James Macinko

James Macinko
Associate Professor of Public Health, NYU Steinhardt School of Education

James Macinko is Associate Professor of Public Health and Health Policy in the Department of Nutrition, Food Studies, and Public Health and the Robert F. Wagner Graduate School of Public Service. Since 2008, he has directed the NYU Master's program in Global Public Health. Dr. Macinko was formerly a Robert Wood Johnson Foundation Health and Society Scholar at the University of Pennsylvania and a Fulbright Scholar in Brazil. His field experience includes evaluation of primary health care programs and policies in Latin America and the Caribbean; assessment of microenterprise development programs in Africa and Latin America; assisting the US Agency for International Development and the World Health Organization to develop indicators for assessing infectious disease prevention and control programs in Sub-Saharan Africa; coordinating election monitoring in Ethiopia; and working with the Latino communities in Washington DC, Philadelphia and New York City to identify and eliminate barriers to primary health care.

Date Publication/Paper
2014

Torres, J.L., R.C. Dias, F.R. Ferreira, J. Macinko, and M.F. Lima-Costa 2014. Functional Performance and Social Relations Among the Elderly in Greater Metropolitan Belo Horizonte, Minas Gerais State, Brazil: a Population-Based Epidemiological Study Cadernos de Saude Publica, Vol. 30, no. 5 (May 2014), pp. 1018-1028. doi: 10.1590/0102-311X00102013
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Abstract

This study was conducted in a probabilistic sample of 2,055 elderly in Greater Metropolitan Belo Horizonte, Minas Gerais State, Brazil, to examine components of social network (conjugal status and visits by the children, other relatives, and friends) and social support (satisfaction with personal relations and having persons on whom to rely) associated with limitations in performing basic activities of daily living (ADL). Multivariate analysis used the Hurdle model. Performance of ADL showed independent and statistically significant associations with social network (fewer meetings with friends and not having children) and personal support (dissatisfaction/indifference towards personal relations). These associations remained after adjusting for social and demographic characteristics, health status, and other indicators of social relations. Our results emphasize the need for greater attention to social network and social support for elderly with functional limitations and those with weak social networks and social support.

Elo, I.T., H. Beltran-Sanchez, and J. Macinko 2014. The Contribution of Health Care and Other Interventions to Black-White Disparities in Life Expectancy, 1980-2007 Population Research and Policy Review, Vol. 33, no. 1 (Feb 2014), pp. 97-126. doi: 10.1007/s11113-013-9309-2
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Abstract

Black–white mortality disparities remain sizable in the United States. In this study, we use the concept of avoidable/amenable mortality to estimate cause-of-death contributions to the difference in life expectancy between whites and blacks by gender in the United States in 1980, 1993, and 2007. We begin with a review of the concept of “avoidable mortality” and results of prior studies using this cause-of-death classification. We then present the results of our empirical analyses. We classified causes of death as amenable to medical care, sensitive to public health policies and health behaviors, ischemic heart disease, suicide, HIV/AIDS, and all other causes combined. We used vital statistics data on deaths and Census Bureau population estimates and standard demographic decomposition techniques. In 2007, causes of death amenable to medical care continued to account for close to 2 years of the racial difference in life expectancy among men (2.08) and women (1.85). Causes amenable to public health interventions made a larger contribution to the racial difference in life expectancy among men (1.17 years) than women (0.08 years). The contribution of HIV/AIDS substantially widened the racial difference among both men (1.08 years) and women (0.42 years) in 1993, but its contribution declined over time. Despite progress observed over the time period studied, a substantial portion of black–white disparities in mortality could be reduced given more equitable access to medical care and health interventions.

Uyei, J., D. Coetzee, J. Macinko, S.L. Weinberg, and S. Guttmacher 2014. Measuring the Degree of Integrated Tuberculosis and HIV Service Delivery in Cape Town, South Africa Health Policy and Planning, Vol. 29, no. 1 (Jan 2014), pp. 42-55. doi: 10.1093/heapol/czs131
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Abstract

To address the considerable tuberculosis (TB)/HIV co-infected population in Cape Town, a number of clinics have made an effort of varying degrees to integrate TB and HIV services. This article describes the development of a theory-based survey instrument designed to quantify the extent to which services were integrated in 33 clinics and presents the results of the survey. Using principal factor analysis, eight factors were extracted and used to make comparisons across three types of clinics: co-located TB and antiretroviral therapy (ART) services, clinics with TB services only and clinics with ART only. Clinics with co-located services scored highest on measures related to integrated TB/ART service delivery compared to clinics with single services, but within group variability was high indicating that co-location of TB and ART services is a necessary but insufficient condition for integrated service delivery. In addition, we found almost all clinics with only TB services in our sample had highly integrated pre-ART services, suggesting that integration of these services across a large number of clinics is feasible and acceptable to clinic staff. TB clinics with highly integrated pre-ART services appear to be efficient sites for introducing ART given that co-infected patients are already engaged in care, and may potentially facilitate earlier access to treatment and minimize loss to follow-up.

Bae, J.Y., E. Anderson, D. Silver, and J. Macinko 2014. Child Passenger Safety Laws in the United States, 1978–2010: Policy Diffusion in the Absence of Strong Federal Intervention Social Science & Medicine, Vol. 100 (Jan 2014), pp. 30-37. doi:10.1016/j.socscimed.2013.10.035
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Abstract

This article examines the diffusion of U.S. state child passenger safety laws, analyzing over-time changes and inter-state differences in all identifiable features of laws that plausibly influence crash-related morbidity and mortality. The observed trend shows many states' continuing efforts to update their laws to be consistent with latest motor vehicle safety recommendations, with each state modifying their laws on average 6 times over the 30-year period. However, there has been a considerable time lag in knowledge diffusion and policy adoption. Even though empirical evidence supporting the protective effect of child restraint devices was available in the early 1970s, laws requiring their use were not adopted by all 50 states until 1986. For laws requiring minors to be seated in rear seats, the first state law adoption did not occur until two decades after the evidence became publicly available. As of 2010, only 12 states explicitly required the use of booster seats, 9 for infant seats and 6 for toddler seats. There is also great variation among states in defining the child population to be covered by the laws, the vehicle operators subject to compliance, and the penalties resulting from non-compliance. Some states cover only up to 4-year-olds while others cover children up to age 17. As of 2010, states have as many as 14 exemptions, such as those for non-residents, non-parents, commercial vehicles, large vehicles, or vehicles without seatbelts. Factors such as the complexity of the state of the science, the changing nature of guidelines (from age to height/weight-related criteria), and the absence of coordinated federal actions are potential explanations for the observed patterns. The resulting uneven policy landscape among states suggests a strong need for improved communication among state legislators, public health researchers, advocates and concerned citizen groups to promote more efficient and effective policymaking.

