and sub-units; and clarify organizational policy on the central
operational issues facing sub-units. Expresses the hope that the conclusions drawn
here will help other organizations in Israel and abroad in planning and
implementing decentralization.
Publication Types:
1887: China Popul Today. 1995 Dec;12(5-6):25-7.

Related Articles
Cutting out the scalpel: a unique approach to vasectomies. Interview

with Dr. Li Shunqiang, the originator of no-scalpel vasectomy.
[No authors listed]
PIP: In this interview, Dr. Li Shunqiang, who developed the no-scalpel vasectomy
(NSV) technique, discusses his life and work. As a youth, Dr. Li, who was born
into a farming family, noted that farm wives had large families to care for in
addition to their other chores. He always felt that it was unfair for women to have
to assume the entire responsibility for family planning. Thus, in the early 1960s,
Dr. Li began his research on male contraception. By this time, concern had arisen
in China about rapid population growth. Dr. Li performed his first traditional
vasectomy in 1963. He soon found that the use of a knife in vasectomy was
associated in the minds of his clients with castration. Therefore, Dr. Li began to
try to develop a means of chemical vasocclusion. In 1973, this work led to the
development of the NSV, in which the anesthetized scrotum is punctured (rather
than cut) with a special instrument in order to allow access to the vas deferens.
Dr. Li believes that the NSV should be promoted beyond Sichuan Province, and
he intends to continue his efforts to improve the procedure. In order to expand the
NSV throughout China, Dr. Li recommends that couples who wish to end child-
bearing should be fully informed about male and female sterilization. Quality
follow-up services should be available to acceptors. In addition, a pilot project
should proceed large-scale promotion of NSV. High quality training must be
given to the surgeons, and information, education, and communication activities
should be used to create a social environment in which NSV will be accepted. Dr.
Li is continuing his research in the areas of basic androgyny and pathology,
biochemistry, and the male hormone system as well as in sterilization reversal. He
is involved in NSV workshops and continues to refine the procedure.
1888: JOICFP News. 1995 Dec;(257):1-2.
Reproductive health at the grass roots.
[No authors listed]
PIP: The Regional Traveling Seminar on Community-based Reproductive Health

Services was held in Vietnam in October 1995 with the objective of shifting the
emphasis from family planning (FP) to comprehensive reproductive health in the
wake of the 1994 International Conference on Population and Development.
Participants came from Bangladesh, Laos, Nepal, and the Philippines
implementing the sustainable community-based FP and maternal-child health
(MCH) project. Participants from China and Vietnam were implementing the
integrated community-based FP project. The 25 participants focused on
reproductive health strategies and their availability in the community. They were
divided into two groups who visited two districts in two provinces. In Vietnam
numerous examples of community self-help efforts were encountered against a
backdrop of fast economic development, although most people still live in poor
conditions. Yet the people of communes ensure the availability of health care,
e.g., by providing rice to health workers and by constructing a health center.
Vietnam also has rapidly integrated its reproductive health services into its
existing FP/MCH system. The shift to comprehensiveness aimed to reduce the
rate of induced abortion, provide more pre- and postabortion counseling, and
expand postnatal care. Women play an active role in these efforts owing to their
empowerment at all levels including policy making and decision making. Raising
the health and socioeconomic status of women is a government policy. The role of
the Women's Union in a network of motivated volunteers was perceptible: they
promote health education and FP linking the health center and the community.
Incentives, more information, education, and communication materials, and
income-generating programs are proposed for sustaining this volunteer system.
The need to increase the range of contraceptives and wider access to services was
also noted.
1889: Acta Paediatr Jpn. 1995 Dec;37(6):731-4.

