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AIDS risk taking behaviour among homosexual men : sociodemographic markers and policy implications Hogg, Robert S.; Craib, Kevin J.P.; Willoughby, Brian; Sestak, Philip; Montaner, Julio; Schechter, Martin T. Jun 30, 1992

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AIDS RISK TAKING BEHAVIOURAMONG HOMOSEXUAL MEN:SOCIODEMOGRAPHIC MARKERSAND POLICY IMPLICATIONSRobert S. Hogg, PhDKevin J.P. Craib, MMathBrian Willoughby, MD, CCFPPhilip Sestak, MD, CCFPJulio S.G. Montaner, MD, FRCPCMartin T. Schechter, MD, MSc, PhD, FRCPCHPRU 92:5D JUNE, 1992AIDS RISK TAKING BEHAVIOURAMONG HOMOSEXUAL MEN:SOCIODEMOGRAPHIC MARKERSAND POLICY IMPLICATIONSRobert S. Hogg, PhDKevin J.P. Craib, MMathBrian Willoughby, MD, CCFPPhilip Sestak, MD, CCFPJulio S.G. Montaner, MD, FRCPCMartin T. Schechter, MD, MSc, PhD, FRCPCHPRU 92:5D JUNE, 1992HEALTH POLICY RESEARCH UNITCENTRE FOR HEALTH SERVICES AND POLICY RESEARCH429 - 2194 HEALTH SCIENCES MALLUNIVERSITY OF BRITISH COLUMBIAVANCOUVER, B.C. CANADAV6T lZ3The Centre for Health Services and Policy Research was established by theBoard of Governors of the University of British Columbia in December 199 0 .It was officially opened in July 1991. The Centre's primary objective isto co-ordinate, facilitate, ~nd undertake multidisciplinary research int he areas of health policy, health services research, population health ,and health human resources. It brings together researchers in a varietyof disciplines who are committed to a multidisciplinary approach tor esearch, and to promoting wide dissemination and discussion of researchresults, in these areas. The Centre aims to contribute to the improvementof population health by being responsive to the research needs of thoseresponsible for health policy. To this end, it provides a researchresource for graduate students; develops and facilitates access to healthand ~ealth care databases; sponsors seminars, workshops, conferences andpol icy consultations; and distributes Discussion Papers, Research Report sand publication reprints resulting from the research programs of Centref aculty.The Centre's Health Policy Research Unit Discussion Paper series providesa vehicle for the circulation of preliminary (pre-publication) work ofCentre faculty and associates. It is intended to promote discussion andto elicit comments and suggestions that might be incorporated within thewor k prior to publication. While the Centre prints and distributes thesepapers for this purpose, the views in the papers are those of theauthor(s) .A complete list of available Health Policy Research Unit Discussion Papersand Reprints, along with an address to which requests for copies should besent, appears at the back of each paper.AIDS RISK TAKING BEHAVIOUR AMONG HOMOSEXUAL MEN:SOCIODEMOGRAPHIC MARKERS AND POLICY IMPLICATIONSRobert S. Hogg, PhDKevin J.P. Craib, MMathBrian Willoughby, MD, CCFPPhilip Sestak, MD, CCFPJulio S.C. Montaner, MD, FRCPCMartin T. Schechter, MD, MSc, PhD, FRCPCThe Vancouver Lymphadenopathy-AIDS Study Group, U.B.C., the Department ofHealth Care and Epidemiology, & B.C. Centre for Excellence in HIV and RelatedDiseases, the University of British Columbia, and St. Paul's Hospital, Vancouver.ABSTRACfThe objective of this study is to determine whether there are sociodemographicmarkers which distinguish seronegative men who continue to place themselves atrisk through unprotected anal intercourse with casual sex partners from thoseseronegative men who do not participate in this practice. Eligible subjects wereidentified in large urban cohort of homosexual men as those who were HIVnegative and who completed an index visit between October 1989 and September1990 and reported having sexual contact with casual partners during the previous 12month period. Risk takers were those who reported having unprotected analreceptive or insertive intercourse with casual partners; while the remaining subjects(controls) were those who reported either not engaging in anal intercourse withcasual partners or using condoms at all times when they did. Nonparametricmethods were used to compare sociodemographic variables between the risk takersand the controls. A total of 139 seronegative men were eligible. Of these, 31 subjectswere included in the risk taking group and 108 in the control group. Risk