“Primary” Rationing of Health Services in Ageing Societies—A Normative Analysis

While most of the debate on rationing in health care focusses on the distribution of scarce medical resources among competing needs, which we propose to call secondary rationing, this paper is concerned with primary rationing, i.e., the conscious decision by society to limit the amount of resources devoted to a collectively financed health care system. Based upon a number of transparent normative criteria, we analyze whether primary rationing should be performed and, if so, what type should be chosen (hard vs. soft, explicit vs. implicit). Finally we discuss whether age should be used as a criterion in any systematic attempt at primary rationing of health care.     

Hard hats vs. soft hearts: The conflict between principles and reality in child and adolescent care and treatment programs

Much of child care in volves quick reactions based on one's automatic pilot derived from how we were parented. This paper is about two seemingly universal automatic pilot systems—the hard hats and the soft hearts. Hard hats are behavior management and modification oriented, while soft hearts are psychodynamically and counselling oriented. Typically, the hard hats tend to have the upper hand due to the nature of our culture, and they therefore have the effect of preventing the contributions of the soft hearts from being realized. That all too frequently sets up a dominant culture and a resentful minority situation. To correct this imbalance, a value orientation from the top which emphasizes mutual respect and utilization is suggested.Grateful acknowledgement is made to Ray Peterson for his helpful suggestions in the preparation of this paper.     

Media reviews

Of the three films reviewed in this issue, only the first, All Women Have Periods, deals with both areas of sexuality and disability. The second film, A Masturbatory Story, deals with sexuality but not disability. The third film, A Different Approach, deals with disability but not sexuality. The reason I have included the last two films are that A Masturbatory Story is one of the best, most permission giving films I have seen on the subject of masturbation and A Different Approach while focusing on employment of the disabled, is one of the most entertaining and effective films I have seen dealing with attitudes.     

Muscle Learning Therapy—Efficacy of a Biofeedback Based Protocol in Treating Work-Related Upper Extremity Disorders

Work-related upper extremity disorders (WRUEDs) continue to present significant treatment and financial challenges to providers, employers, and insurers. This retrospective study reviews outcomes for 309 subjects who, between 1995 and 1999, were referred through the workers' compensation system for treatment of computer keyboard- and mouse-related WRUED injuries. The mean length of time from the recorded date of injury to the date of intake was 12.9 months. Subjects were offered a 12-visit course in muscle learning therapy (MLT). MLT is an operant conditioning program which uses surface electromyography (sEMG) to train injured workers to control their muscles during work activities. Patient response to therapy was obtained by a therapist-administered questionnaire during Visit 8 of 12. A group of 309 subjects, who had failed to respond to a previous course of therapy (typically physical therapy), reported significant improvements of pain in the neck, thorax, and upper extremities. Ninety six percent reported that they felt more in control, 86% reported feeling better overall, and 81% reported either working the same and feeling better or working and accomplishing more. This study provides preliminary support for this approach and provides justification for controlled clinical trials in the future.     

Psychosocial stressors associated with Mexican migrant farmworkers in the midwest United States

Although estimates suggest that there are upwards of 5 million migrant farmworkers in the United States, scant research has explored the stressors associated with their lifestyle. Contrary to previous work, the present study directly explored migrant farmworkers' own perceptions of what is difficult in their lives. The purposes of the present study were to qualitatively explore, from a phenomenological standpoint, the stressors associated with living as a migrant farmworker in the Midwest United States; and to determine the stressors that were most strongly related to symptoms of anxiety and depression. The findings indicated that 18 stressors were commonly experienced by the migrant farmworkers and that the farmworkers experienced overall elevated levels of anxiety and depression. A number of stressors that were not previously reported in the literature were identified. The stressors of rigid work demands and poor housing conditions were significantly associated with higher levels of anxiety and low family income/living in poverty and rigid work demands were significantly associated with depression. Implications of findings and prevention strategies are discussed.     

