When push comes to shove: implementing VBAC practice guidelines

The dramatic increase in U.S. cesarean sections over the past two decades has been significantly driven by repeat C-sections. In response to this trend, clinical guidelines recommending vaginal birth after cesarean-section (VBAC) have been promulgated by national organizations. Adherence to these guidelines would reduce the number of repeat C-sections, lower the overall C-section rate, and improve both the quality and the cost of health care. While these guidelines have received professional endorsement, their implementation has been clouded by issues of patient acceptance and provider payment. To examine implementation of these guidelines by health care organizations, the authors surveyed 156 members of the American College of Physician Executives to determine their policies, practices, and attitudes toward VBAC guidelines. Those surveyed generally were medical directors in HMOs, hospitals, and other practice settings. The findings indicate that the health care organizations represented by these physician executives have not consistently implemented VBAC guideline and that they are reluctant to hold physicians, their patients, or hospitals accountable for the financial, utilization, and quality impact of the elective decision ot to pursue appropriate VBACs. We conclude that, even when widely accepted, clinical practice guidelines may be ineffective in reducing the costs or improving the quality of medical care.     

Ascendancy of primary care will create role intensification for physician executives

The need for physicians in management roles in the health care system has never been greater. And the years ahead will see that need broadened and intensified. To maintain their leadership role in medical affairs in hospitals and other types of health care delivery organizations, physician executives will have to envision provider organizations and systems that have not yet been conceived, let alone developed and implemented. They have to become totally open-minded and futuristic in their thinking. And they will have to help other physicians accommodate this new way of thinking if the medical profession is to continue in a leading role in health care matters. Although numerous factors will have to be anticipated and analyzed by these new physician leaders, the ascendancy of primary care in a managed health care world long dominated by the technical and technological superiority of hospital care will present a particular challenge to the physician executive.     

Recent fertility trends in industrialized countries: Toward a fluctuating or a stable pattern?

By the mid-1980s, fertility in most of the world's developed countries had declined to unprecedentedly low levels. Since then, it has declined still further in some, increased slightly in others, and fluctuated in still others. Irrespective of cause, these changes could not have occurred in the absence of substantial control over childbearing.While future increases and decreases are both possible, it is argued that, contrary to the usual demographic expectations for populations exercising substantial control over fertility, fertility in most of these countries will increase to approximate replacement levels and then undergo only minor fluctuations around these levels thereafter.     

An evaluation of population projection errors for census tracts

"In this article we evaluate the accuracy and bias of projections of total population and population by age group for census tracts in three counties in Florida. We use [U.S. census] data from 1970 and 1980 and several simple extrapolation techniques to produce projections for 1990; we then compare these projections with 1990 census counts and evaluate the differences. For the total sample, we find mean absolute errors of 17%-20% for the three most accurate techniques for projecting total population and find no indication of overall bias. For individual age groups, mean absolute errors range from 20%-29%." This is a revised version of a paper presented at the 1993 Annual Meeting of the Population Association of America.     

A cultural economy perspective on service sector migration in the global city: the case of Hong Kong

This article argues that in order to fully understand the geography of labour migration to global cities, it is necessary to consider economic forces in conjunction with mediating socio-cultural influences. Support for this argument is based on an examination of the pattern of migration to Hong Kong, a city which plays a significant role in the world economy.
Reported here are the results of an analysis of recently released 1996 by-census data, and the authors' interviews with foreign domestic workers in Hong Kong. These findings have shown that highly skilled immigrant workers were drawn largely from developed countries, the main sources of inward investment in this city, while less skilled immigrants were drawn from less developed neighbouring labour markets.
While the geographical pattern of immigration followed broadly that predicted from Hong Kong's position in the world economy, the results have revealed that cultural influences such as language and social networks are also important in shaping the economic roles of migrant workers.     

Community,Family, and Race/Ethnic Differences in Health Status in Rural Areas1

Abstract Many race-specific differences in health outcomes that have been observed in previous research have been attributed to class and racebased group differences which either facilitate or constrain health opportunities and behaviors. These include such variables as different rates of poverty, health insurance coverage, and access to medical care. However, these relationships have been inadequately examined in rural communities where minority status may be even more detrimental to health than in urban areas, due to various constraints on access to health care. We present an analysis that assesses the effects of community, family structure, sociodemographic, and medical care variables on self-reported health status among Hispanics, Mrican Americans, and non-Hispanic whites in six rural communities in Florida. Community structural characteristics had a significant effect on self-reported health, as did some of the measures of how respondents “experience” community. These relationships held even when other sets of variables were added to the models. Family/household characteristics and sociodemographic and medical care variables were less important in explaining self-reported health status. These findings suggest that community continues to be important in explaining differences in health status in rural areas.     

Is There a Forest Transition? Deforestation,Reforestation, and Development1

Abstract Environmental social scientists have recently begun to use the term 'forest transition' to describe how forest cover changes as economic development occurs in nations. The hypothesized transition occurs as follows. An initial surge in economic activity in impoverished societies spurs deforestation, but as economic activity continues to intensify and cities grow larger, a 'turnaround' occurs, and deforestation gives way to reforestation. This paper uses cross-national data from five successive surveys of world forest resources to assess this empirical claim. A turnaround in forest cover trends does occur in a significant number of nations. The paper also evaluates two explanations for the turnaround, a wood scarcity hypothesis derived from microeconomic theory and an industrialization hypothesis linked to central place theory. It finds period specific support for the industrialization hypothesis. The paper concludes with a brief discussion of the implications of these findings for proposals to alleviate the biodiversity crisis through programs of reforestation.