2013

Lima-Costa, M.F., M.A. Turci, and J. Macinko 2013. A comparison of the Family Health Strategy to other sources of healthcare: utilization and quality of health services in Belo Horizonte, Minas Gerais State, Brazil Cadernos de Saude Publica, Vol. 29, no. 7. 10.1590/S0102-311X2013000700011
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Abstract

Indicators of healthcare utilization and quality were compared in a probabilistic sample of adults (N = 7,534) covered by private health plans, the Family Health Strategy (FHS), and "traditional" primary care clinics (UBS) in Belo Horizonte, Minas Gerais State, Brazil. After adjusting for demographics, health conditions, and socioeconomic status, indicators of healthcare utilization (longitudinality, health-seeking, and medical consultations) showed better performance among users of the FHS and private health plans compared to those covered by the UBS. Hospitalizations, preventive tests, and flu vaccinations varied little between sources of care. Quality indicators (difficulty in making an appointment, waiting lines, complaints about obtaining medications, and receiving an appointment within 24 hours) were better among private health plans. Recommending one's healthcare providers to others was more frequent among FHS users (61.9%) and those with private health plans (55.6%), compared to those served by UBS (45.4%).

2012

Macinko, J., P. Mullachery, F.A. Proietti, and M.F. Lima-Costa 2012. Who Experiences Discrimination in Brazil? Evidence From a Large Metropolitan Region International Journal for Equity in Health, 2012 Dec 18;11:80. doi: 10.1186/1475-9276-11-80
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Abstract

Introduction Perceived discrimination is related to poor health and has been offered as one explanation for the persistence of health inequalities in some societies. In this study, we explore the prevalence and correlates of perceived discrimination in a large, multiracial Brazilian metropolitan area.

Methods The study uses secondary analysis of a regionally representative household survey conducted in 2010 (n=12,213). Bivariate analyses and multiple logistic regression assess the magnitude and statistical significance of covariates associated with reports of any discrimination and with discrimination in specific settings, including when seeking healthcare services, in the work environment, in the family, in social occasions among friends or in public places, or in other situations.

Results Nearly 9% of the sample reported some type of discrimination. In multivariable models, reports of any discrimination were higher among people who identify as black versus white (OR 1.91), higher (OR 1.21) among women than men, higher (OR 1.33) among people in their 30’s and lower (OR 0.63) among older individuals. People with many health problems (OR 4.97) were more likely to report discrimination than those with few health problems. Subjective social status (OR 1.23) and low social trust (OR 1.27) were additional associated factors. Perceived discrimination experienced while seeking healthcare differed from all other types of discrimination, in that it was not associated with skin color, social status or trust, but was associated with sex, poverty, and poor health.

Conclusions There appear to be multiple factors associated with perceived discrimination in this population that may affect health. Policies and programs aimed at reducing discrimination in Brazil will likely need to address this wider set of interrelated risk factors across different populations.

Lima-Costa, M.F.; L.A. Facchini; D.L. Matos, and J. Macinko 2012. Changes in ten years of social inequalities in health among elderly Brazilians (1998-2008) Revista de Saude Publica, Vol. 46, supp. 1. 10.1590/S0034-89102012005000059
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Abstract

OBJECTIVE: To assess the changes in income-related inequalities in health conditions and in the use of health services among elderly Brazilians.

METHODS: Representative samples of the Brazilian population aged 60 years and more were analyzed between 1998 and 2008 (n = 27,872 and 41,198, respectively), derived from the Pesquisa Nacional por Amostra de Domicílios (National Household Sample Survey). The following variables were considered in this study: per capita monthly household income, self-rated health, physical functioning, medical consultations and hospitalizations in the previous 12 months and exclusive use of the Sistema Único de Saúde (Unified Health System). Data analysis was based on estimates of prevalence and prevalence ratios obtained with robust Poisson regression.

RESULTS: In 1998 and 2008, the prevalence of poor self-rated health, mobility limitations and inability to perform activities of daily living (ADLs), adjusted for age and sex, showed strong gradients associated with per capita household income quintiles, with the lowest values being found among those in the lowest income quintile. The prevalence ratios adjusted for age and sex between the lowest quintile (poorest individuals) and highest quintile (richest individuals) of income remained stable for poor self-rated health (PR = 3.12 [95%CI 2.79;3.51] in 1998 and 2.98 [95%CI 2.69;3.29] in 2008), mobility limitations (PR = 1.54 [95%CI 1.44;1.65 and 1.69 [95%CI 1.60;1.78], respectively) and inability to perform ADLs (PR = 1.79 [95%CI 1.52;2.11] and 2.02 [95%CI 1.78;2.29], respectively). There was a reduction in income-related disparities when three or more medical consultations had been made and with the exclusive use of the Unified Health System. Inequalities were not observed for hospitalizations. 

CONCLUSIONS: Despite reductions in income-related inequalities among indicators of use of health services, the magnitude of disparities in health conditions has not decreased. Longitudinal studies are necessary to better understand the persistence of such inequalities among elderly Brazilians.

Macinko, J., and D. Silver 2012. Improving State Health Policy Assessment: An Agenda for Measurement and Analysis American Journal of Public Health: September 2012, Vol. 102, No. 9, pp. 1697-1705. doi: 10.2105/AJPH.2012.300716
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Abstract

We examine the scope of inquiry into the measurement and assessment of the state public health policy environment. We argue that there are gains to be made by looking systematically at policies both within and across health domains. We draw from the public health and public policy literature to develop the concepts of interdomain and intradomain policy comprehensiveness and illustrate how these concepts can be used to enhance surveillance of the current public health policy environment, improve understanding of the adoption of new policies, and enhance evaluations of the impact of such policies on health outcomes.

Lima-Costa, M.F., C. De Oliveira, J. Macinko, and M. Marmot 2012. Socioeconomic Inequalities in Health in Older Adults in Brazil and England American Journal of Public Health: August 2012, Vol. 102, No. 8, pp. 1535-1541. doi: 10.2105/AJPH.2012.300765
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Abstract

Objectives. We examined socioeconomic inequalities in health among older adults in England and Brazil.

Methods. We analyzed nationally representative samples of residents aged 50 years and older in 2008 data from the Brazilian National Household Survey (n = 75 527) and the English Longitudinal Study of Ageing (n = 9589). We estimated prevalence ratios for self-rated health, functional limitations, and reported chronic diseases, by education level and household income tertiles.

