Does the Gats Undermine Democratic Control Over Health?

This paper examines the General Agreement on Trade in Services (GATS), which is one of the World Trade Organisations free trade agreements. In particular, I examine the extent to which the GATS unduly restricts the scope for national democratic choice. For purposes of illustration, I focus on the domestic health system as the subject of policy choice. I argue that signatories to the GATS effectively acquire a constitutional obligation to maintain a domestic health sector with a certain minimum degree of privatisation. Like constitutional obligations, the restrictions the GATS imposes on the freedom of future generations to structure their domestic health sector are (i) very difficult, though not strictly impossible, to alter; and (ii) not chosen in any ordinary sense by the subject generation. To gain democratic legitimacy, therefore, the relevant provisions of the GATS must pass some higher standard of democratic scrutiny, such as ratification by a super-majority. Ordinary legislative ratification does not suffice.     

School-based applications of the wraparound process: Early results on service provision and student outcomes

The application of a school-based wraparound approach presents different challenges, perspectives, and knowledge from those seen in mental health or child welfare settings. For the past three years, the La Grange Area Department of Special Education's Wraparound Project has been implementing a school-based individualized service network that is now being integrated into the larger local and state special education, mental health, and social service systems. We present school-based applications of wraparound for students with emotional and behavioral disabilities, including the community and system context, program application, evaluation process and preliminary results. Students who were identified through self-contained special education classrooms were compared to students who were identified from various other school and mental health settings. Students from the school-based program were less clinically involved than students identified from other settings. Service provision differed between program groups and by out-of-home experiences. Finally, the use of wraparound approaches across a variety of educational settings to prevent out-of-school and out-of-home care are discussed.     

Children and adolescents discharged from public psychiatric hospital: Evaluation of outcome in a continuum of care

Ninety children and adolescents admitted to two state-operated psychiatric hospitals were followed from the time of their admission through one year post discharge. Data were collected from the children and adolescents, their families and clinicians at three intervals (during hospitalization, three months post discharge, and one year post discharge) to identify demographic, clinical, and service history characteristics of the children and adolescents, as well as to track their placement and other dispositional status following discharge from the hospital. The data indicated that the children and adolescents were seriously emotionally and behaviorally disturbed, came from families which were economically disadvantaged, and did not typically live in two-parent families. While the majority of the children and adolescents received recommended aftercare services during the three months following discharge from the hospital, there was a decline in placement stability for the children at the one-year post discharge followup. The most important predictors of successful outcome at discharge were living with a family member at the time of hospitalization and the participation of the family in the treatment planning during hospitalization.     

Oral contraceptive use among African American adolescents: Individual and community influences

Side effects of oral contraceptives are a noteworthy problem, particularly among low-income young women who reside in inner-city communities. The problem may be compounded by inadequate family planning services, particularly when such services are provided by general medical practices with high volumes of clients. This study examined the prevalence and correlates of pill-related side effects, with particular attention to the role of clinic characteristics. Participants were 177 pregnant and parenting African American adolescents and young women (average age=18.34). The experience of a pill-related side effect was the most frequently cited barrier to birth control use, and it was significantly related to contraceptive behavior. Finally, although participants attending comprehensive clinics experienced more barriers to medical service use than those attending neighborhood clinics, they reported fewer problems with pill-related side effects and better psychological functioning. Implications for future research and policy are discussed. This study was completed with the assistance of grants from the Illinois Department of Alcoholism and Substance Abuse, the National Institute of Child Health and Human Development, and the Office of Research on Women's Health to Jean Rhodes. Portions of this paper were presented at the 1993 Biennial Meeting of the Society for Community Research and Action, Williamsburg, Virginia. The authors gratefully acknowledge the assistance of Julian Rappaport, Joel Meyers, Hope Landrine, Lori Ebert, the Reverend Annette Collins, Margaret Daniels, Khya Lawrence, and the professionals and participants at the service settings.     

Integrating systems of care in California for youth with severe emotional disturbance III: Answers that lead to questions about out-of-home placements and the AB377 evaluation project

This paper is the third in a series of reports on preliminary empirical findings from replications of an integrated system of care for youth suffering from serious emotional disturbance. The development of the innovative system of care was pioneered in Ventura County, California, and the replications in three other California counties were legislatively enabled through California legislation (Assembly Bill 377). This report presents results on the expenditure and utilization of foster homes, residential placements made through special education programs, and state hospitals. Evaluation results indicate that foster home and state hospital utilization and expenditures are lower for the counties replicating the innovative system of care than for the state of California as a whole. Expenditures for special education residential placements are either at the state rate or lower in one county. The cumulative evidence supports the conclusion that the replication counties are utilizing restrictive levels of care at lower rates than would be expected, given state-wide patterns. The results, in conjunction with prior findings, are discussed in the context of questions about the possible fates of youth who no longer live in publicly funded residential facilities.     

