Description

Social Science & Medicine provides an international and interdisciplinary forum for the dissemination of research findings, reviews and theory in all areas of common interest to social scientists and health practitioners and policy makers. The journal publishes material relevant to any aspect of health from a wide range of social science disciplines (eg. anthropology, economics, education, ethics, geography, political science, psychology, social policy and sociology), and material relevant to any of the social sciences from any of the professions concerned with physical and mental health, and with health care practice, policy and organisation. It is particularly keen to publish findings or reviews which are of general interest to an international readership.The journal will publish the following types of contribution:1) Original research reports (preferably not more than 8,000 words in length).2) Critical or analytical reviews in any area of theory, policy or research relevant to health and illness (again preferably not more than 8,000 words in length).3) Short research reports or "think pieces" on topical theoretical or empirical issues (not more than 2,000 words).4) Letters relating to materials previously published in Social Science & Medicine, or to topical and internationally relevant issues concerning social science and health.5) Editorials or commentaries commissioned by the Editors.6) Part or whole Special Issues bringing together collections of papers on a particular theme, and usually edited by a guest editor.7) Reviews commissioned by the book review editor, or recently published books or groups of books which are likely to be of general interest to an international readership. Health Abstracts Online Health Abstracts Online is the new online service that has replaced Abstracts Online Social Science & Medicine. This new online service provides full details of the aims and scope, table of content, free abstracts, author lists and keywords of all articles published in Social Science & Medicine and Health & Place from 1995 onwards. Search each individual journal, or across the whole programme, for a particular topic and access the abstracts provided absolutely free of charge. Access is quick and easy for any user. Whether you are a new user or an existing user simply go to the new website at http://www.healthabstractsonline.com/healthab/show/ and you will automatically enter the new site where you can browse the information provided. When you wish to access the free journal abstracts you will be asked to login by providing your name and e-mail address. You will only need to login once, subsequent visits and access to the abstracts will be automatic. Health Abstracts Online will be regularly updated so visit the website and create a bookmark now - make Health Abstracts Online a regular stop for your research needs. http://www.healthabstractsonline.com/healthab/show/ The XVth International Conference on the Social Sciences & Medicine took place on 16-20 October 2000 in Veldhoven (near Eindhoven), The Netherlands. Proposals to host the XVIth International Conference are invited. Arranged as a series of workshops, each led by a discussion leader, the conference addresses key issues relating to the behavioural and social aspects of health and healthcare. For full details visit http://www.elsevier.nl/locate/ssmconf/

Publisher details

Elsevier

Publications in this journal

• Is travel-time to a specialist centre a risk factor for non-referral, nonattendance and loss to follow-up among patients with hepatitis C (HCV) infection?

  Authors: Thomas Astell-Burt, Robin Flowerdew, Paul J Boyle, John F Dillon

  Social Science [?] Medicine. In press.

  Little is known about why many people diagnosed with hepatitis C virus (HCV) infection fail to reach and stay within specialist care services. We used a Geographic Information System and logitLittle is known about why many people diagnosed with hepatitis C virus (HCV) infection fail to reach and stay within specialist care services. We used a Geographic Information System and logit regression to investigate whether travel-time to a specialist centre was associated with an increased likelihood of non-referral, non-attendance and loss to follow-up among persons diagnosed with HCV between 1991 and 2003 in Tayside, Scotland (UK). Information was available on referral to, and utilisation of, the single HCV specialist centre in Tayside between 1991 and 2006. Longer travel-time to a specialist centre was associated with an increased likelihood of non-referral to a specialist centre following diagnosis (Odds Ratio: 1.25, 95% Confidence Interval: 1.09, 1.44). Patients living further from an HCV specialist centre were less likely to be referred to it for treatment that could cure their HCV infection. Neither a history of intravenous drug use (IDU), nor area deprivation predicted non-referral. Subsequent to referral, travel-time to a specialist centre was not associated with either non-attendance (0.83 (0.56, 1.21)) or loss to follow-up (0.98 (0.78, 1.22)), although a history of IDU was a strong predictor of both non-attendance and loss to follow-up. Non-attendance was less likely among older patients, while loss to follow-up was more common among those living in deprived areas. Once referred, patients appear able to cope with stress and financial cost of long and frequent journeys to hospital. However, as rates of referral improve from more geographically remote areas, long travel-times to an HCV specialist centre may become an important factor determining future utilisation.