In a Secular Spirit: Strategies of Clinical Pastoral Education

The Clinical Pastoral Education (CPE) model forthe provision of spiritual care represents theemergence of a secularized professionalpractice from a religiously-based theologicalpractice of chaplaincy. The transformation ofhospital chaplaincy into spiritual careservices is one means by which religioushealthcare ministry negotiates modernity, inthe particular forms of the secular realm ofbiomedicine and the pluralism of thecontemporary United States healthcaremarketplace. Spiritual is a labelstrategically deployed to extend the realm ofrelevance to any patient's belief system,regardless of his or her religious affiliation.Theological language is recast as a tool forconceptualizing the spiritual lens. Suchmoves transform chaplaincy from a peripheralservice, applicable only to the few religiouspatients, into an integral element of patientcare for all. Such a secularized professionalpractice is necessary to demonstrate therelevance and utility of spiritual care for allhospital patients in an era of cost-containmentpriorities and managed care economics.     

Comparison of attitudes toward transsexuality and homosexuality

Attitudes toward transsexuality and homosexuality were compared in a sample of 318 university students. More people felt that homosexuality was wrong than felt that transsexuality was wrong. This difference in favor of transsexuality was more pronounced in female than in male respondents. In addition, more people rejected the notion that biological factors were responsible for homosexuality than was the case for transsexuality. General attitudes about the morality of transsexuality and homosexuality, however, were not mirrored in response to questions pertaining to job discrimination. To the contrary, male respondents, especially, were more inclined toward equal opportunity for homosexuals than for transsexuals. One hypothesis supported by this study was that homosexual denial and homophobia in some transsexuals may, in part, be a reflection of society's greater moral condemnation of homosexuality relative to transsexuality.     

Mother,father, sister,friend: Metaphor and the craft of child care

Language not only reflects, but shapes our perception of the world. In child care, the perception has been shaped by imagery borrowed from the medical and behavioral-learning models. But these fail to illuminate the key feature of child care, the relationship between child and worker. The metaphors of competence and professionalism attempt to make up for the inadequacies of the other models, yet neither of these ground the abstract care in everyday experience. Developmental science provides the base for a child care perspective, and the metaphors of care need to be sensitive to this base.     

Ultraviolet and volatility loss of herbicides

Herbicide 2,4-D formulated as a urea-type polymer was readily destroyed by long-wave uv (356-nm) irradiation, whereas conventional 2,4-D was more resistant. The opposite relationship was noted for polymeric and conventional formulations of dicamba. Polymerized 2,4-D was more resistant to thermal degradation (60°C) than non-polymerized formulations. Ultraviolet degradation of polymerized 2,4-D was eliminated by the incorporation of RYLEX-H and UVINUL D-50, industrial uv absorbers. Exposure of polymeric dicamba to 60°C heat, followed by trapping of the volatile component, indicated that 21 percent was lost by thermal degradation and 46.6 percent by volatilization. Comparable values for non-polymerized dicamba were 37.9 and 60.1 percent.     

The evaluation of pornography: Effects of attitude and perceived physiological reaction

Twenty-three medical and 28 nonmedical male student Ss read four erotic prose passages and then rated each on obscenity, censorship, and four semantic differential evaluation scales. Ss were given varying levels of false (experimenter-controlled) GSR feedback for each stimulus passage, as well as different explanations of the significance of this arousal feedback. Four-way analyses of variance showed that low Stolerance of erotica, pedophelic passage content, and GSR feedback indicating physiological arousal resulted in passages being labeled as more obscene and unfavorable. Explanations to Ss that GSR feed-back indicated sexual arousal resulted in more favorable ratings by the medical Ss and interacted with passage type for the nonmedical Ss. Concurrently monitored heart rate was not significantly influenced by any of the experimental variables and was (with one marginal exception) uncorrelated with any of the dependent labeling variables. An earlier version of this article was presented at the XVIIth International Congress of Applied Psychology, Liege, Belgium, July 1971.     