Results. Brazilians reported worse health than did English respondents. Country-specific differences were higher among the poorest, but also affected the wealthiest persons. We observed a strong inverse gradient of similar magnitude across education and household income levels for most health indicators in each country. Prevalence ratios (lowest vs highest education level) of poor self-rated health were 3.24 in Brazil and 3.50 in England; having 2 or more functional limitations, 1.81 in Brazil and 1.96 in England; and having 1 or more diseases, 1.14 in Brazil and 1.36 in England.

Conclusions. Socioeconomic inequalities in health affect both populations, despite a less pronounced absolute difference in household income and education in Brazil than in England.

Macinko, J., and M.F. Lima Costa 2012. Horizontal Equity in Health Care Utilization in Brazil, 1998–2008 International Journal for Equity in Health, Vol. 11 no. 33. 10.1186/1475-9276-11-33
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Abstract

Introduction This study assesses trends in horizontal equity in the utilization of healthcare services from 1998 to 2008--a period of major economic and social change in Brazil.

Methods Data are from nationally representative surveys repeated in 1998, 2003, and 2008. We apply established methods for assessing horizontal inequity in healthcare access (the principle that people with the same healthcare needs should have similar access to healthcare services). Horizontal inequity is calculated as the difference between observed healthcare utilization and utilization predicted by healthcare needs. Outcomes examined include the probability of a medical, dental, or hospital visit during the past 12 months; any health service use in the past two weeks; and having a usual source of healthcare. We use monthly family income to measure differences in socioeconomic position. Healthcare needs include age, sex, self-rated health, and chronic conditions. Non-need factors include income, education, geography, health insurance, and Family Health Strategy coverage.

Results The probability of having at least one doctor visit in the past 12 months became substantially more equitable over time, ending with a slightly pro-rich orientation in 2008. Any hospitalization in the past 12 months was found to be pro-poor in all periods but became slightly less so in 2008. Dental visits showed the largest absolute decrease in horizontal inequity, although they were still the most inequitably (pro-rich) distributed outcome in 2008. Service use in the past two weeks showed decreased inequity in 2003 but exhibited no significant change between 2003 and 2008. Having a usual source of care became less pro-rich over time and was nearly income-neutral by 2008. Factors associated with greater inequities include income, having a private health plan, and geographic location. Factors associated with greater equity included health needs, schooling, and enrolment in the Family Health Strategy.

Conclusions Healthcare utilization in Brazil appears to have become increasingly equitable over the past 10 years. Although this does not imply that equity in health outcomes has improved correspondingly, it does suggest that government policies aimed at increasing access, especially to primary care, have helped to make healthcare utilization in Brazil fairer over time.

Macinko, J., and M.F. Lima Costa 2012. Access to, use of and satisfaction with health services among adults enrolled in Brazil’s Family Health Strategy: evidence from the 2008 National Household Survey Tropical Medicine & International Health, Vol. 17, no. 1, pp. 36-42. 10.1111/j.1365-3156.2011.02866.x
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Abstract

Objective  To assess the effects of participation in Brazil’s primary healthcare programme (the Family Health Strategy or FHS) on access, use and satisfaction with health services among adults.

Methods  Data are from the 2008 National Household Survey (PNAD) on 264 754 adults. This cross-sectional analysis compares FHS enrollees to both non-enrollees and those with private health plans. We calculated predicted probabilities of each outcome stratified by household wealth quintile, rural/urban location and sex using robust Poisson regression. We performed propensity score analysis to assess the differences in access among FHS enrollees and the rest of the population, once relevant socio-demographic characteristics and other determinants of access were balanced.

Results  Compared to families with neither FHS enrolment nor private health plans, adult FHS enrollees were generally more likely to have a usual source of care, to have visited a doctor or dentist in the past 12 months, to have access to needed medications and to be satisfied with the care they received. The FHS effect was largest among urban dwellers and the poorest.

Conclusions  The FHS appears to be associated with enhanced access to and utilization of health services in Brazil. However, it has not yet been able to match levels of access experienced by those with private health plans, perhaps because the population served by the FHS is among the poorest, most rural and least healthy in the country.

2011

Macinko, J., V. Camargos, J.O.A. Firmo, and M.F. Lima Costa 2011. Trajectories of cognitive decline over 10 years in a Brazilian elderly population: the Bambuí Cohort Study of Aging Cadernos de Saude Publica, Vol. 27, supp. 3. 10.1590/S0102-311X2011001500003
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Abstract

We use data from a population-based cohort of elderly Brazilians to assess predictors of hospitalizations during ten years of follow-up. Participants were 1,448 persons aged 60 years and over at baseline (1997). The outcome was self-reported number of hospitalizations per year. Slightly more than a fifth (23%) experienced no hospitalizations during the 10 year follow-up. About 30% had 1-2 events, 31% had between 3 and 7 events, and about 18% had 8 or more events during this time. Results of multivariable hurdle and Cox proportional hazards models showed that the risk of hospitalization was positively associated with male sex, increased age, chronic conditions, and visits to the doctors in the previous 12 months. Underweight was a predictor of any hospitalization, while obesity was an inconsistent predictor of hospitalization.

Uyei, J., D. Coetzee, J. Macinko, and S. Guttmacher 2011. Integrated delivery of HIV and tuberculosis services in sub-Saharan Africa: a systematic review The Lancet Infectious Diseases, Vol. 11, no. 11. 10.1016/S1473-3099(11)70145-1
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Abstract

Tuberculosis is a major cause of morbidity and mortality in people with HIV and about a quarter of HIV-related deaths are attributed to tuberculosis. In this Review we identify and synthesise published evidence for the effectiveness and cost-effectiveness of eight integrated strategies recommended by WHO that represent coordinated delivery of HIV and tuberculosis services. Evidence supports concurrent screening for tuberculosis and HIV, and provision of either co-trimoxazole during routine tuberculosis care or isoniazid during routine HIV care and at voluntary counselling and testing centres. Although integration of antiretroviral therapy into tuberculosis care has shown promise for improving health outcomes for patients, evidence is insufficient to make conclusive claims. Evidence is also insufficient on the accessibility of condoms at tuberculosis facilities, the benefits of risk reduction counselling in patients with tuberculosis, and the effectiveness of tuberculosis infection control in HIV health-care settings. The vertical response to the tuberculosis and HIV epidemics is ineffective and inefficient. Implications for policy makers and funders include further investments in implementing integrated tuberculosis and HIV programmes with known effectiveness, preferably in a way that strengthens health systems; evaluative research that identifies barriers to integration; and research on integrated strategies for which effectiveness, efficiency, and affordability are not well established.