• Is travel-time to a specialist centre a risk factor for non-referral, nonattendance and loss to follow-up among patients with hepatitis C (HCV) infection?

  Authors: Thomas Astell-Burt, Robin Flowerdew, Paul J Boyle, John F Dillon

  Social Science [?] Medicine. In press.

• 1. Indoor air pollution due to cooking with biomass is associated with depletion of platelet serotonin and depression among premenopausal women in rural India

  Authors: M Banerjee, S Siddique, A Dutta, B Mukherjee, MR Ray

  Social Science [?] Medicine.

  Cooking with biomass fuel, a common practice in rural India, is associated with a high level of indoor air pollution (IAP). The aim of this study was to investigate whether IAP from biomass burningCooking with biomass fuel, a common practice in rural India, is associated with a high level of indoor air pollution (IAP). The aim of this study was to investigate whether IAP from biomass burning increases the risk of depression. For this cross-sectional study, we enrolled a group of 952 women (median age 37 years) who cooked regularly with biomass and a control group of 804 age-matched women who cooked with cleaner fuel (liquefied petroleum gas). Depression was assessed using the second edition of Beck’s depression inventory (BDI-II). Platelet P-selectin expression was assessed by flow cytometry and platelet serotonin was measured by ELISA. Particulate matter having diameter of less than 10 and 2.5 mm (PM10 and PM2.5, respectively) in indoor air was measured by real-time aerosol monitor. Carbon monoxide (CO) in exhaled breath was measured by CO monitor. Compared with the control group, women who cooked with biomass had a higher prevalence of depression and depleted platelet serotonin, suggesting altered serotonergic activity in the brain. In addition, P-selectin expression on platelet surface was up-regulated implying platelet hyperactivity and consequent risk of cardiovascular disease. Biomass-using households had increased levels of PM10 and PM2.5, and biomass users had elevated levels of CO in expired air. Controlling potential confounders, cooking with biomass was found to be an independent and strong risk factor for depression. IAP from cooking with biomass is a risk for depression among rural women in their child-bearing age.

• "Is travel-time to a specialist centre a risk factor for non-referral, nonattendance and loss to follow-up among patients with hepatitis C (HCV) infection?

  Authors: Thomas Astell-Burt, Robin Flowerdew, Paul J Boyle, John F Dillon

  Social Science [?] Medicine. In press.

• Is travel-time to a specialist centre a risk factor for non-referral, nonattendance and loss to follow-up among patients with hepatitis C (HCV) infection?

  Authors: Thomas Astell-Burt, Robin Flowerdew, Paul J Boyle, John F Dillon

  Social Science [?] Medicine. In press.

  Little is known about why many people diagnosed with hepatitis C virus (HCV) infection fail to reach and stay within specialist care services. We used a Geographic Information System and logitLittle is known about why many people diagnosed with hepatitis C virus (HCV) infection fail to reach and stay within specialist care services. We used a Geographic Information System and logit regression to investigate whether travel-time to a specialist centre was associated with an increased likelihood of non-referral, non-attendance and loss to follow-up among persons diagnosed with HCV between 1991 and 2003 in Tayside, Scotland (UK). Information was available on referral to, and utilisation of, the single HCV specialist centre in Tayside between 1991 and 2006. Longer travel-time to a specialist centre was associated with an increased likelihood of non-referral to a specialist centre following diagnosis (Odds Ratio: 1.25, 95% Confidence Interval: 1.09, 1.44). Patients living further from an HCV specialist centre were less likely to be referred to it for treatment that could cure their HCV infection. Neither a history of intravenous drug use (IDU), nor area deprivation predicted non-referral. Subsequent to referral, travel-time to a specialist centre was not associated with either non-attendance (0.83 (0.56, 1.21)) or loss to follow-up (0.98 (0.78, 1.22)), although a history of IDU was a strong predictor of both non-attendance and loss to follow-up. Non-attendance was less likely among older patients, while loss to follow-up was more common among those living in deprived areas. Once referred, patients appear able to cope with stress and financial cost of long and frequent journeys to hospital. However, as rates of referral improve from more geographically remote areas, long travel-times to an HCV specialist centre may become an important factor determining future utilisation.