takerswere significantly younger (median age of 35 versus 40 years; p=0.013) and weremore likely to have incomes below $10,000 (37 versus 12 per cent; p=0.002), to smokecigarettes (58 versus 35 per cent; p=0.022), and to use nitrite inhalants (55 versus 30per cent; p=0.010) than controls. These results indicate that there are numbersociodemographic variables that characterize seronegative men who continue themselves at risk through unprotected anal intercourse with casual sexpartners. Overall our findings suggest the importance of targeting AIDS preventionactivities to younger gay men, to those of lower socioeconomic status, and to thoseexhibiting other risk behaviour such as smoking and use of nitrite inhalants.INTRODUCTIONAnal intercourse without a condom is the principal mode of HIV transmissionamong homosexual men [1, 2, 3,4, 5]. Several prospective studies have shown thatsince the promotion of 'safer sex practices', the self-reporting of unprotected analintercourse by gay men has declined between 50 and 90 per cent in several settings[6]. Most recently, however, studies have shown that the decline in the frequency ofunprotected anal intercourse may not be uniform throughout this population. [7]. Inparticular, there are some men who have had relapses in risky sexual behaviour,especially those in long-term or monogamous relationships [8], and other men whohave not modified their behaviour at all.With conservative estimates in the range of 2 per cent for the prevalence ofmen who have sex with men [9], there are likely several million such men in NorthAmerica. Any increase in the seroconversion rate in this group, even a small one,could represent tens of thousands of new cases of HIV infection. The purpose ofthis study is to determine whether there are sociodemographic markers whichdistinguish seronegative men who continue to place themselves at risk throughunprotected anal intercourse with casual sex partners from those seronegative menwho do not participate in this practice.MEfHODSThe methods and aims of the Vancouver Lymphadenopathy-AIDS Study (VLAS)have been described in detail elsewhere [10, 11]. Briefly, the VLAS is an ongoingprospective study of 1,000 homosexual men who were enrolled during tworecruitment periods. From November 1982 to December 1984, a total of 729 men1Page 2were recruited through six general practices in central Vancouver. An additionaltwo practices were added and 271 men were enrolled during the period from October1986 to December 1987. Follow-up visits occurred approximately every six monthsuntil September 1986 after which subjects completed visits on an annual basis.During each visit subjects completed a self-administered questionnaire whichelicited information on age, income, educational and occupational status, sexualpartners and practices, use of alcohol, tobacco, and illicit drugs, and how AIDS hadchanged gay society. Subjects were also counseled by their physicians on how toadopt safer sex practices including reducing the number of sexual partners andavoiding unprotected sexual intercourse.Eligible men for this study were those who were HIV negative, whocompleted an index visit between October 1989 and September 1990, and whoreported sexual contact with casual partners (less than one sexual encounter permonth) during the previous 12 month period. Risk takers in this group wereidentified as those who had reported unprotected anal receptive or insertiveintercourse with casual partners; while controls (the remaining subjects in thegroup) were identified as either those who did not engage in anal intercourse withcasual partners or who reported using condoms at all times when they did.Patterns of sexual behaviour were measured using the questionnaire itemspertaining to the number of different sexual partners in the previous 12 months, the.frequency of various sexual practices during this period, and condom use duringthese practices. In addition, information on lifestyle was assessed using questionspertaining to the use of alcohol, tobacco, and illicit drugs.Page 3Statistical analyses of the data were conducted using distribution-freemethods. Comparisons of risk takers and control subjects with respect to categoricalvariables were based on Pearson's chi-square statistic. Fisher's exact test was usedwhen sample sizes were