Perinatal medical support in the area surrounding the Hanshin-
Awaji earthquake.
Kusuda S, Fujimura M, Takeuchi T.
Department of Neonatology, Osaka City General Hospital, Japan.
After natural disaster, perinatal medical care must usually be provided from
outside the disaster area, because most of the medical efforts inside the area focus
on patients without special needs. This study reviews the emergency perinatal
medical response after the great Hanshin-Awaji earthquake. In the present study,
we summarize records of telephone calls and reports from the Neonatal Mutual
Cooperative System (NMCS). The day of the earthquake, very little information
was available to or from the disaster area. The day after the earthquake, Osaka
City General Hospital (OCGH) and Osaka Medical Center and Research Institute
for Maternal and Child Health were established as key facilities, and OCGH
served as a center through which information passed to and from the disaster area.
Most telephone calls to OCGH were placed on the second day after the
earthquake by pregnant women concerned about their deliveries. Many high-risk
pregnancies and newborn infants were transferred out of the disaster area over the
next month. This analysis shows that although the emergency response was very
rapid in this instance, the operation may be significantly improved in disasters of
this magnitude: (i) if a communication mechanism able to serve a large volume is
established; (ii) if helicopter transport was easily available; and (iii) if key
facilities to handle communications were previously established so as to be
available immediately.
1890: Clin Infect Dis. 1995 Dec;21 Suppl 3:S213-17.
Effectiveness of control programs for pneumonia among children in

China and Fiji.
Shimouchi A, Yaohua D, Zhonghan Z, Rabukawaqa VB.
Department of Preventive Medicine, Kyoto Prefectural University of Medicine,

Japan.
This article summarizes the implementation and efficacy of the World Health
Organization's standard case management program for pediatric pneumonia in
three counties in China and in the Western Division of Fiji. The information
provided through this program was simple enough to be understood by parents
and health care workers with a basic educational background. The program
reduced mortality from pneumonia even when implemented through the existing
health care system in a relatively poor county in China. The factors important in
the success of the program included improved recognition of the signs of
childhood pneumonia by parents, earlier presentation of children with these signs
to health care facilities, availability of antimicrobial agents at the primary health
care level, and rational decisions by health care workers about the use of these
agents.
Publication Types:
1891: J Formos Med Assoc. 1995 Dec;94 Suppl 2:S87-93.
[Three years' experience of emergency medical services in Ilan

County]
[Article in Chinese]
Hu SC, Tsai J, Kao WF, Chern CH, Yen D, Lo HC, Chang CH, Chern TL,
Lee CH.
Department of Emergency, Veterans General Hospital-Taipei.
The Emergency Medical Services (EMS) aims to improve the survival rate of
patients who are dead on arrival (DOA) at hospital, particularly those whose
coronary artery disease (CAD) has induced sudden death. Based on the low
prevalence of CAD-induced sudden death in Taipei city, as well as the differences
between urban and rural communities in Taiwan, an understanding of the
characteristics of rural areas is necessary in order to establish a well-organized
and cost-effective EMS policy in this country. The data were drawn from a
computer database which stored prehospitalization information from Ilan County
from 1992 through 1994, including age, sex, response time, time spent on the
scene, transportation time, service unit, reasons for emergency call and trauma
mechanism. In 1096 study days, 20058 cases (18/day) were collected, of which
16560 (15/day; 83.6%) were transported to hospital. Trauma was responsible for
the majority (77%) of these cases, followed by chronic diseases (4.0%), trivial
matters (2.6%), drunkenness (2.3%), altered mental status (2.3%), suicide attempt
(2.2%), and cardiac arrest (1.8%). Among the trauma cases, traffic accidents were
the most common cause (84%); motorcycle accidents comprised 65% of trauma
cases. The average response time was 6.6 minutes, time spent on the scene was
3.6 minutes, and transportation time was 17.7 minutes. Trauma and non-trauma
accounted for half of the DOA cases, with each making up 0.9% of the total cases
transported. In conclusion, it is important that the EMS needs of each community
are known for a proper system appropriate to that particular area to be developed.
Publication Types:
1892: Kekkaku. 1995 Dec;70(12):691-703.
[Tuberculosis among immigrants in Japan--epidemiological, clinical

and sociological features, and the future of control]
Ishikawa N.
Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Tokyo,