• Building institutions for an effective health system: Lessons from China’s experience with rural health reform

  Authors: Gerald Bloom

  Social Science [?] Medicine. 72(8):1302-1309.

  This paper is concerned with the management of health system changes aimed at substantially increasing access to safe and effective health services. It argues that an effective health sector reliesThis paper is concerned with the management of health system changes aimed at substantially increasing access to safe and effective health services. It argues that an effective health sector relies on trust-based relationships between users, providers and funders of health services, and that one of the major challenges governments face is to construct institutional arrangements within which these relationships can be embedded. It presents the case of China, which is implementing an ambitious health reform, drawing on a series of visits to rural counties by the author over a ten year period. It illustrates how the development of reform strategies has been both a response to the challenges arising from the transition to a market economy and the result of actions by different actors, which have led to the gradual creation of increasingly complex institutions. The overall direction of change has been strongly influenced by the efforts by the political leadership to manage a transition to a modern economy which provides universal access to basic benefits. The paper concludes that the key lessons for other countries from China’s experience with health system reform are less about the detailed design of specific interventions than about its approach to the management of institution-building in a context of complexity and rapid change.

• The promotion of olanzapine in primary care: an examination of internal industry documents.

  Authors: Glen I Spielmans

  Social science & medicine (1982). 69(1):14-20.

  Media reports have discussed how olanzapine was marketed off-label for dementia and subsyndromal bipolar disorder. Much of this marketing occurred in primary care settings. However, these reportsMedia reports have discussed how olanzapine was marketed off-label for dementia and subsyndromal bipolar disorder. Much of this marketing occurred in primary care settings. However, these reports have provided few details. In legal proceedings, Lilly disclosed internal documents that detail the strategies utilized to market olanzapine. The current paper addresses the marketing of olanzapine in detail based upon a review of these documents. All 358 documents released by Lilly are publicly available online. Documents were utilized for this review if they were relevant to the marketing of olanzapine in primary care settings in the United States. It was found that olanzapine was marketed off-label in primary care settings for relatively mild symptoms that were framed as bipolar disorder and schizophrenia. A key strategy in this campaign was the use of hypothetical patient profiles in detailing visits, most of which clearly failed to meet diagnostic criteria for any recognized mental disorder. Evidence emerged that olanzapine was also marketed off-label as a treatment for dementia.

• The neighborhood effects of disrupted family processes on adolescent substance use.

  Authors: Jon Gunnar Bernburg, Thorolfur Thorlindsson, Inga D Sigfusdottir

  Social science & medicine (1982). 69(1):129-37.

  In the current paper, we argue that the neighborhood-level of disrupted family processes (weak social ties to parents and coercive family interaction) should have a contextual effect on adolescentIn the current paper, we argue that the neighborhood-level of disrupted family processes (weak social ties to parents and coercive family interaction) should have a contextual effect on adolescent substance use (cigarette smoking, heavy drinking, and lifetime cannabis use), because adolescents living in neighborhoods in which disrupted family processes are prevalent should be more likely to associate with deviant (substance using) peers. We use nested data on 5491 Icelandic adolescents aged 15 and 16 years in 83 neighborhoods to examine the neighborhood-contextual effects of disrupted family processes on adolescent substance use (cigarette smoking, heavy drinking, and lifetime cannabis use), that is, whether neighborhoods in which disrupted family processes are common have more adolescent substance use, even after partialling out the individual-level effects of disrupted family processes on substance use. As predicted, we find that the neighborhood-levels of disrupted family processes have significant, contextual effects on all the indicators of substance use, and that association with substance using peers mediates a part of these contextual effects. The findings illustrate the limitation of an individual-level approach to adolescent substance use.

• Objectification, standardization, and commodification in health care: a conceptual readjustment.

  Authors: Stefan Timmermans, Rene Almeling

  Social science & medicine (1982). 69(1):21-7.

  Historically, medical sociologists have used the interrelated concepts of objectification, commodification, and standardization to point to the pathologies of modern medicine, such as theHistorically, medical sociologists have used the interrelated concepts of objectification, commodification, and standardization to point to the pathologies of modern medicine, such as the depersonalization of care and the effects of bureaucratic control. More recent work in science studies, economic sociology, and sociology of health and illness, however, has begun to explore how the social processes of objectification, commodification, and standardization produce a wide variety of biomedical achievements. We provide a theoretical synthesis of this emerging body of scholarship centered upon the intended and unintended consequences of objectification, commodification, and standardization to improve health. We then outline a research agenda that would result from a more comprehensive assessment of how these processes manifest themselves in clinical care.