Heterosexual copulatory patterns in stumptail macaques (Macaca arctoides) and in other macaque species

A comparison of the mating behavior patterns of several macaque species reveals that the mating behavior of Macaca arctoidesexhibits several unique features. The laboratory groups of stumptail monkeys observed had exceptionally long single-mount copulations characterized by a large number of pelvic thrusts, a slow thrusting rate, and an unusually salient male orgasmic pattern (characterized by body rigidity followed by body spasms and a typical facial expression and vocalization). The frequency with which the copulation culminates in ejaculation is unusually high, and copulating stumptails generally manifest tieing in a genital lock after ejaculation. This research was supported in part by the Interdisciplinary Training Program, Langley Porter Neuropsychiatric Institute, University of California, San Francisco; by United States Public Health Service Training Grant No. 5-T1-MH-7082 from the National Institute of Public Health; and by Grant No. GS-31943X from the National Science Foundation to Dr. S. L. Washburn of the University of California at Berkeley, given for Primate Studies and Human Evolution.This paper was given as one part of the presentation prepared for the symposium Male and Female Sexual Behavior in Primate Societies, Fourth International Congress of Primatology, Portland, Oregon, August 1972. The first part was published as Male-Female, Female-Female, and Male-Male Sexual Behavior in the Stumptail Monkey, with Special Attention to the Female Orgasm,Archives of Sexual Behavior 3: 95–116, 1974.     

Inter and intea-observer variation in ultrasonographic detection of gallstones: The Multicenter Italian Study on Epidemiology of Cholelithiasis (M.I.COL.)

Inter and intea-observer agreement in classifying the presence of gallstones by ultrasonographic images according to established criteria was studied. A film recording of 50 routine ultrasonographic examinations of the gallbladder was read by each of the 46 observers who participated in the Multicenter Italian Study on Epidemiology of Cholelithiasis (M.I.COL.). The overall Kappa score for inter-observer agreement was 0.649, while intea-observer agreement was good or excellent (Kappa scores >0.60) in 75% of the observers. No statistical difference for inter-observer agreement between novices and expert echographers was found in the overall Kappa statistic or in category-specific Kappa scores (gallstone, no gallstone, doubtful and inconclusive examinations) The present study suggests that the development of explicit criteria by a group of trained echographers does not eliminate inter-and intea-observer disagreement in categorizing subjects for gallbladder stones. M.I.COL. (Multicentrica Italiana Colelitiasi).Corresponding author.See appendix.     

Assessment of occupational exposure to 4,4′-methylene-bis-(2-chloroaniline) “MOCA” by a new sensitive method for biological monitoring

Summary A new specific and sensitive method for the urinary determination of 4,4-methylene-bis-(2-chloroaniline) (MOCA), a known carcinogen in rats, mice and dogs, has been developed. After a brief study on rats to determine some peculiarities in MOCA urinary excretion, this method was used to assess occupational exposure in French industrial firms. Both the manufacture of MOCA and its use as a curing agent in the production of polyurethane elastomers were surveyed. MOCA excretion levels were distributed from non-detectable (<0.5 g/l) up to 1600 g/l. Concentrations of N-acetyl metabolites, when present, were largely lower than MOCA levels. The results seemed to reflect workers' overall exposure fairly. Preventive measures following analytical determinations often led to an obvious lowering of excretion levels.     

Biological aspects and self-evaluation of shiftwork adaptation

Summary Two male truck drivers working in a Brazilian cellulose plant and classifying themselves as well- and ill-adapted to a shiftwork schedule of 4 days-on and 1 day-off, participated in an autorhythmometric study. Psychophysiological self-ratings (calmness, stress and alertness), oral temperature measurements and urine collections (detection of K⁺,Na⁺ and 17-OH concentrations) were performed regularly during the waking period for 15 consecutive days during the shift schedule — the midday shift (11:00 to 19:00h), early-morning shift (03:00 to 11:00 h) and evening shift (18:00 to 02:00 h), including days-off. Cosine fitting of the data to a successive running one-day window revealed different individual temporal patterns, with the well-adapted subject showing a relatively stable phase relationship of the variables under study and the ill-adapted subject showing a less stable relationship. The different patterns could explain, at least partially, the fact that one subject feels adapted to shiftwork and the other not.Dedicated to the memory of Prof. Dr. Dr. Joseph Rutenfranz, former Director of the Institut für Arbeitsphysiologie, Dortmund, FRG, who contributed so much to the development of studies on occupational and environmental health     

Development of cardiovascular risk factors during adolescence

Summary Results of a first phase of follow-up in the population of the Basle Adolescents Study indicate that average blood pressure increased more in boys than in girls, blood lipids remained at the same level. Boys cought up with girls as far as cigarette smoking is concerned.