small. Continuous variables were analyzed using theWilcoxon rank-sum test for independent samples. All reported p-values are two­sided.RESULTSA total of 139 seronegative men who completed the index visit and reported sexualcontact with casual partners were included in this analysis. Of these, 31 subjects (22per cent) were risk takers and 108 subjects (78 per cent) were controls. The controlgroup was made up of 72 subjects (67 per cent) who did not engage in analintercourse with casual partners and 36 subjects (33 per cent) who reported alwaysusing condoms during anal intercourse with casual partners .Although risk takers tended to report higher numbers of casual partners thancontrols, the observed difference was not statistically significant. The mediannumber of casual partners was ten for risk takers compared to five for controls(p=0.976) . Risk takers and controis were similar with respect to their reportedfrequency of sexual contact in bath houses (p=0.278), bars/discos (p=0.696), and publicwashrooms or parks (p=0.976).Table 1 compares risk takers and controls with respect to age, annual income,and education. As shown here risk takers were younger (median age of 35 versus 40years; p=0.013) and more likely to have incomes below $10,000 (37 versus 12 per cent;p=0.002) than controls. A higher proportion of risk takers also did not complete aPage 4university degree (68 versus 51 per cent; p=0.107). However, this difference was notstatistically significant.Table 2 compares risk takers and controls with respect to consumption ofalcohol and cigarette smoking. Risk takers were significantly more likely to beheavy drinkers of alcoholic beverages, as defined as more than 60 drinks per month(16 versus 6 per cent; p=0.067), and to smoke cigarettes (58 versus 35 per cent;p=O.022).Table 3 compares risk takers and controls with respect to uses of nitrateinhalants and other illicit drugs. As noted here a higher percentage of risk takersreported using nitrite inhalants during the previous year (55 versus 30 per cent;p=0.010). However, no differences were observed for the use of amphetamine,cocaine, lysergic acid diethylamide (LSD), marijuana, and methylene-dioxy­amphetamine (MDA).Table 4 compares risk takers and controls with respect to opinion regardingchanges in gay society brought on by the AIDS epidemic. All subjects reported thatthey felt AIDS had significantly changed gay society. However, risk takers weremore likely to report that these changes were "more bad than good" (39 versus 20per cent); while control subjects were more likely to report that these changes were"more good than bad" (62 versus 50 per cent) .DISCUSSIONThis present study has identified, in a large cohort of homosexual men, severalsociodemographic characteristics of a mv negative subgroup who continue to placethemselves at high risk of HIV infection through their sexual behaviour. InPageScomparison to controls, risk takers were identified as men who were younger, hadlower incomes, and were more likely to smoke cigarettes and use nitrite inhalantson a regular basis.Our results demonstrate that risk takers are part of a subgroup of young andeconomically disadvantaged homosexual men. This is not surprising consideringthat other behavioural studies have identified younger homosexual men andhomosexual men of lower socioeconomic status to be less receptive to AIDSeducation ' and information campaigns [7]. The heavy drug use by risk takers,especially the use of nitrite inhalants, is also not unexpected considering that anumber of studies [12, 13, 14] have shown drug use to be associated with high risksexual behaviour among homosexual men. Unlike other behavioural studies,however, the present findings were observed within a cohort of men who wererelatively homogeneous. The overwhelming majority of men in the VLAS cohortare white and identify as being part of the same large urban gay community.There are several mediating factors which might help explain the associationbetween the above scciodemographic characteristics and risk taking behaviour inthis cohort. In particular, seronegative risk takers may underestimate their ownsusceptibility to HIV infection and instead operate under an "optimistic bias"regarding their health [15, 16]. This health belief, often referred to as personalef~icacy, relates to the notion