Native Americans appear to be at higher risk than other U.S. ethnic groups for mental health problems, including depression, substance abuse, domestic violence, and suicide. Despite recent increases in the federal budget for mental health services for Native Americans, less than 50 percent of the estimated need for ambulatory services is being met. Initiatives to improve the quantity and quality of mental health services for Native Americans in the 1990s include development of a national mental health plan, increased technical assistance to Native American communities, additional training and research, and continued attention to standards that promote high-quality, culturally relevant care. Tribes themselves are seen as the most appropriate locus for initiation of programs for preventing emotional problems in their communities.
Avoidable mortality has been proposed as an outcome measure of health services and our aim, in this study, is to trace its general features and regional variations in Québec. For that purpose, comparisons are established between two time periods (1969-73 and 1982-90) and with several countries. Furthermore, regional SMRs (for the period 1982-90) are submitted to the Gail heterogeneity test and introduced in a stepwise regression with variables describing health services, socio-economic context and prevalence or incidence of related diseases. An analysis of proportional mortality is carried out in the two northern regions of Kativik and Baie-James. Avoidable mortality has dropped substantially in Québec, except in the case of asthma, and now displays excellent scores at the international level. Only three causes of death show significant regional variations: tuberculosis, hypertensive and cerebrovascular diseases and perinatal mortality. These variations are mainly associated with socio-economic factors but also with health services. Furthermore, the highest rates of avoidable death have been observed in Gaspésie, Saguenay/Lac St-Jean and in the two northern regions. These results are discussed through information already available on health services in Québec.
The authors describe the implementation of a comprehensive quality assurance program, within a multi-disciplinary, multi-program mental health clinic. The quality assurance program is reviewed in relation to measures of structure, process and outcome.
A population approach and the general right to health and medical care have been important issues in the development of health policy over many centuries. However, equity is still a crucial issue in the planning and evaluation of health care. Many definitions and criteria related to equity have been formulated on the basis of conflicting theories and models. Three dimensions of fair and just resource allocation are essential when needs-based models are used: equity in access, utilization, and quality of care relative to needs. Health services research should concentrate on such outcome measures regarding equity and the effect of organizational and processual characteristics of health care systems. Prominent examples of such research efforts are presented, but, unfortunately, there are few reliable and systematic data from this kind of study. Health care researchers have a special responsibility towards the population at large to undertake qualified research on equity and to communicate the results to the general public.
Although diagnostic radiology developed rapidly following Roentgen's discovery, limitations on voltage delayed penetrating external radiation therapy until after World War II. Quality assurance has developed in both the USA and Canada in many different institutions. Tolerances for implementation of the prescribed tumor dose have been established. A series of quality assurance procedures for calibration, three dimensional dose distributions, the treatment planning process, and for treatment delivery have been formulated in protocols and their development is sketched briefly. The importance of computerized tomography in treatment planning and computerized record and verify systems in treatment delivery is emphasized.
Treatment activity of vascular diseases varies depending on population, preference of doctors and the availability of vascular surgical services. Vascular registry offers an opportunity to review practice, to compare outcome with a standard, and to implement change to improve practice. Prospective data collection of all reconstructive vascular procedures has been performed in Finland for seven years. According to a review of the first five years, combined vascular and endovascular activity has increased nation-wide from 3508 procedures done in 1991 to 5200 in 1995. There are marked regional differences in the frequency and selection of various treatment modalities, which can not be explained only by epidemiological data but as well by skewed vascular care delivery. This data can be used for decision-making and should be used for planning of the vascular surgical services in Finland.
United States interest in the potential early childhood programs have for improving outcomes for children is shared by policymakers and researchers in many other nations. Throughout the world, enrollments in preschool and child care programs are rising. This article reviews international research documenting how participation in early childhood programs influenced children's later development and success in school. Studies conducted in 13 nations (Australia, Canada, Colombia, France, Germany, India, Ireland, Japan, Singapore, South Korea, Sweden, Turkey, and the United Kingdom) are included, along with key features of each nation's provision of early childhood programs. The article summarizes conclusions that are supported by research in various countries, indicating that participation in preschool promotes cognitive development and school success, although the specific type of program attended matters little. Preschool experience helps low-income children narrow, but not close, the achievement gap separating them from more advantaged children. International evidence also suggests that maternal employment and reliance on child care do not harm children and may yield benefits if the child care is of good quality. The author draws insights from the experience of other nations concerning such issues as defining quality, the effectiveness of early childhood programs in redressing social and economic inequities, and understanding how research can influence policy.
In the 1980s, faced with a rapidly increasing elderly population and soaring costs of health and long-term care services, many European governments began to reexamine fiscal policies that often encouraged institutionalization of frail and dependent elders. A number of these countries have now turned to new models of home and community-based care. This report describes home care policies that serve the needs of frail elders in Sweden, Denmark, the Netherlands, and Great Britain, with special attention to experimental projects that have tested varying approaches for providing high quality, low-cost care in the home and in the community. The central governments in these countries have developed long-term care systems that improve quality of care, ensure more efficient delivery of services, and control or lower costs. They have (1) discouraged the building of additional nursing homes and instead supported the development and expansion of a range of housing alternatives; (2) shifted greater responsibility to local governments for delivering long-term care services, bringing those services closer to those who need them; (3) developed care management techniques that enable care providers to better target appropriate services to each elderly client; and (4) provided incentives for different types of care providers to coordinate their work, resulting in improved service delivery and greater client satisfaction.