Macinko, J., V.B. de Oliveira, M.A. Turci, F.C. Guanais, P.F. Bonolo, and M.F. Lima Costa 2011. The Influence of Primary Care and Hospital Supply on Ambulatory Care–Sensitive Hospitalizations Among Adults in Brazil, 1999–2007 American Journal of Public Health: October 2011, Vol. 101, No. 10, pp. 1963-1970. 10.2105/AJPH.2010.198887
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Abstract

Objectives. We assessed the influence of changes in primary care and hospital supply on rates of ambulatory care–sensitive (ACS) hospitalizations among adults in Brazil.

Methods. We aggregated data on nearly 60 million public sector hospitalizations between 1999 and 2007 to Brazil's 558 microregions. We modeled adult ACS hospitalization rates as a function of area-level socioeconomic factors, health services supply, Family Health Program (FHP) availability, and health needs by using dynamic panel estimation techniques to control for endogenous explanatory variables.

Results. The ACS hospitalization rates declined by more than 5% annually. When we controlled for other factors, FHP availability was associated with lower ACS hospitalization rates, whereas private or nonprofit hospital beds were associated with higher rates. Areas with highest predicted ACS hospitalization rates were those with the highest private or nonprofit hospital bed supply and with low (< 25%) FHP coverage. The lowest predicted rates were seen for areas with high (> 75%) FHP coverage and very few private or nonprofit hospital beds.

Conclusions. These results highlight the contribution of the FHP to improved health system performance and reflect the complexity of the health reform processes under way in Brazil.

2010

Macinko, J., I. Dourado, R. Aquino, et al 2010. Major Expansion of Primary Care in Brazil Linked to Decline in Unnecessary Hospitalization Health Affairs, Vol. 29, no. 12, pp. 2149-2160. 10.1377/hlthaff.2010.0251
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Abstract

In 1994 Brazil launched what has since become the world’s largest community-based primary health care program. Under the Family Health Program, teams consisting of at least one physician, one nurse, a medical assistant, and four to six trained community health agents deliver most of their services at community-based clinics. They also make regular home visits and conduct neighborhood health promotion activities. This study finds that during 1999–2007, hospitalizations in Brazil for ambulatory care–sensitive chronic diseases, including cardiovascular disease, stroke, and asthma, fell at a rate that was statistically significant and almost twice the rate of decline in hospitalizations for all other causes. In municipalities with high Family Health Program enrollment, chronic disease hospitalization rates were 13 percent lower than in municipalities with low enrollment, when other factors were held constant. These results suggest that the Family Health Program has improved health system performance in Brazil by reducing the number of potentially avoidable hospitalizations.

Turci, M.A., M.F. Lima-Costa, F.A. Proietti, C.C. Cesar, and J. Macinko 2010. Intraurban Differences in the Use of Ambulatory Health Services in a Large Brazilian City Journal of Urban Health, Vol. 87 no. 6, pp. 994-1006. 10.1007/s11524-010-9499-4
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Abstract

A major goal of health systems is to reduce inequities in access to services, that is, to ensure that health care is provided based on health needs rather than social or economic factors. This study aims to identify the determinants of health services utilization among adults in a large Brazilian city and intraurban disparities in health care use. We combine household survey data with census-derived classification of social vulnerability of each household’s census tract. The dependent variable was utilization of physician services in the prior 12 months, and the independent variables included predisposing factors, health needs, enabling factors, and context. Prevalence ratios and 95% confidence intervals were estimated by the Hurdle regression model, which combined Poisson regression analysis of factors associated with any doctor visits (dichotomous variable) and zero-truncated negative binomial regression for the analysis of factors associated with the number of visits among those who had at least one. Results indicate that the use of health services was greater among women and increased with age, and was determined primarily by health needs and whether the individual had a regular doctor, even among those living in areas of the city with the worst socio-environmental indicators. The experience of Belo Horizonte may have implications for other world cities, particularly in the development and use of a comprehensive index to identify populations at risk and in order to guide expansion of primary health care services as a means of enhancing equity in health.

Black, J.L., J. Macinko, L.B. Dixon, and G.E. Fryer, Jr. 2010. Neighborhoods and Obesity in New York City Health & Place, Vol. 16, no. 3, pp. 489-499. 10.1016/j.healthplace.2009.12.007
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Recent studies reveal disparities in neighborhood access to food and fitness facilities, particularly in US cities; but few studies assess the effects of multiple neighborhood factors on obesity. This study measured the multilevel relations between neighborhood food availability, opportunities and barriers for physical activity, income and racial composition with obesity (BMI≥30 kg/m2) in New York City, controlling for individual-level factors. Obesity rates varied widely between neighborhoods, ranging from 6.8% to 31.7%. Obesity was significantly (p<0.01) associated with neighborhood-level factors, particularly the availability of supermarkets and food stores, fitness facilities, percent of commercial land use and area income. These findings are consistent with the growing literature showing that area income and availability of food and physical activity resources are related to obesity.

2010. The Changing Distribution and Determinants of Obesity in the Neighborhoods of New York City, 2003–2007 American Journal of Epidemiology, Vol. 171, no. 7, pp. 765-775. 10.1093/aje/kwp458
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Abstract

Obesity (body mass index 30 kg/m2 ) is a growing urban health concern, but few studies have examined whether, how, or why obesity prevalence has changed over time within cities. This study characterized the individual- and neighborhood-level determinants and distribution of obesity in New York City from 2003 to 2007. Individual-level data from the Community Health Survey (n ¼ 48,506 adults, 34 neighborhoods) were combined with neighborhood measures. Multilevel regression assessed changes in obesity over time and associations with neighborhood-level income and food and physical activity amenities, controlling for age, racial/ethnic identity, education, employment, US nativity, and marital status, stratified by gender. Obesity rates increased by 1.6% (P < 0.05) each year, but changes over time differed significantly between neighborhoods and by gender. Obesity prevalence increased for women, even after controlling for individual- and neighborhood-level factors (prevalence ratio ¼ 1.021, P < 0.05), whereas no significant changes were reported for men. Neighborhood factors including increased area income (prevalence ratio ¼ 0.932) and availability of local food and fitness amenities (prevalence ratio ¼ 0.889) were significantly associated with reduced obesity (P < 0.001). Findings suggest that policies to reduce obesity in urban environments must be informed by up-to-date surveillance data and may require a variety of initiatives that respond to both individual and contextual determinants of obesity.