Japan.
Case of tuberculosis among immigrants in Japan have been increasing recently as

the entry of the foreigners increases. The 1993 national survey showed that the
number of the newly registered tuberculosis patients among immigrants (new
comers) was 593 (1.2% of total patients) in 1992. Though their proportion among
all patients is still yet small, immigrant cases show remarkable disparity in
geographical and age distribution. Immigrant patients present various challenges
in the control of tuberculosis, with higher rates of defaulter in treatment and drug
resistance. This study analysed the characteristics of the problems with various
data and made recommendations for the future control programme.
Epidemiologically, the mean tuberculosis incidence during the period from 1987
to 1992 was estimated for the population of each country of origin. The rate for
the whole immigrants was between 58.1 and 76.7 per 100,000, which was 2 to 5
times of the rate (i.e. 39) for Japan in 1992. The trend of the incidence after the
arrival in Japan by year cohort was also estimated. It was found that the shorter
the stay, the higher the incidence. Future estimate of tuberculosis incidence in
immigrants was made based on the assumptions of the population in and out
flows. In 2005, the number of new immigrant patients will be between 1169 and
846, representing 3.4% to 2.5% of all tuberculosis patients expected a decade
hence. By reviewing the clinical data and chest radiogrphy of 157 immigrant
patients currently diagnosed in Tokyo area, the attack timing of the disease for
each patient was estimated. Nearly half the patients who would be diagnosed later
was estimated to have some abnormal shadows on chest radiography before
arrival in Japan, while the other half or at least 30% developed tuberculosis after
arrival. These indicate the importance and the limitations of screening by chest
radiography at the early stage of arrival. The clinical status and treatment
compliance were better among the legal immigrants such as Japanese language
school students that the over-stay (illegal) immigrants. The extra-pulmonary cases
consisted only 7% of the total disease, which was similar to the whole patients in
Japan. The perception and knowledge about tuberculosis and tuberculosis services
among immigrants was found some different from those among Japanese. With
the data analysed above and the information on the policy and guidelines in other
countries, it is recommended that guidelines for improved Case-finding and
treatment of tuberculosis among immigrants need to be developed in Japan, and
pilot trials at local level should be instituted. For surveillance for tuberculosis in
immigrants a standardized information system must be developed.
Publication Types:
Effect of a drug supply and cost sharing system on prescribing and

utilization: a controlled trial from Nepal.
Chalker J.
Save the Children Fund (UK), Hanoi, Vietnam.
The effect on prescribing habits of a drug supply and cost sharing system was
studied in a hill district in Nepal. In this district the inadequate yearly supply of
drugs from the government was supplemented by an extra supply from the
project. Drugs were sold at a fixed prescription charge which covered all drugs for
one episode of illness. The prescribing pattern in this district was compared to a
control district with only the yearly government drug supply and no drug scheme.
Drugs prescribed were also compared to theoretical needs based on the recorded
diagnoses of the same patients and recommended treatment guidelines.
Attendance figures were studied before and after the introduction of the drug
scheme in the test district. A 25% sample of prescriptions was taken from all
health posts in both districts, over a one year period. This was in total 11,772
prescriptions from 22 health posts. The results show that in the drug scheme
district health workers prescribed essential drugs excessively. However, the doses
that were prescribed were somewhat better than in the control district. Utilization
of health facilities dropped by 18% in the drug scheme district and then increased
in the second year. A supply of essential drugs does not necessarily improve the
quality of care, or increase attendance levels. The WHO indicators designed to
assess the quality of drug use at health facilities can give a misleading picture, as
they do not include information on dosages. The effect on quality of care of
supply and financing mechanisms needs further study.
Publication Types:
• Clinical Trial
• Randomized Controlled Trial
1894: Anticancer Res. 1995 Nov-Dec;15(6B):2739-43.
A novel tree-structured analysis for non-invasive diagnosis of gastric

adenocarcinoma.
Wu MS, Lee WC, Lin JT, Wang HP, Wang TH, Chen CJ.
Department of Internal Medicine, College of Medicine, College of Public Health,

National Taiwan University, Taipei, Taiwan.
Non-invasive diagnosis of gastric adenocarcinoma (GAC) is usually difficult due