• Age and disability: explaining the wage differential.

  Authors: Brenda Gannon, Margaret Munley

  Social science & medicine (1982). 69(1):47-55.

  This paper estimates the level of explained and unexplained factors that contribute to the wage gap between workers with and without disabilities, providing benchmark estimates for Ireland. ItThis paper estimates the level of explained and unexplained factors that contribute to the wage gap between workers with and without disabilities, providing benchmark estimates for Ireland. It separates out the confounding impact of productivity differences between disabled and non-disabled, by comparing wage differentials across three groups, disabled with limitations, disabled without limitations and non-disabled. Furthermore, data are analysed for the years 1995-2001 and two sub-samples pre and post 1998 allow us to decompose wage differentials before and after the Employment Equality Act 1998. Results are comparable to those of the UK and the unexplained component (upper bound of discrimination) is lower once we control for productivity differences. The lower bound level depends on the contribution of unobserved effects and the validity of the selection component in the decomposition model.

• Risk of smoking initiation among Mexican immigrants before and after immigration to the United States.

  Authors: Pamela Stoddard

  Social science & medicine (1982). 69(1):94-100.

  Research has suggested that Latinos are less likely to initiate smoking than non-Latino whites. This advantage may be due in part to social and structural factors that deter smoking initiation amongResearch has suggested that Latinos are less likely to initiate smoking than non-Latino whites. This advantage may be due in part to social and structural factors that deter smoking initiation among Latino immigrants, such as entry into the restrictive regulatory environment surrounding smoking in the U.S. and decreased exposure to family smoking influences, given that immigrants often leave parents and siblings behind in countries of origin. Although available data do not support a direct test of this hypothesis this study conducts an indirect test by comparing risk of initiation among Mexican immigrants before and after immigration to the U.S. If such factors influence initiation among Mexican immigrants, their risk should decline after immigration, relative to risk before immigration, since they are subject to these forces only after moving to the U.S. Using data from the National Health Interview Survey, discrete-time hazards analysis is used to estimate risk of initiation of regular smoking from ages 10 to 30, based on retrospective reports of age of smoking initiation. Retrospective data on age at immigration are used to create a time-varying variable indicating country of residence (U.S. or Mexico) during each person year of risk. Through this approach, risk in the person years before immigration is determined only among those who will eventually immigrate, which discounts health selection as an explanation for changes in risk after immigration. Consistent with the social and structural perspective, results indicate that the odds of smoking initiation decline among Mexican immigrants after immigration, relative to risk before immigration. This decline is unlikely due to alternative factors often cited to explain patterns of health behaviors among Mexican immigrants, such as health-protective cultural characteristics, since such characteristics are presumably in place before immigration. Findings suggest that Mexican immigrants may be particularly receptive to smoking prevention efforts after immigration.

• Use of khat and posttraumatic stress disorder as risk factors for psychotic symptoms: a study of Somali combatants.

  Authors: Michael Odenwald, Harald Hinkel, Elisabeth Schauer, Thomas Elbert, Frank Neuner, Brigitte Rockstroh

  Social Science [?] Medicine.

• Physician as partner or salesman? Shared decision-making in real-time encounters.

  Authors: Orit Karnieli-Miller, Zvi Eisikovits

  Social science & medicine (1982). 69(1):1-8.

  The results of recent research have led to the increased advocacy of shared decision-making regarding medical treatment. Nonetheless, only a limited number of studies have focused on the process ofThe results of recent research have led to the increased advocacy of shared decision-making regarding medical treatment. Nonetheless, only a limited number of studies have focused on the process of decision-making in real-time encounters. The present paper aims to document and analyze this process. Specifically, we assess whether these decisions are the result of partnership or of persuasive tactics based on power and hierarchical relationships. We will describe and analyze different strategies used by pediatric gastroenterologists in breaking bad news encounters, as well as their consequences. The analysis is based on a multi-method, multi-participant phenomenological study on breaking bad news to adolescents and their families regarding a chronic illness. It included 17 units of analysis (actual encounters and 52 interviews with physicians, parents and adolescents). Data were collected from three hospitals in Northern Israel using observations and audiotapes of diagnosis disclosure encounters and audio-taped interviews with all participants. The analysis identified eight different presentation tactics used in actual encounters during which physicians made various use of language, syntax and different sources of power to persuade patients to agree with their preferred treatment choice. The tactics included various ways of presenting the illness, treatment and side effects; providing examples from other success or failure stories; sharing the decision only concerning technicalities; and using plurals and authority. The findings suggest that shared decision-making may be advocated as a philosophical tenet or a value, but it is not necessarily implemented in actual communication with patients. Rather, treatment decisions tend to be unilaterally made, and a variety of persuasive approaches are used to ensure agreement with the physician's recommendation. The discussion is focused on the complexity of sharing a decision, especially in the initial bad news encounter; and the potentially harmful implications on building a trusting relationship between the physician and the family when a decision is not shared.