2009

Macinko, J., and I.T. Elo 2009. Black–White Differences in Avoidable Mortality in the USA, 1980–2005 Journal of Epidemiology and Community Health, Vol. 63 no. 9, pp. 715-721. 10.1136/jech.2008.081141
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Abstract

Background: Avoidable Mortality (AM) describes causes of death that should not occur in the presence of highquality and timely medical treatment and from causes that can be influenced at least in part by public policy/ behaviour. This study analyses black–white disparities in AM.

Methods: Mortality under age 65 was analysed from: (1) conditions amenable to medical care; (2) those sensitive to public policy and/or behaviour change; (3) ischaemic heart disease; (4) HIV/AIDS; and (5) the remaining causes of death. Age-standardised death rates (ASDRs) were constructed for each race and sex group using vital statistics and census data from 1980–2005. Absolute rate differences and the proportionate contribution of each cause of death group to all-cause black–white mortality disparities are calculated based on the ASDRs. Negative binomial regression was used to model relative risks of death.

Results: In 2005, medical care amenable mortality was the largest source of absolute black–white mortality disparity, contributing 30% of the black–white difference in all-cause mortality among men and 42% among women; mortality subject to policy/behaviour interventions contributed 20% of the black–white difference for men and 4% for women. Although absolute black–white differences for most conditions diminished over time, relative disparities as measured by rate ratios showed little change, except for HIV/AIDS for which relative risks increased substantially for black men and women.

Conclusions: There is considerable potential for narrowing of the black–white difference in AM, especially from causes amenable to medical care and (for men) policy/behaviour interventions.

Guanais, F., and J. Macinko 2009. The Health Effects of Decentralizing Primary Care in Brazil Health Affairs, Vol. 28 no. 4, pp. 1127-1135. doi 10.1377/hlthaff.28.4.1127
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A renewed focus on primary health care could lead to improved health outcomes in developing countries. Moving more control to local authorities, or decentralization, is one approach to expanding primary care’s reach. Proponents argue that it increases responsiveness to local needs and helps local resources reach those in need. Critics argue that it might increase fragmentation and disparities and provide opportunities for local economic and political gains that do not improve population health. We explore questions surrounding decentralization using the example of infant mortality in Brazil. Our study of two programs identified positive effects on health outcomes in the context of infant mortality.

Macinko, J., B. Starfield, and T. Erinosho 2009. The Impact of Primary Healthcare on Population Health in Low‐ and Middle‐Income Countries Journal of Ambulatory Care Management, Vo. 32 no. 2, pp. 150-171. 10.1097/JAC.0b013e3181994221
Abstract

This article assesses 36 peer-reviewed studies of the impact of primary healthcare (PHC) on health outcomes in low- and middle-income countries. Studies were abstracted and assessed according to where they took place, the research design used, target population, primary care measures, and overall conclusions. Results indicate that the bulk of evidence for PHC effectiveness is focused on infant and child health, but there is also evidence of the positive role PHC has on population health over time. Although the peer-reviewed literature is lacking in rigorous experimental studies, a small number of relatively well-designed observational studies and the consistency of findings generally support the contention that an integrated approach to primary care can improve health. A few large-scale experiences also help identify elements of good practice. The review concludes with several recommendations for future studies, including a focus on better conceptualizing and measuring PHC, further investigation into the advantages of comprehensive over selective PHC, need for experimental or quasi-experimental research designs that allow testing of the independent effect of primary care on outcomes over time, and a more detailed conceptual framework guiding overall evaluation design that places limits on the parameters under consideration and describes relationships among different levels and types of data likely to be collected in the evaluation process.

Guanais, F., and J. Macinko 2009. Primary Care and Avoidable Hospitalizations: Evidence from Brazil Journal of Ambulatory Care Management, Vol. 32 no. 2, pp. 115-122
Abstract

This article provides evidence of the effectiveness of family-based, community-oriented primary healthcare programs on the reduction of ambulatory care sensitive hospitalizations in Brazil. Between 1998 and 2002, expansions of the Family Health Program were associated with reductions in hospitalizations for diabetes mellitus and respiratory problems and Community Health Agents Program expansions were associated with reductions in circulatory conditions hospitalizations. Results were significant for only the female population only, suggesting that these programs were more effective in reaching women than men. Program coverage may have contributed to an estimated 126 000 fewer hospitalizations between 1999 and 2002, corresponding to potential savings of 63 million US dollars.

2008

Shi, L., and J. Macinko 2008. Changes in Medical Care Experiences of Racial and Ethnic Groups in the United States, 1996-2002 International Journal of Health Services, Vol. 38 no. 4, pp. 653-670
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The authors examined changes in medical care experiences of racial/ethnic groups (non-Hispanic white, Asian and Pacific Islander, Hispanic, and non- Hispanic black) between 1996 and 2002, using data from the Household Component of Medical Expenditure Panel Surveys. Proportions and adjusted odds ratios for each group's primary care experience are presented. Comparisons are made between groups at each time period and within groups between the two time periods. Multivariable analyses control for demographic and socioeconomic characteristics, health care needs and source of care, and health insurance. Racial/ethnic minorities experienced worse medical care than non-Hispanic whites, but results differed among groups. Non-Hispanic blacks were no different from non-Hispanic whites and showed a slight improvement over time, except for lower odds of having a usual source of care and worse sociodemographic and health indicators. Hispanics had worse experiences than whites in 5 of 8 indicators in 2002 (vs. 3 in 1996). Asians assessed their experience as worse than that of whites in 6 of 8 indicators in 2002 (vs. 3 in 1996), yet had higher self-rated health and education than non-Hispanic whites. Disparities in medical care experience have increased for some groups, and efforts must be made to reduce financial and nonfinancial barriers to care for racial/ethnic minority populations.

Black, J.L., and J. Macinko 2008. Neighborhoods and Obesity Nutrition Reviews, Vol. 66 no. 1, pp. 2-20
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Abstract

This review critically summarizes the literature on neighborhood determinants of obesity and proposes a conceptual framework to guide future inquiry. Thirty-seven studies met all inclusion criteria and revealed that the influence of neighborhood-level factors appears mixed. Neighborhood-level measures of economic resources were associated with obesity in 15 studies, while the associations between neighborhood income inequality and racial composition with obesity were mixed. Availability of healthy versus unhealthy food was inconsistently related to obesity, while neighborhood features that discourage physical activity were consistently associated with increased body mass index. Theoretical explanations for neighborhood-obesity effects and recommendations for strengthening the literature are presented.