that one is capable of making necessary behaviouralchanges to reduce risk or improve health. Personal efficacy has been shown to be animportant predictor of risk taking behaviour in homosexual and bisexual men. Inparticular, several studies have demonstrated that 'men at high risk of HIV havelow personal efficacy and that men at low risk have high personal efficacy [17].Although personal efficacy is not examined here, this belief is brought out in thePage 6question on how AIDS had changed gay society where risk takers were more likelyto report that these changes were "more bad than good."Risk taking behaviour may also be influenced by peer group norms. Recentresearch on social support systems among HIV infected homosexual and bisexualmen has demonstrated that race, as a possible proxy for fewer resources and greaterinstitutional and structural barriers, works as an intermediary to affect therelationship between social support systems and mental health [18]. There is reasonto believe that social support could also be an important mediating variable affectingbehaviour change in seronegative risk takers. In the San Francisco Men's HealthStudy, loneliness and the lack of social support has been shown to be related to highrisk sexual behaviour [19] . Also, several independent studies have suggested thatpeer group norms and support are important to the maintenance of high risk sexualbehaviour [20, 21, 22]. Taken together, these studies imply that individuals arereluctant to appear more concerned about high risk taking behaviour than theirpeers. This is especially so with the norms of younger individuals which generallypromote personal invincibility and risk taking behaviour [23].Caution should be taken in attempting to interpret our data on risk takingbehaviour of seronegative homosexual men. First, there may be problems withrespondents having misstated or forgotten past sexual behaviour [24]. Although theeffect of these recall problems is difficult to estimate, several studies have shown.that interview-administered and self-administered questionnaires can providereasonably reliable data concerning sexual behaviour in homosexual men when therecall period is relatively short [25, 26]. In this case, the effect of recall error is likelyto be relatively small as the data collected always pertained to sexual behaviourwhich occurred at most a year prior to questionnaire completion.Page 7Second, homosexual men who choose to attend family practices that providecare to large numbers of gay men may not accurately reflect the homosexualcommunity at large. In general, this type of selection tends to overrepresenthomosexual men living in urban environments who are of higher socioeconomicstatus and who identify with the gay community and lifestyle [7]. Furthermore, thebehaviour of participants may be affected by their mere participation in aprospective study involving repeated questionnaires, physical examinations,serologic testing, and counseling by committed practitioners. This form ofsurveillance bias may actually help to minimize risk taking behaviour in the cohort.In summary, we have identified sociodemographic characteristics of asubgroup of HIV negative homosexual men who continue to place themselves athigh risk for infection through unprotected anal intercourse with casual partners.Risk takers were characterized as men who were younger, of lower socioeconomicstatus, and more likely to smoke cigarettes and to use nitrite inhalants. Potentialbiases associated with this study would tend to attenuate the differences betweenrisk takers and controls and to make the seronegative men in our cohort lessrepresentative of the those in the gay community. Thus, these markers are likely tobe even stronger in the community outside the context of this cohort. Ultimately,our findings suggest the importance of targeting AIDS prevention activities toyounger gay men, to those of lower socioeconomic status, and to those exhibitingother risk behaviour such as smoking and use of nitrite inhalants.Page 8ACKNOWLEDGEMENTSThis work was supported by the Federal Centre for AIDS and the National HealthResearch Development Programme of the Department of National Health andWelfare of Canada through an operating grant (#6610-1389-AIDS) and through aNational Health Research Scholar award to Dr Montaner