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Dévelopement des facteurs de risque pour les maladies cardiovasculaires entre 14 et 20 ans

Résumé Les résultats de la première phase du follow-up chez les participants de l'étude báloise des adolescents montrent que le changement de la pression sanguine est plus important chez les jeunes gens que chez les jeunes filles. Cependant, le taux des lipides dans le sang n'avait guère changé. La consommation de tabac est devenue équivalente pour les filles et les garÇons.

     

Factor analysis of the psychosocial items of the EORTC QLQ-C30 in metastatic breast cancer patients participating in a psychosocial intervention study

The underlying factor structure of a subset of 12 items, which comprise the psychosocial subscales of the EORTC QLQ-C30 was explored in a group of women, all with metastatic breast cancer who were participating in a psychosocial intervention study. Two main factors were identified in this exploratory factor analysis, representing emotional distress and functional ability dimensions. A preliminary assessment of the external validity of the two factor structure was undertaken. The results support the validity of a summative emotional distress and functional ability score in this sample of patients. The functional ability score discriminated well for subgroups defined by clinical status indicators (e.g., performance status, pain, chemotherapy treatment, fatigue). The emotional distress subscale discriminated with respect to suffering, fatigue and sleep disturbance. Both subscales converged with related concepts measured by independent instruments, providing support for convergent validity. Summative index scores may be advantageous for application in particular research situations; applying quality adjustments in health policy analyses; for screening purposes; to monitor populations and make comparisons across broad groups and as stratification variables in clinical trials. Further research to confirm the 2 factor structure is required in other samples before the interpretation can be accepted with confidence.     

Men in day care: You've come a long way,buddy!

Male day care teachers have more to offer young children than their masculine presence. It is suggested that pleas for a male role model are misdirected, and that men in day care have valuable contributions to make by modeling and reinforcing not only positive masculine traits but also positive feminine traits. Emphasis, therefore, is placed upon the balance the male caregiver can provide for a humanized environment for young children. Suggestions are given on ways to establish androgynous environment for current and future caregivers.     

What is a normal family? Common assumptions and current evidence

The social and applied human sciences have been built upon the assumption that the normal family consists of a first-marriage conjugal couple cohabiting with biological children. It is taken for granted that the wife should be responsible for child and domestic work, and that the husband should be the family's economic provider and ultimate authority. In the professional literature such traditional family structure is often described as normal in the sense of most common, as well as normal in the sense of well-functioning. Current psychological, sociological, anthropological and historical studies, however, do not support the assumption that the traditional nuclear family is the most natural, common, and/or healthy form of family arrangement. The idealization of the traditional nuclear family has had implications for theory, research, mental health practice, and social policy. Scientists and practitioners have been slow to recognize pathology in traditional nuclear families. Families other than traditional nuclear ones have been rendered invisible or pathologized. It is time for contemporary social and applied human sciences to recognize that the traditional nuclear family is a culturally- and historically-specific construct. It is also time for contemporary social and applied human sciences to develop an account of, and a research agenda about, families that take into consideration their variations across time, place, social class, ethnicity, and culture.     

The Magical Age of 10

Developmental processes of puberty and their cultural contexts in understanding the emergence of sexual subjectivity, especially sexual attraction, prior to gonadarche are critically examined. In particular, we consider the hypothesis that sexual attraction follows the onset of adrenal puberty, termed adrenarche, precipitating the development of stable and memorable attraction toward others approximately by the age of 10. In a prior study, the authors suggested that adrenarche is a significant source of this developmental change in sexuality (McClintock, M., and Herdt, G., 1996). The inferential evidence from New Guinea is compared with recent studies from the United States, including clinical findings on precocious puberty. We conclude with the question of whether the age of 10 is a human universal in the development of attraction and sexuality.     

Managing for health: why health care?

Health and health care are increasingly big business. The challenge is to apply our knowledge and skills to meet people's needs, if not their demands as efficiently, effectively and beneficially as possible. Value for money is the slogan. For those who deliver the goods as required, the converse, money for value should equally apply, and not only in a market driven system. This paper offers a very personal view of these issues in the light of recent UK policy developments.