2007

de Souza, M., de Fatima, M., Macinko, J., Alencar, A.P., Malta, D.C. & de Morais Neto, O.L. 2007. Reductions In Firearm-Related Mortality And Hospitalizations In Brazil After Gun Control Health Affairs, Mar/Apr 2007, Vol. 26 Issue 2, p575-584, 10p.
Abstract

This paper provides evidence suggesting that gun control measures have been effective in reducing the toll of violence on population health in Brazil. In 2004, for the first time in more than a decade, firearm-related mortality declined 8 percent from the previous year. Firearm-related hospitalizations also reversed a historical trend that year by decreasing 4.6 percent from 2003 levels. These changes corresponded with anti-gun legislation passed in late 2003 and disarmament campaigns undertaken throughout the country since mid-2004. The estimated impact of these measures, if they prove causal, could be as much as 5,563 firearm-related deaths averted in 2004 alone.

2006

Macinko, J. Guanais, F. & Souza, F. 2006. An Evaluation of the Impact of the Family Health Program on Infant Mortality in Brazil, 1990-2002 Journal of Epidemiology and Community Health,
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Abstract

Objective: To use publicly available secondary data to assess the impact of Brazil's Family Health Program on state level infant mortality rates (IMR) during the 1990s.

Design: Longitudinal ecological analysis using panel data from secondary sources. Analyses controlled for state level measures of access to clean water and sanitation, average income, women's literacy and fertility, physicians and nurses per 10 000 population, and hospital beds per 1000 population. Additional analyses controlled for immunisation coverage and tested interactions between Family Health Program and proportionate mortality from diarrhoea and acute respiratory infections.

Setting: 13 years (1990-2002) of data from 27 Brazilian states.

Main results: From 1990 to 2002 IMR declined from 49.7 to 28.9 per 1000 live births. During the same period average Family Health Program coverage increased from 0% to 36%. A 10% increase in Family Health Program coverage was associated with a 4.5% decrease in IMR, controlling for all other health determinants (p<0.01). Access to clean water and hospital beds per 1000 were negatively associated with IMR, while female illiteracy, fertility rates, and mean income were positively associated with IMR. Examination of interactions between Family Health Program coverage and diarrhoea deaths suggests the programme may reduce IMR at least partly through reductions in diarrhoea deaths. Interactions with deaths from acute respiratory infections were ambiguous.

Conclusions: The Family Health Program is associated with reduced IMR, suggesting it is an important, although not unique, contributor to declining infant mortality in Brazil. Existing secondary datasets provide an important tool for evaluation of the effectiveness of health services in Brazil.

 

2005

Shi, L., Macinko, J. Starfield, B. Politzer, R., Wulu, J. & J. Xu. 2005. Primary Care, Social Inequalities, and All-Cause, Heart Disease, and Cancer Mortality in U.S. Counties, 1990. American Journal of Public Health.
Abstract

We tested the association between the availability of primary care and income inequality on several categories of mortality in US counties. Methods. We used cross-sectional analysis of data from counties (n=3081) in 1990, including analysis of variance and multivariate ordinary least squares regression. Independent variables included primary care resources, income inequality, and sociodemographics. Results. Counties with higher availability of primary care resources experienced between 2% and 3% lower mortality than counties with less primary care. Counties with high income inequality experienced between 11% and 13% higher mortality than counties with less inequality. Conclusions. Primary care resources may partially moderate the effects of income inequality on health outcomes at the county level.

Starfield, B., Shi, L. & Macinko, J. 2005. Contribution of Primary Care to Health Systems and Health Milbank Quarterly, Vol. 83 Issue 3, p457-502, 46p.
Abstract

Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.

Starfield, B., Shi, L. & Macinko, J. 2005. Primary care impact on health outcomes: A literature review Milbank Quarterly Volume 83 Number 3, pages 457-502.
Abstract

Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.

Shi, L., Macinko, J., Starfield, B., Politzer, R. & J. Xu. 2005. Primary care, race and mortality in the United States Social Science & Medicine Volume 61 Number 1, pages 65-75.
Abstract

This study used US state-level data from 1985 to 1995 to examine the relationship of primary care resources and income inequality with all-cause mortality within the entire population, and in black and white populations. The study is a pooled ecological design with repeated measures using 11 years of state-level data (n=549). Analyses controlled for socioeconomic and demographic characteristics. Contemporaneous and time-lagged covariates were modeled, and all analyses were stratified by race/ethnicity. In all models, primary care was associated with lower mortality. An increase of one primary care doctor per 10,000 population was associated with a reduction of 14.4 deaths per 100,000. The magnitude of primary care coefficients was higher for black mortality than for white mortality. Income inequality was not associated with mortality after controlling for state-level sociodemographic covariates. The study provides evidence that primary care resources are associated with population health and could aid in reducing socioeconomic disparities in health.

Starfield, B., Shi, L., Grover, A. & Macinko, J. 2005. The Effects of Specialist Supply on Population Health: Assessing the Evidence Health Affairs Volume 5, pages 97-107.
Abstract

Analyses at the county level show lower mortality rates where there are more primary care physicians, but this is not the case for specialist supply. These findings confirm those of previous studies at the state and other levels. Increasing the supply of specialists will not improve the United States' position in population health relative to other industrialized countries, and it is likely to lead to greater disparities in health status and outcomes. Adverse effects from inappropriate or unnecessary specialist use may be responsible for the absence of relationship between specialist supply and mortality.

Starfield, B., Shi, L., Grover, A. & Macinko, J. 2005. The Need For Real Evidence In Physician Workforce Decision Making: A Reply To Ed Salsberg (3/15/2005) Health Affairs, Jan-Jun 2005 Supplement Web Exclusiv, Vol. 24, pS-7-S-8, 2p.
Abstract

Presents a letter to Edward Salsberg about the need for real evidence in physician workforce decision making. Opinion that one needs more information before making decisions about specialty composition in the health professions; Notion that primary care physicians could maintain expertise in several specialty areas by greatly limiting their practice size; Information that some health systems are trying to increase the supply of at least certain specialists.