• Can physicians both persuade and partner? A commentary on Karnieli-Miller and Eisikovits.

  Authors: Susan Eggly

  Social science & medicine (1982). 69(1):9-11; discussion 12-3.

• Hospital efficiency and transaction costs: a stochastic frontier approach.

  Authors: Martijn Ludwig, Wim Groot, Frits Van Merode

  Social science & medicine (1982). 69(1):61-7.

  The make-or-buy decision of organizations is an important issue in the transaction cost theory, but is usually not analyzed from an efficiency perspective. Hospitals frequently have to decide whetherThe make-or-buy decision of organizations is an important issue in the transaction cost theory, but is usually not analyzed from an efficiency perspective. Hospitals frequently have to decide whether to outsource or not. The main question we address is: Is the make-or-buy decision affected by the efficiency of hospitals? A one-stage stochastic cost frontier equation is estimated for Dutch hospitals. The make-or-buy decisions of ten different hospital services are used as explanatory variables to explain efficiency of hospitals. It is found that for most services the make-or-buy decision is not related to efficiency. Kitchen services are an important exception to this. Large hospitals tend to outsource less, which is supported by efficiency reasons. For most hospital services, outsourcing does not significantly affect the efficiency of hospitals. The focus on the make-or-buy decision may therefore be less important than often assumed.

• Racialized identity and health in Canada: Results from a nationally representative survey.

  Authors: Gerry Veenstra

  Social science & medicine (1982).

  This article uses survey data to investigate health effects of racialization in Canada. The operative sample was comprised of 91,123 Canadians aged 25 and older who completed the 2003 CanadianThis article uses survey data to investigate health effects of racialization in Canada. The operative sample was comprised of 91,123 Canadians aged 25 and older who completed the 2003 Canadian Community Health Survey. A "racial and cultural background" survey question contributed a variable that differentiated respondents who identified with Aboriginal, Black, Chinese, Filipino, Latin American, South Asian, White, or jointly Aboriginal and White racial/cultural backgrounds. Indicators of diabetes, hypertension and self-rated health were used to assess health. The healthy immigrant effect suppressed some disparity in risk for diabetes by racial/cultural identification. In logistic regression models also containing gender, age, and immigrant status, no racial/cultural identifications corresponded with significantly better health outcomes than those reported by survey respondents identifying as White. Subsequent models indicated that residential locale did little to explain the associations between racial/cultural background and health and that socioeconomic status was only implicated in relatively poor health outcomes for respondents identifying as Aboriginal or Aboriginal/White. Sizable and statistically significant relative risks for poor health for respondents identifying as Aboriginal, Aboriginal/White, Black, Chinese, or South Asian remained unexplained by the models, suggesting that other explanations for health disparities by racialized identity in Canada - perhaps pertaining to experiences with institutional racism and/or the wear and tear of experiences of racism and discrimination in everyday life - also deserve empirical investigation in this context.

• Occupational career and risk of mortality among US Civil War Veterans.

  Authors: Dejun Su

  Social science & medicine (1982).