and a National AIDSScientist Award to Dr. Schechter.The authors are indebted to colleagues in the AIDS Care Group at S1. Paul's Hospitaland to Bonnie Devlin, and [oeane Zadra for their research assistance.Page 9REFERENCES1 Darrow WW, Echenberg DF, Jaffe HW, et al.: Risk factors for humanimmunodeficiency virus (HIV) infections in homosexual men. Am J PublicHealth 1987; 77:479-483.2 Martin JL: The impact of AIDS on gay male sexual behavior reported by gay menin New York City. Am J Public Health 1987; 77:578-581.3 Golombok S, Sketchley J, Rust J: Condom use among homosexual men. AIDSCare 1989;1:27-33.4 Detels R, English P, Visscher BR, et al.: Seroconversion, sexual activity andcondom use among 2915 HIV seronegative men followed for up to 2 years. JAcquir Immune Defic Syndr 1989; 2:77-83.5 Kingsley LA, Detre K, Kelsey S, et al.: Risk factors for seroconversion to humanimmunodeficiency virus among male homosexuals. Lancet 1987; 1:345-349.-6 Becker MH, Joseph JG: AIDS and behavioral change to reduce risk: A review.Am J Public Health 1988; 78:349-410.7 Coates TJ, Stall RD, Catania JA, Kegeles SM: Behavioral factors in the spread ofHIV infections. AIDS 1988; 2(5-1):239-246.8 Ekstrand ML, Stall RD, Coates TJ, McKusick L: Risky sex relapse, the nextchallenge for AIDS prevention programs: The AIDS Behavioral ResearchProject. Paper presented at the V International Conference on AIDS, Montreal,1989.Page 109 Fay RE, Turner CF, Klassen AD, Gagnon JH: Prevalence and patterns of same­gender sexual contact among men. Science 1989; 243:338-348.10 Boyko WJ, Schechter MT, Jefferies E, Douglas B, Maynard M, O'Shaughnessy M:The Vancouver Lymphadenopathy-AIDS Study, 3: Relation of HTLV-IIIseropositivity, immune status, and lymphadenopathy. Can Med Assoc J 1985;133:28-32.11 Schechter MT, Boyko WI, Douglas B, et al.: The Vancouver Lymphadenopathy­AIDS Study, 6: HIV seroconversion in a cohort of homosexual men. Can MedAssoc J1986; 135:1355-1360.12 Mayer KH: Medical consequences of the inhalation of volatile nitrites . In:Ostrow DG, Sandholzer TA, Felman YM, eds. Sexually Transmitted Diseases inHomosexual Men. Diagnosis, Treatment and Research. New York: PlenumPress, 1990:237-242.13 Stall R, McKusick L, Wiley J, Coates TJ, Ostrow DG: Alcohol and drug use duringsexual activity and compliance with safe sex guidelines for AIDS: The AIDSBehavioral Research Project. Health Educ Q 1986; 13:359-371.14 Ostrow DG, VanRanden MJ, Fox R, et al.: Recreational drug use and sexualbehavior change in a cohort of homosexual men. AIDS 1990; 4:759-765.15 Weinstein N: Reducing unrealistic optimism about illness susceptibility. HealthPsychol 1983; 2:11-20.Page 1116 Montgomery SB, Joseph JG, Becker HM, Ostrow DG, Kessler RC, Kirscht JP: TheHealth Belief Model in understanding compliance in preventiverecommendations for AIDS: How Useful? AIDS Educ Prev 1989; 1:303-323.17 Stall RD, Coates TJ, Hoff C: Behavioral risk reduction for HIV infection amonggay and bisexual men. A review of results from the United States. Am Psychol1988;43:878-885.18 Ostrow DG, Whitaker RED, Frasier K. et al.: Racial differences in social supportand mental health in men with HIV infection: a pilot study. AIDS Care 1991;3:55-62.19 Ekstrand M, Coates TJ: Prevalence and change in AIDS high-risk behavioramong gay and bisexual men. Paper present at the IV International Conferenceon AIDS, Stokholm, 1988.20 Emmons C-A, Joseph JG, Kessler RC, Wortman CB, Montgomery SB, OstrowDG: Psychosocial predictors of reported behavior change in homosexual men atrisk for AIDS. Health Educ Q 1986; 13:331-345.21 McKusick L, Coates TJ, Stall R, Morin 5: Psychosocial and behavioral predictorsof AIDS risk reduction. Paper presented at the IV International conference onAIDS, Stockholm, 1988.22 Joseph JG, Montgomery SB, Kessler RC, Ostrow DG, Wortman CB:Determinants of high-risk behavior and recidivism in gay men. Paper presentat the IV International conference on AIDS, Stockholm, 1988.Page 1223 Fisher JD: Possible effects of reference group-based social influence on AIDS-riskbehavior and AIDS prevention. Am Psychol 1988; 43:914-920.24 Spanier GB: Use of recall data in survey research on human sexual behavior.Soc BioI 1976; 23:244-253.25 Saltzman SP, Stoddard AM, McCusker J, et al.: Reliability of self-reportedbehavior risk factors for HIV infection in homosexual