2004

Macinko, J., Almeida, C. & Oliveira, E. 2004. Avaliação das características organizacionais dos serviços de atenção básica em Petrópolis: teste de uma metodologia [Evaluation of the primary care services organization in Petrópolis: a methodological test ] Saude & Debate Volume 65 Number 27, pages 243-256.
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Abstract

O objetivo da pesquisa foi adaptar e aplicar um instrumento para medir dimensões organizacionais do sistema de atenção básica no município de Petrópolis (RJ), comparando as dimensões organizacionais selecionadas em dois tipos de unidades: as do Programa Saúde da Família (PSF) e as Unidades Básicas de Saúde (UBS) tradicionais. A pesquisa utilizou a metodologia de informantes-chave. A ferramenta testada foi aplicada de forma rápida o que sugere que ela pode ser empregada nas avaliações regulares do desempenho das unidades. Conclui-se que apesar de Petrópolis ter realizado avanços importantes na atenção básica, enfrenta vários desafios, incluindo: melhorar acesso, reforçar o papel da atenção básica como porta de entrada no sistema, alcançar maior integralidade na atenção à saúde, melhorar a coordenação e aumentar a orientação para a comunidade.

Shi, L. Macinko, J. Starfied, B. 2004. Primary care, social inequalities, and birth outcomes in U.S. states Journal of Epidemiology and Community Health Volume 58 Number 5, pages 374-80.
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Abstract

Study objective: The study tests the extent to which primary care physician supply (office based primary care physicians per 10 000 population) moderates the association between social inequalities and infant mortality and low birth weight throughout the 50 states of the USA.

Design: Pooled cross sectional, time series analysis of secondary data. Analyses controlled for state level education, unemployment, racial/ethnic composition, income inequality, and urban/rural differences. Contemporaneous and time lagged covariates were modelled.

Setting: Eleven years (1985-95) of data from 50 US states (final n = 549 because of one missing data point).

Main results: Primary care was negatively associated with infant mortality and low birth weight in all multivariate models (p<0.0001). The association was consistent in contemporaneous and time lagged models. Although income inequality was positively associated with low birth weight and infant mortality (p<0.0001), the association with infant mortality disappeared with the addition of sociodemographic covariates.

Conclusions: In US states, an increased supply of primary care practitioners-especially in areas with high levels of social disparities-is negatively associated with infant mortality and low birth weight.

 

Macinko, J., Shi, L. & Starfield, B. 2004. Wage inequality, health care, and infant mortality in 19 industrialized countries Social Science & Medicine Volume 58 Number 2, pages 279-292.
Abstract

This pooled, cross-sectional, time-series study assesses the impact of health system variables on the relationship between wage inequality and infant mortality in 19 OECD countries over the period 1970-1996. Data are derived from the OECD, World Value Surveys, Luxembourg Income Study, and political economy databases. Analyses include Pearson correlation and fixed-effects multivariate regression. In year-specific and time-series analyses, the Theil measure of wage inequality (based on industrial sector wages) is positively and statistically significantly associated with infant mortality rates--even while controlling for GDP per capita. Health system variables--in particular the method of healthcare financing and the supply of physicians--significantly attenuated the effect of wage inequality on infant mortality. In fixed effects multivariate regression models controlling for GDP per capita and wage inequality, variables generally associated with better health include income per capita, the method of healthcare financing, and physicians per 1000 population. Alcohol consumption, the proportion of the population in unions, and government expenditures on health were associated with poorer health outcomes. Ambiguous effects were seen for the consumer price index, unemployment rates, the openness of the economy, and voting rates. This study provides international evidence for the impact of wage inequalities on infant mortality. Results suggest that improving aspects of the healthcare system may be one way to partially compensate for the negative effects of social inequalities on population health.
2003

Shi, L., Macinko, J., Starfield, B., Wulu, J., Regan, J. & Politzer, R. 2003. The relationship between primary care, income inequality, and mortality in US States, 1980-1995. Journal of the American Board of Family Practice Volume 16, Number 5 Sep-Oct 2003; pages 412-22.
Abstract

OBJECTIVES: This study tests the robustness of the relationships between primary care, income inequality, and population health by (1) assessing the relationship during 4 time periods-1980, 1985, 1990 and 1995; (2) examining the independent effect of components of the primary care physician supply; (3) using 2 different measures of income inequality (Robin Hood index and Gini coefficient); and (4) testing the robustness of the association by using 5-year time-lagged independent variables. DATA SOURCES/STUDY SETTING: Data are derived from the Compressed Mortality Files, the US Department of Commerce and the Census Bureau, the National Center for Health Statistics, the Centers for Disease Control and Prevention, and the American Medical Association Physician Master File. The unit of analysis was the 50 US states over a 15-year period. STUDY DESIGN: Ecological, cross-sectional design for 4 selected years (1980, 1985, 1990, 1995), and incorporating 5-year time-lagged independent variables. The main outcome measure is age-standardized, all-cause mortality per 100,000 population in all 50 US states in all 4 time periods. DATA COLLECTION/EXTRACTION METHODS: The study used secondary data from publicly available data sets. The CDC WONDER/PC software was used to obtain mortality data and directly standardize them for age to the 1980 US population. Data used to calculate the income inequality measure came from the US census population and housing summary tapes for the years 1980 to 1995. Counts of the number of households that fell into each income interval along with the total aggregate income and the median household income were obtained for each state. The Gini coefficient for each state was calculated using software developed for this purpose. RESULTS: In weighted multivariate regressions, both contemporaneous and time-lagged income inequality measures (Gini coefficient, Robin Hood Index) were significantly associated with all-cause mortality (P <.05 for both measures for all time periods). Contemporaneous and time-lagged primary care physician-to-population ratios were significantly associated with lower all-cause mortality (P <.05 for all 4 time periods), whereas specialty care measures were associated with higher mortality (P <.05 for all time periods, except 1990, where P <.1). Among primary care subspecialties, only family medicine was consistently associated with lower mortality (P <.01 for all time periods). CONCLUSIONS: Enhancing primary care, particularly family medicine, even in states with high levels of income inequality, could lead to lower all-cause mortality in those states.

Macinko, J., Shi, L., Starfield, B. & Wulu, J. 2003. Income inequality, primary care, and health outcomes�a critical review of the literature Medical Care Research and Review Volume 60 Number 4, pages 407-52.
Abstract

This article critically reviews published literature on the relationship between income inequality and health outcomes. Studies are systematically assessed in terms of design, data quality, measures, health outcomes, and covariates analyzed. At least 33 studies indicate a significant association between income inequality and health outcomes, while at least 12 studies do not find such an association. Inconsistencies include the following: (1) the model of health determinants is different in nearly every study, (2) income inequality measures and data are inconsistent, (3) studies are performed on different combinations of countries and/or states, (4) the time period in which studies are conducted is not consistent, and (5) health outcome measures differ. The relationship between income inequality and health is unclear. Future studies will require a more comprehensive model of health production that includes health system covariates, sufficient sample size, and adjustment for inconsistencies in income inequality data.