  Previous studies have extended the traditional framework on occupational disparities in health by examining mortality differentials from a career perspective. Few studies, however, have examined thePrevious studies have extended the traditional framework on occupational disparities in health by examining mortality differentials from a career perspective. Few studies, however, have examined the relation between career and mortality in a historical U.S. population. This study explores the relation between occupational career and risk of mortality in old age among 7096 Union Army veterans who fought the American Civil War in the 1860s. Occupational mobility was commonplace among the veterans in the postbellum period, with 54% of them changing occupations from the time of enlistment to 1900. Among veterans who were farmers at enlistment, 46% of them changed to a non-farming occupation by the time of 1900. Results from the Cox Proportional Hazard analysis suggest that relative to the average mortality risk of the sample, being a farmer at enlistment or circa 1900 are both associated with a lower risk of mortality in old age, although the effect is more salient for veterans who were farmers at enlistment. Occupational immobility for manual labors poses a serious threat to chance of survival in old age. These findings still hold after adjusting for the effects of selected variables characterizing risk exposures during early life, wartime, and old age. The robustness of the survival advantage associated with being a farmer at enlistment highlights the importance of socioeconomic conditions early in life in chance of survival at older ages.

• Negotiating 'depression' in primary care: A qualitative study.

  Authors: Susan McPherson, David Armstrong

  Social science & medicine (1982).

  Psychiatry has provided primary care physicians with tools for recognising and labelling mild, moderate or severe 'depression'. General practitioners (GPs) in the UK have been guided to managePsychiatry has provided primary care physicians with tools for recognising and labelling mild, moderate or severe 'depression'. General practitioners (GPs) in the UK have been guided to manage depression within primary care and to prescribe anti-depressants as a first-line treatment. The present study aimed to examine how GPs would construct 'depression' when asked to talk about those anomalous patients for whom the medical frontline treatment did not appear to be effective. Twenty purposively selected GPs were asked in an interview to talk about their experience and management of patients with depression who did not respond to anti-depressants. GPs initially struggled to identify a group, but then began to construct a category of person with a pre-medicalised status characterised by various deviant features such as unpleasant characters and personalities, manipulative tendencies, people with entrenched social problems unable to fit in with other people and relate to people normally. GPs also responded in non-medical ways including feeling unsympathetic, breaking confidentiality and prescribing social interventions. In effect, in the absence of an effective medical treatment, depression appeared to become demedicalised. The implications of this process are discussed in relation to patients' subsequent access or lack of access to services and the way in which these findings highlight the processes by which medicine frames disease.

• Gender and access to HIV testing and antiretroviral treatments in Thailand: Why women have more and earlier access?

  Authors: Sophie Le Cœur, Intira J Collins, Julie Pannetier, Eva Lelièvre

  Social science & medicine (1982).

  In the recent scale-up of antiretroviral treatment, gender differences in access to treatment have been reported. In Thailand, as the HIV epidemic became more generalised, there has been a shift fromIn the recent scale-up of antiretroviral treatment, gender differences in access to treatment have been reported. In Thailand, as the HIV epidemic became more generalised, there has been a shift from men being disproportionately affected to increased vulnerability of women. In 2007, the Living with Antiretrovirals (LIWA-ANRS 12141) study investigated the gender distribution of all adult patients receiving antiretroviral therapy (N=513 patients) in four community hospitals in northern Thailand and factors influencing the disparities observed. From this retrospective life-event history survey, we found that proportionately more women (53%) were receiving antiretroviral therapy than men, an unexpected result for a country with a higher proportion of infections among men. They were more likely to initiate treatment within one year of diagnosis and were at a more advanced stage of the disease compared to women. This gender distribution is partly explained by the evolving dynamics of the HIV epidemic, initial prioritization of mothers for treatment and earlier access to HIV testing for women. These issues are also entangled with gender differences in the reasons and timing to HIV testing at the individual level. This study found that the majority of men underwent HIV testing for health reasons while the majority of women were tested following family events such as a spouse/child death or during pregnancy. Further qualitative research on gender specific barriers to HIV testing and care, such as perceived low risk of infection, poor access to medical care, lack of social support, actual or anticipated HIV/AIDS-related stigma would provide greater insight. In the meantime, urgent efforts are needed to increase access to voluntary counselling and testing inside and outside the family setting with targeted interventions for men.

• Comparing hospital costs: What is gained by accounting for more than a case-mix index?

  Authors: Anne Hvenegaard, Andrew Street, Torben Højmark Sørensen, Dorte Gyrd-Hansen

  Social science & medicine (1982).