to the low sensitivity and specificity of serologic markers,including pepsinogens
and gastrin. For the improvement of the diagnostic values of these markers, a
"recursive partitioning and amalgamation" algorithm was employed to construct a
decision protocol. A total of 636 subjects including 161 healthy subjects, 163
patients with GAC, 196 with gastric ulcer and 116 with duodenal ulcer were
enrolled. Serum levels of gastrin, pepsinogen I, pepsinogen II, and the ratio of
pepsinogen I / pepsinogen II were determined for each of the subjects. The
proposed "decision tree" classifies subjects into five subgroups with different
risks of GAC and peptic ulcer, based on the information of age, serum pepsinogen
and gastrin levels. Using this novel analysis system, an expected probability of
GAC or ulcers could be obtained. Patients with an age > 62 years and a serum
level of pepsinogen I < or = 33 ng/ml were strongly indicated for further
confirmatory tests of GAC. This treestructured analysis is also helpful in
clarifying the interactions between various serologic markers and demographic
factors.
Publication Types:
1895: Med Educ. 1995 Nov;29(6):403-6.
Telematics in undergraduate teaching.
Norman JN, Brebner JA, Brebner EM, Lloyd OL, Ruddick-Bracken H, El

Sadig H Ahmed M, Catto GR, Ledingham IM.
Faculty of Medicine and Health Sciences, UAE University, United Arab

Emirates.
The use of telematics in the practice of medicine has received much recent
attention but little has been written about the use of these techniques in medical
education. This is a report of a pilot study in which an interactive video-
conference took place between medical students at the UAE University and their
opposite numbers at Aberdeen University. In Aberdeen, the Dean of the Medical
Faculty simultaneously taught Aberdeen and UAE students on a clinical case. He
was able to confine his activities largely to the correction of misconceptions, the
emphasis of important points and the addition of missing information, while the
students themselves conducted most of the presentation. The UAE students
presented their Community Health projects and had a spirited discussion on them
with the Aberdeen students. Recent technological advances have so improved the
quality of transmission of both visual and auditory images and at reasonable cost,
using the ISDN telephone system, that the feasibility of using this medium as an
aid to teaching has suddenly materialized. The experiment showed that the
technology was adequate for easy, fully interactive teaching among students from
different continents and with different cultural backgrounds. It is particularly
suitable for the Arab world where it is the custom to teach males and females
separately. The pilot study has pointed out the existence of a medium of
communication and teaching which, if proved to be effective, could have far-
reaching consequences in the undergraduate and postgraduate teaching of
medicine.
1896: Isr J Med Sci. 1995 Nov;31(11):670-3.
Comment in:
• Isr J Med Sci. 1995 Nov;31(11):700-1.
Gastrointestinal patients in the emergency room.
Hadas N, Eshchar J, Kochavi D, Scapa E.
Department of Emergency Medicine, Assaf Harofeh Medical Center, Zerifin,

Israel.
Of 4,839 patients who visited the Emergency Room (ER) of a 650-bed general
hospital (serving a regional population of 220,000) over a period of 28
consecutive days, 436 were suffering from gastrointestinal (GI) problems. The
patients, together with their 140 ER doctors, were interviewed by 40 trained
interviewers and information concerning demographic data, tests performed,
diagnosis, treatment and hospitalization was collected and evaluated. Most of the
GI patients (39.9%) were aged 16 years or younger, were Israeli born and were
suffering from infections of the GI system. Twenty percent of all GI patients were
hospitalized. Most came to the ER on working days although their symptoms
began at home. A total of 77.9% of the GI group expected to be treated in the ER
and sent home without being hospitalized. The ER, which is open for 24 hours a
day, is considered by the population as a kind of an outpatient clinic.
1897: Community Dev J. 1995 Oct;30(4):317-26.
Community mobilization and health care in rural China.
Cheung YB.
PIP: This study is based on interviews conducted in Xiao San Jiang Township,
China. This article describes the health care system before and after the reforms of
the late 1970s and the impact on community mobilization and health care
provision. The success of the Chinese health care system is attributed to mass
participation in disease prevention. There were the public health campaigns of the
1950s at the brigade level that mobilized people to adopt personal and
environmental sanitation, pest control, and primary health education. There were
organizations, such as the Youth Leagues and the Women's Federations. The large
groups encouraged use of services, such as family planning services,
gynecological screening, and immunization. The Barefoot Doctor and
Cooperative Medical Care Insurance Schemes were introduced. Brigades became
directly involved in health care delivery, and health workers increased access to
primary health services. There was multisectoral collaboration between mass and
government organizations. Each commune official had multiple roles and
information flowed between sectors. The end result was community mobilization
of resources in an organization-intensive social structure and increased hopes for
improvements in health. The propaganda was effective in health promotion. In the
late 1970s, township management districts and village committees replaced the
brigades and communes. The responsibility system gave households
responsibility for the productivity of specific plots of land in order to fulfill
government quotas. Members of a health project funded by a Hong Kong-based
primary health care organization discovered a number of problems. Community
mobilization was waning, and mass organizations were not effective. The
insurance system collapsed. People tired of political slogans. Although other
countries are now adopting community health approaches, China is moving away
from this approach.
1898: Health Millions. 1995 Oct;21(Souvenir):54-62.
Action re-SEARCH with people: exploring new horizons of primary