Shi, L., Macinko, J., Starfield, B. & Politzer, R. 2003. Primary Care, Social Inequality, and Stroke Mortality in U.S. States--a Longitudinal Analysis, 1985-1995 Stroke Volume 34 Number 8, pages 1958-64.
Abstract

BACKGROUND AND PURPOSE: The goal of this study was to test whether primary care reduces the impact of income inequality on stroke mortality. METHODS: This study used pooled time-series cross-sectional analysis of 11 years of state-level data (n=549). Analyses controlled for education levels, unemployment, racial/ethnic composition, and percent urban. Contemporaneous and time-lagged covariates were modeled. RESULTS: Primary care was negatively associated with stroke mortality in models including all covariates (P<0.0001). The impact of income inequality on stroke mortality was reduced in the presence of primary care (P<0.0001) but disappeared with the addition of covariates (P>0.05). CONCLUSIONS: In the absence of social policy that addresses sociodemographic determinants of health, primary care promotion may serve as a palliative strategy for combating stroke mortality and reducing the adverse impact of income inequality on health.

Macinko, J., Starfield, B. & Shi, L. 2003. The contribution of primary care systems to health outcomes in OECD countries, 1970-1998. Health Services Research Volume 38, Number 3, pages 819-854.
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Abstract

Objective
To assess the contribution of primary care systems to a variety of health outcomes in 18 wealthy Organization for Economic Cooperation and Development (OECD) countries over three decades.

Data Sources/Study Setting
Data were primarily derived from OECD Health Data 2001 and from published literature. The unit of analysis is each of 18 wealthy OECD countries from 1970 to 1998 (total n=504).

Study Design
Pooled, cross-sectional, time-series analysis of secondary data using fixed effects regression.

Data Collection/Extraction Methods
Secondary analysis of public-use datasets. Primary care system characteristics were assessed using a common set of indicators derived from secondary datasets, published literature, technical documents, and consultation with in-country experts.

Principal Findings
The strength of a country's primary care system was negatively associated with (a) all-cause mortality, (b) all-cause premature mortality, and (c) cause-specific premature mortality from asthma and bronchitis, emphysema and pneumonia, cardiovascular disease, and heart disease (p<0.05 in fixed effects, multivariate regression analyses). This relationship was significant, albeit reduced in magnitude, even while controlling for macro-level (GDP per capita, total physicians per one thousand population, percent of elderly) and micro-level (average number of ambulatory care visits, per capita income, alcohol and tobacco consumption) determinants of population health.

Conclusions
(1) Strong primary care system and practice characteristics such as geographic regulation, longitudinality, coordination, and community orientation were associated with improved population health. (2) Despite health reform efforts, few OECD countries have improved essential features of their primary care systems as assessed by the scale used here. (3) The proposed scale can also be used to monitor health reform efforts intended to improve primary care.

 

2002

Macinko, J. & Starfield, B. 2002. Annotated bibliography on equity in health Intl J of Equity in Health Volume 1, Number 1, pages 1-20.
Abstract

The purposes of this bibliography are to present an overview of the published literature on equity in health and to summarize key articles relevant to the mission of the International Society for Equity in Health (ISEqH). The intent is to show the directions being taken in health equity research including theories, methods, and interventions to understand the genesis of inequities and their remediation. Therefore, the bibliography includes articles from the health equity literature that focus on mechanisms by which inequities in health arise and approaches to reducing them where and when they exist.
2001

Rodriguez-Garcia, R., Macinko, J. & Waters, W. 2001. Microenterprise Development for Better Health Outcomes Westport, CT: Greenwood Publishing.
Abstract

Showing that economic development and public health, often thought of as distinct, are both interdependent and dependent on social and political conditions, this book provides a new appreciation of the close relationship between microenterprise development and health in developing countries. Many of the world's poor earn a living from microenterprises, often outside the formal economy, and international practitioners have recently turned their attention to this underground economy, providing support through group poverty lending and village banking models, but overlooking the potential benefits of linking income generation with public health. This book argues for a conceptual and practical relationship between microenterprise development and household health, nutrition, and sanitation. To support their framework, the authors look at specific actions for harnessing the power of microeconomic development to improve health and human development. They support their argument further with case studies of innovative programs carried out in Latin America, Asia, and Africa. The book challenges the reader to cross disciplinary and professional boundaries to not only understand the interrelationships between health and income generation but to use available tools to enhance those interrelationships.

Macinko, J. & Starfield, B. 2001. The utility of social capital in studies on health determinants Milbank Quarterly Volume 79, Number 3, pages 387-428.
Abstract

Social capital has become a popular subject in the literature on determinants of health. The concept of social capital has been used in the sociological, political science, and economic development literatures, as well as in the health inequalities literature. Analysis of its use in the health inequalities literature suggests that each theoretical tradition has conceptualized social capital differently. Health researchers have employed a wide range of social capital measures, borrowing from several theoretical traditions. Given the wide variation in these measures and an apparent lack of consistent theoretical or empirical justification for their use, conclusions about the likely role of "social capital" on population health may be overstated or even misleading. Elements of a research agenda are proposed to further elucidate the potential role of factors currently subsumed under the rubric of "social capital."

1998

Rodriguez-Garcia, R., Macinko, J. & Casas, J. (Eds.) 1998. From Humanitarian Assistance to Human Development Washington, DC: Pan American Health Organization/WHO. .
Abstract

Civil, political and military conflict--Natural and man-made disasters--Poverty and human suffering...As the new millennium approaches, the need for humanitarian assistance in response to these global challenges endures. Complex humanitarian emergencies demand human, financial and material resources on an international scale. This presents the global community, and particularly the health sector, with a formidable and daunting task: Faced with limited resources, how can organizations and actors simultaneously meet immediate humanitarian needs while maintaining their commitment to long term human development? More specifically, how can humanitarian relief and sustainable human development efforts be linked? From Humanitarian Assistance to Human Development responds and reacts to this question by serving as a forum for distinguished members of the health and development arena to present issues, policies and innovative programs in response. Divided into three sections, the book examines the humanitarian assistance-human development continuum within the global-policy context of human development, reviews humanitarian assistance as a social phenomena, highlights country experiences in Rwanda and Bosnia, and discusses means of relieving human suffering and restoring infrastructure and health and social services in the aftermath of conflict. In this thought-provoking, informative volume, the perspectives, experiences and proposals of specialists from academic institutions, national and international agencies and non-governmental organizations are united to help inform future policy, inspire programmatic action and, ultimately, bridge the gap between humanitarian assistance and human development.

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