  We explore what effect controlling for various patient characteristics beyond a case-mix index (DRG) has on inferences drawn about the relative cost performance of hospital departments. We estimateWe explore what effect controlling for various patient characteristics beyond a case-mix index (DRG) has on inferences drawn about the relative cost performance of hospital departments. We estimate fixed effect cost models in which 3754 patients are clustered within six Danish vascular departments. We compare a basic model including a DRG index only with models also including age and gender, health related characteristics, such as smoking status, diabetes, and American Society of Anesthesiogists score (ASA-score), and socioeconomic characteristics such as income, employment and whether the patient lives alone. We find that the DRG index is a robust and important explanatory factor and adding other routinely collected characteristics such as age and gender and other health related or socioeconomic characteristics do not seem to alter the results significantly. The results are more sensitive to choice of functional form, i.e. in particular to whether costs are log transformed. Our results suggest that the routinely collected characteristics such as DRG index, age and gender are sufficient when drawing inferences about relative cost performance. Adding health related or socioeconomic patient characteristics only slightly improves our model in terms of explanatory power but not when drawing inferences about relative performance. The results are, however, sensitive to whether costs are log transformed.

• Economic valuation of informal care in Asia: A case study of care for disabled stroke survivors in Thailand.

  Authors: Arthorn Riewpaiboon, Wachara Riewpaiboon, Kanyarat Ponsoongnern, Bernard Van den Berg

  Social science & medicine (1982).

  This study values informal care for disabled stroke survivors in Thailand. It applies the conventional recommended opportunity cost method to value informal care in monetary terms. Data wereThis study values informal care for disabled stroke survivors in Thailand. It applies the conventional recommended opportunity cost method to value informal care in monetary terms. Data were collected by means of face-to-face interviews conducted during 2006. The sample consisted of 101 disabled persons who had suffered a stroke at least six months prior to the interview, and who had a functional status score of less than 95 as measured by the Barthel Index. Average monthly time spent on informal care was 94.6hours, and the major source of opportunity cost was forgone unpaid work (43.5%). The average monthly monetary value of informal care was 4642.6 baht, based on 2006 prices. This study shows that providing informal care involves a substantial opportunity cost, implying a hidden value to Thai society.

• Who feeds children? A child's-eye-view of caregiver feeding patterns among the Aka foragers in Congo.

  Authors: Hillary N Fouts, Robyn A Brookshire

  Social science & medicine (1982).

  This study describes the contributions of various types of caregivers to the direct provisioning and feeding of Aka children in households reliant on foraging in Congo. Ecological and family factorsThis study describes the contributions of various types of caregivers to the direct provisioning and feeding of Aka children in households reliant on foraging in Congo. Ecological and family factors that predict allomaternal caregiving (i.e., caregiving by individuals other than mothers) are identified and discussed in light of current anthropological and public health perspectives on child feeding and cooperative caregiving. The study is based on 8 months of ethnographic fieldwork in the Republic of Congo in 2004 and 2005, and utilizes naturalistic observations of 22 focal children between two and four years of age. Observations spanned 12 daylight hours spread out over three different days. The results of this study demonstrate that even though mothers were the single highest contributor to child feeding, combined allomaternal contributions (i.e., contributions by fathers, grandmothers, aunts, siblings, and cousins) to child feeding was higher than that of mothers. Furthermore, birth order and the transition in families to having a new infant predicted allomaternal contributions. These results reinforce the need to extend public health and nutrition education programs to target more than just parents, as other individuals may have substantial influence over child feeding patterns. Furthermore, these results exemplify a cooperative child rearing pattern that is consistent with behavioral ecology perspectives that have suggested that humans evolved as cooperative childrearers rather than as maternal-centric or parent-only childrearers. Lastly, individual child and family characteristics predicted allomaternal contributions to child feeding and therefore research and public health initiatives need to consider variation in child and family characteristics in order to accurately describe and serve populations throughout the world.

• Tales of the unexpected? Hidden resilience in poor households in Britain.

  Authors: Krysia Canvin, Anneli Marttila, Bo Burstrom, Margaret Whitehead

  Social science & medicine (1982).