health care.
Bang A, Bang R.
PIP: Village health workers and illiterate traditional birth attendants (TBAs) are
successfully treating children with pneumonia in an area of 58 villages called
Gadchiroli, a remote tribal district in Maharashtra state. The district was created
in 1993 with the goal of speeding up the development of the area with a literacy
rate of only 22% and 80% of the population living below the poverty line.
Alcohol consumption was rampant, and the tribal people had been exploited by
various entrepreneurs and government officials. The nongovernmental
organization SEARCH was found in 1985 and chose this district to develop a
comprehensive health care program to complement the government's own primary
health care (PHC). SEARCH managed two PHC centers, provided specialty
clinical services at the district hospital, and introduced administrative reforms.
Unfortunately, no civil surgeon would stay in the district and the absenteeism of
government doctors was widespread. However, SEARCH initiated the training of
auxiliary nurse midwives (ANMs), which led to improvement of health care and
the regular food and drug supplies. Patient attendance increased by 50%. Yet two
years after the start of the experiment it was discontinued because of stiff health
department resistance. Two major problems were encountered: 1) the health
department was working to meet its own goals, and 2) the decision making was
extremely centralized and hierarchical. In 1988 links were severed with the
government programs and SEARCH started out on its own. These renewed
activities consisted of community-based rural health care in 58 villages through
village health workers and TBAs; referral service through a small hospital; the
training of the above personnel and paramedic nurses, youth, and tribal people;
health education; research on acute respiratory infections in children,
gynecological diseases, unwanted pregnancies and abortion, and sexually
transmitted diseases; a vital statistics information system; and popular education
on alcoholism, forest issues, tribal development, and women's status.
Publication Types:
• Case Reports
1899: Indian J Lepr. 1995 Oct-Dec;67(4):447-65.
An evaluation of the contribution of the Swedish International

Development Authority (SIDA) to leprosy control in India based on
the implementation of multiple drug therapy (MDT) 1981-1993.
Peat M, Brolin L, Ganapati R, McDougall AC, Revankar CR, Watson JW.
School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada.
The Swedish International Development Authority (SIDA) first supported the

National Leprosy Control Programme in India in 1978. In 1981/82 priority was
given to the implementation of multiple drug therapy (MDT), starting in two
high-endemic districts, and gradually extending to a total of 19 districts in the
years by 1993. SIDA then decided to undertake a detailed evaluation of its 12-
year contribution and this was carried out by an international team between
November 1993 and April 1994. In terms of epidemiological and public health
impact, the main results were impressive and clear-cut; 837,519 cases (old and
newly arising) were successfully treated, with few complications and a low rate of
relapse. The voluntary reporting rate had improved significantly. Data relating to
new case detection, child and disability rates were, however, less clear and
difficult to interpret. Deficiencies were also identified in the areas of health
education, community participation, gender issues, disability prevention and
management, rehabilitation, operational research and assessment of cost-
effectiveness. These problems should not, however, detract from the contribution
of SIDA, from 1981 onwards, in establishing the implementation of MDT in two
'pilot' districts at an early and important stage in the history of the MDT
programme in India. SIDA also made significant contributions in other areas,
namely pre-MDT 'screening' of registers in 45 endemic districts in 1990-1993,
appointment of consultant leprologists at district level, group education activities,
annual meetings of voluntary agencies and the development of a monitoring and
information system, with computer facilities, at national level. This paper
describes the design and methodology, main findings and conclusions of the
evaluation, based on the final report and the appendices submitted to SIDA in
Stockholm in April 1994.
1900: Int J Biomed Comput. 1995 Oct;40(2):89-93.
Erratum in:
• Int J Biomed Comput 1996 Jan;40(3):241-2.
National Patient Master Index in Singapore.
Tan LT.
National Computer Board, Republic of Singapore.
It has been the practice of hospitals and medical institutions to keep their patients'
medical records. Access to such valuable information will be confined within the
respective health institutions if there is no proper infrastructure to facilitate
sharing of the information. On the other hand, it has been the wish of medical
professionals, as well as patients who frequent hospitals and medical institutions
that patients' medical records, especially essential medical conditions, are readily
available, whenever required, regardless of the health institution by which the
patient is being attended to. In response, the National Patient Master Index
(NPMI) system was conceived and implemented by the Singapore Ministry of
Health in 1994. The NPMI system aims at providing a patient database at national
level that allows authorised users faster access to a patient's essential medical data
thereby facilitating patient management. This paper describes the implementation
of the NPMI system, its data elements, system functionality and access control to
address data confidentiality and privacy.
PMID: 8847128