对“四一三”医保模式破解双向转诊困境的思考

双向转诊困境成为制约社区卫生服务和医疗保障体系发展的关键问题。引入“四一三”医保模式，分析了该模式破解双向转诊困境的可能性，有助于优化城市卫生资源配置、调整医疗机构利益分配格局，有助于双向转诊制度的建立，有助于医疗信息的交流，以及风险分析。建议鼓励包括“四一三”医保模式在内的各种保障制度的发展。     

Perceptions of Family Environment and Wraparound Processes: Associations with Age and Implications for Serving Transitioning Youth in Systems of Care

Addressing the unique needs of youth transitioning to adulthood has long been viewed as a priority in implementation of systems of care (SOCs) and wraparound. Developmental research and "practice-based evidence" suggest that there are differences between transitioning youth and their younger peers in family environment and wraparound team processes. Although these differences are thought to have significant implications for wraparound practice, few studies have examined them empirically. The present research involves two studies examining differences across several age cohorts (i.e., 10–12, 13, 14, 15, 16–17 year-olds) ranging from early adolescent to transitioning youth in: (1) caregiver perceptions of role-related strain and family environment quality, and (2) facilitator, caregiver, and youth perceptions of wraparound processes. In Study #1, older age was associated with higher levels of caregiver strain. In Study #2, age was associated with differences between youth and other team members' perceptions of wraparound processes, such that older youth perceived teams as less cohesive than others on their teams. These findings suggest that transitioning youth and their families merit special consideration in wraparound implementation and underscore the importance of considering the perceptions of transitioning youth in system change and practice improvement efforts (192 words).     

新疆农村医疗救助制度实施效果评价

为评价新疆农村医疗救助制度实施效果,利用2008年和2012年两次横断面调查资料,分析医疗救助对象和非医疗救助对象的卫生服务需要、利用及费用变化.救助对象的两周患病率由2008年的181.34‰下降到2012年的87.81‰,2008年两周患病率救助对象高于非救助对象.救助对象两周就诊率由2008年的110.92‰下降至2012年的46.93‰,2012年两周就诊率救助对象高于非救助对象.年住院率救助对象均高于非救助对象.新疆农村医疗救助制度提高了贫困人口对卫生服务的利用,应将医疗救助制度与新农合紧密结合,持续资助贫困家庭参合.     

‘The experiencing of experience’: a Pragmatic reassessment of Rogerian Phenomenology

This paper draws on a study that asked twenty family users about their first session of family therapy. Analyses of the interviews indicated that families entered therapy with a pre-existent knowledge about therapy, which did not always chime with those of professionals and which positioned speakers in ways which governed their expectations and perceptions of therapy. This paper, therefore, is concerned with the acquisition and deployment of knowledge: specifically, the knowledge involved in being a user of family therapy. Three key discourses were identified through this analysis: medical, counselling and consumerist. We aim to illustrate how these discourses served as a resource for members of the family in constructing therapists, therapy and themselves in relation to their experience. The examination of the rhetorical, ideological and practical effects of the positions chosen and the objects constructed, in terms of how speakers wanted to present themselves, with what enhanced or diminished status as patients, shows users actively engaging with the power of therapeutic institutions. Users’ accounts suggest that while most speakers felt anxious about the prospect of therapy, there were clear differences in overall satisfaction/dissatisfaction with the experience according to the synchrony between speakers’ construction of the therapist, and themselves as client/patients. Those who seemed to take a traditional view of therapy within a medical discourse valued therapists who offered diagnosis and a cure; those who sought and experienced a counselling relationship with the therapist found their experience to be constructive in terms of enhanced self-knowledge. We believe that the research findings discussed in this paper have implications for family therapists in accommodating to parental and child positions to maximise the effectiveness of therapy and so minimise drop-out.     

Understanding and working with existential information in a Norwegian adolescent psychiatry context: a need and a challenge

This is one of several studies on existential information in psychotherapy in Southern Norway. The aim of this study was to explore how therapists' backgrounds and existential information influence their therapeutic practice and philosophy of care, and the use of existential information in psychotherapy. The method used was qualitative, semi-structured interviews. Through emerging themes from the interviews and clinical case illustrations, information relating to therapists' backgrounds and existential orientations strongly influenced: therapeutic practice, philosophy of care, and if as well as how existential information was used in therapy. Professional and continued education/training in this area were insufficient. However, the area itself was considered essential for understanding clients' psychosocial and sociocultural needs in multicultural Norway. Therapists expressed the importance of communication about existential information. Clinical examples were given that focused on this information's usefulness for identifying strategies addressing both salutogenic and pathogenic aspects of adolescent psychosocial functioning. Clinical educational and training insufficiencies related to working with existential information were noted. Although strategic thinking and organisational framework in the working context permitted existential information to be raised in therapy, many expressed the lacking of methodological confidence and training in this area. Education and training were, therefore, priorities. Accessing this type of information with all clients, whatever their existential information, was emphasised for strengthening the therapeutic alliance.