  Society tends to have low expectations for the health, employment, and family stability of people living in poverty and disadvantage, reinforced by a body of research focused on risk factors andSociety tends to have low expectations for the health, employment, and family stability of people living in poverty and disadvantage, reinforced by a body of research focused on risk factors and negative outcomes. This 'deficit model' has pervaded policy and interventions to tackle inequalities in health, in particular in relation to area-based initiatives to improve the health of socio-economically disadvantaged communities. In contrast, the study presented here adopts a positive approach, specifically that of resilience, which we conceptualise as: the process of achieving positive and unexpected outcomes in adverse conditions. Taking account of the critiques of resilience research, we aimed to discover what could be learnt from a health inequalities policy perspective about resilience in poor households in Britain if: a) the voices of people experiencing hardship were heard; b) resilience was conceptualised as a process, rather than as a an individual trait; and c) the social context and conditions that helped or hindered that process of resilience were identified. We interviewed 25 adults with experience of material adversity and 18 social welfare workers with experience of working with people in these circumstances, as well as recording observations at the 13 fieldwork sites in England and Wales. The study provided many "tales of the unexpected" from participants living in disadvantaged circumstances. The participants recounted how they coped with very difficult situations, their achievements in these circumstances, the transitions they had made in their lives and what had helped them along the way. These transitions often occurred contrary to participants' and others' expectations. Interactions that promoted these transitions included family and community support, respectful attitudes and behaviour of service providers, and the chances offered to them to engage in activities that bolstered self-esteem. Recognition of such resilience, however, should complement, rather than detract from, wider societal efforts to reduce the material deprivation in which too many people within the population live.

• Marital status, gender and cardiovascular mortality: Behavioural, psychological distress and metabolic explanations.

  Authors: Gerard John Molloy, Emmanuel Stamatakis, Gemma Randall, Mark Hamer

  Social science & medicine (1982).

  The intermediate processes through which the various unmarried states can increase the risk of subsequent cardiovascular disease mortality are incompletely understood. An understanding of theseThe intermediate processes through which the various unmarried states can increase the risk of subsequent cardiovascular disease mortality are incompletely understood. An understanding of these processes and how they may vary by gender is important for understanding why marital status is strongly and robustly associated with subsequent cardiovascular disease. In a prospective study of 13,889 Scottish men and women (mean age 52.3, Standard Deviation: 11.8 yrs, range 35-95, 56.1% female) without a history of clinically diagnosed cardiovascular disease, we examined the extent to which health behaviours (smoking, alcohol, physical activity), psychological distress (General Health Questionnaire-12 item) and metabolic dysregulation (obesity levels, and the presence of hypertension and diabetes) account for the association between marital status and cardiovascular mortality. There were 258 cardiovascular deaths over an average follow up of 7.1 (Standard Deviation=3.3) years. The risk of cardiovascular mortality was greatest in single, never married men and separated/divorced women compared with those that were married in gender stratified models that were adjusted for age and socio-economic group. In models that were separately adjusted, behavioural factors explained up to 33%, psychological distress explained up to 10% and metabolic dysregulation up to 16% of the relative change in the hazard ratios in the observed significant associations between marital status and cardiovascular mortality. Behavioural factors were particularly important in accounting for the relationship between being separated/divorced and cardiovascular mortality in both men and women (33% and 21% of the relative change in the hazard ratios, respectively). The findings suggest that health behaviour, psychological distress and metabolic dysregulation data have varying explanatory power for understanding the observed relationship between cardiovascular disease mortality and unmarried states.

• Idle chatter or learning? Evidence of social learning about clinicians and the health system from rural Tanzania.

  Authors: Kenneth L. Leonard, Sarah W Adelman, Timothy Essam

  Social science & medicine (1982).

  We examine data from the rural Arusha region in Tanzania in which households are asked to recall the illness episodes of randomly chosen other households in their village. We interviewed 502 randomlyWe examine data from the rural Arusha region in Tanzania in which households are asked to recall the illness episodes of randomly chosen other households in their village. We interviewed 502 randomly selected households from 22 villages in 20 wards of Arusha. We analyze the probability that a household can recall another illness episode as a function of the characteristics of the illness, the location and type of health care chosen and the outcome experienced. We found that households are more likely to recall severe illnesses, illnesses for which good quality care is important, illnesses that resulted in visits to hospitals and illnesses when the patient was not cured. In addition, households are more likely to recall illnesses that resulted in a visit to a facility where the average tenure of clinicians is less than two years. The results suggest that households deliberately collect information in order to learn about clinicians and facilities in their local area. We show evidence that households use this information when they choose whether to visit new health care providers. In particular, households are less likely to visit a new provider when they hear of bad outcomes and more likely to do so when they hear of good outcomes.

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