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1701: Public Health Rev. 1998;26(1):73-7.

Sources of nutritional data in Israel.

Kaluski DN, Meir C, Rotem N, Zadka P.

Department of Nutrition, Ministry of Health, Jerusalem, Israel.

PMID: 9775724 [PubMed - indexed for MEDLINE]

1702: Public Health Rev. 1998;26(1):55-63.

Experiences with dietary assessment in the Middle East.

Department of Community Health Sciences, UCLA School of Public Health and

PMID: 9775722 [PubMed - indexed for MEDLINE]

1703: Occup Environ Med. 1998 May;55(5):300-9.

Comprehensive evaluation of long-term trends in occupational

Symanski E, Kupper LL, Rappaport SM.

University of Texas Health Science Center, Houston, School of Public Health

OBJECTIVES: To conduct a comprehensive evaluation of long term changes in

• Research Support, U.S. Gov't, P.H.S.

PMID: 9764107 [PubMed - indexed for MEDLINE]

1704: J UOEH. 1998 Sep 1;20(3):201-12.

[A plan of the life-long learning support system of UOEH--

Department of Preventive Medicine and Community Health, School of Medicine,

PMID: 9760706 [PubMed - indexed for MEDLINE]

1705: Int J Epidemiol. 1998 Aug;27(4):672-6.

Comparison of key informant and survey methods for ascertainment

Pal DK, Das T, Sengupta S.

Neurosciences Unit, Institute of Child Health, University College London, UK.

BACKGROUND: This study aimed to compare efficacy and cost of key

PIP: Epilepsy is the most important neurological problem in developing countries,

PMID: 9758124 [PubMed - indexed for MEDLINE]

1706: Int J Med Inform. 1998 Jul;51(1):59-68.,

MERIT-9: a patient information exchange guideline using MML,

Kimura M, Ohe K, Yoshihara H, Ando Y, Kawamata F, Tsuchiya F,

Department of Medical Informatics, School of Medicine, Hamamatsu University,

To realize clinical data exchange between healthcare providers, there must be

PMID: 9749900 [PubMed - indexed for MEDLINE]

1707: J Biosoc Sci. 1998 Jul;30(3):333-48.

Infant and child mortality in Bangladesh: age-specific effects of

Alam N, David PH.

Health and Population Surveillance Programme, International Centre for

PMID: 9746832 [PubMed - indexed for MEDLINE]

1708: Bull World Health Organ. 1998;76(3):237-44.

WHO Global Oral Data Bank, 1986-96: an overview of oral health

Nithila A, Bourgeois D, Barmes DE, Murtomaa H.

Division of Noncommunicable Diseases, World Health Organization, Geneva,

The global oral health situation of 12-year-old children--decayed, missing, filled

PMID: 9744243 [PubMed - indexed for MEDLINE]

1709: Eff Clin Pract. 1998 Oct-Nov;1(2):90-3.

Computer-prompted diabetes care.

Spero M, Kenet A, Porter B.

Maccabi Health Care Services, Jerusalem, Israel.

PMID: 10187228 [PubMed - indexed for MEDLINE]

1710: Int J Med Inform. 1998 Mar;49(1):53-8.

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1711: Rinsho Byori. 1998 Jul;46(7):699-705.

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Seoul National University Hospital, Korea.

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Laboratory medicine and hospital central laboratory system were adopted in