men. Public Health Rep1987;102:692-697.26 Coates RA, Soskolne CL, Calzavara, L et al.: The reliability of sexual histories inAIDS-related research: Evaluation of an interview-administered questionnaire.Can J Pub Health 1986; 77:343-348.Page 13Table 1. Comparison of risk takers and controls with respect to age, annual incomeand education.VariableAge (at index visit)MedianRangeAnnual income< $10,000~$1O,000Risk takers3522-4711 (37%)19 (63%)Controls4024-6613 (12%)94 (88%)p-value0.002bEducation (completed university degree)No 21 (68%)Yes 10 (32%)a Based on Wilcoxon rank sum test.b Based on chi-square test (uncorrected).55 (51%)52 (49%)0.107b"Page 14Table 2. Comparison of risk takers and controls with respect to alcoholconsumption and tobacco use.Variable Risk takers Controls p-valueAlcohol (>60 drinks per month)No 26 (84%) 102 (94%) O.068bYes 5 (16%) 6 ( 6%)CigarettesNo 13 (42%) 70 (65%) 0.022aYes 18 (58%) 38 (35%)a Based on chi-square test (uncorrected).b Based on Fisher's exact test.Page 15Table 3. Comparison of risk takers and controls with respect to uses of nitrateinhalants and other illicit drugs.Variable Risk takers Controls p-value"Nitrite inhalantsNo 14 (45%) 76 (70%) 0.010Yes 17 (55%) 32 (30%)AmphetamineNo 30 (97%) 106 (98%) 0.643Yes 1 ( 3%) 2 ( 2%)CocaineNo 26 (84%) 98 (91 %) 0.277Yes 5 (16%) 10 ( 9%)LSDNo 30 (97%) 102 (94%) 0.601Yes 1 ( 3%) 6 ( 6%)MarijuanaNo 19 (61 %) 65 (60%) 0.912Yes 12 (39%) 43 (40%)MDA' N o 28 (90%) 104 (96%) 0.180Yes 3 (10%) 4 ( 4%)a Based on chi-square test (uncorrected).Page 16Table 4. Comparison of risk takers and controls with respect to opinion regardingchanges in gay society brought on by the AIDS epidemic.DescriptionMore bad than goodMore good than badNeutralRisk takers11 (39%)14 (50%)3 (11 %)Controls20 (20%)62 (62%)18 (18%)p-value"0.100a Based on chi-square test (uncorrected).HPRU 88:1R Barer, M.L., Gafni, A. and Lomas, J. (1989), "Accommodating Rapid.Growth in Physician Supply: Lessons from Israel, Warnings for Canada",International Journal of Health Services 19(1):95-115. Originally releasedIn February, 1988.HPRU 88:2R Evans, R.G., Barer, M.L., Hertzman, C., Anderson, G.M., Pulcins, I.R. andLomas, J. (1989), "The Long Goodbye: The Great Transformation of theBritish Columbia Hospital System", Health Services Research 24(4):435­459. Originally released March, 1988.HPRU 88:3R Evans, R.G. (1989), "Reading the Menu With Better Glasses: Aging andHealth Policy Research", In S.J. Lewis (ed.), Aging and Health: LinkingResearch and Public Policy, Lewis Publishers Inc., Chelsea, 145-167.Originally released April, 1988.HPRU 88:4R Barer, M.L. (1988), "Regulating Physician Supply: The Evolution ofBritish Columbia's Bill 41", Journal of Health Politics, Policy and Law13(1):1-25HPRU 88:5R Anderson, G.M. and Lomas, J. (1989), "Regionalization of CoronaryArtery Bypass Surgery: Effects on Access", Medical Care 27(3):288-296.Originally released May, 1988.HPRU 88:6R Barer, M.L., Pulclns, I.R., Evans, R.G., Hertzman, C., Lomas, J. andAnderson, G.M. (1989), "Trends in Use of Medical Services by theElderly in British Columbia", Canadian Medical Association Journal141 :39-45. Originally released July, 1988HPRU 88:70 The Development of Utilization Analysis: How, Why, and Where It'sGoing. August 1988. (G.M. Anderson, J. Lomas)D = Discussion Paper R =Reprint-----~..~, . ::. .~:(:.> ·::::HEAL.TH'"POLICY .RESEARCH UNIT ..t~::~;:::~: ,,:.~,,\~.>::"~;; :.t,~::-:: ~,':' ;.,.<: ":~:rjL\t..:.:~::>·:·:·: <:~;; .: ',,:-. < •::: --::; DISCUSSION PAPERS & REPRINTSHPRU 88:80 Squaring the Circle: Reconciling Fee-for-Service with Global ExpenditureControl. September 1988. (R.G. Evans)HPRU 88:90 Practice Patterns of Physicians with Two Year Residency Versus OneYear Internship Training: Do Both Roads Lead to Rome? September1988. (M.T. Schechter, S.B. Sheps, P. Grantham, N. Finlayson, R. Sizto)HPRU 88:10R And rsen, G.M. and Lomas, J. (1988), "Monitoring the Diffusion of aTechnology: Coronary Artery Bypass Surgery In Ontario", AmericanJournal of Public Health 78(:J):251-254HPRU 88:11R Evans, R.G. (1988),""We'll Take Care of It For You": Health Care In theCanadian Community", Daedalus 117(4):155-189HPRU 88:12R Barer, M.L., Evans, R.G. and Labelle, R.J. (1988), "Fee Controls as CostControl: Tales From the Frozen North", The Milbank Quarterly 66(1):1-64HPRU 88:13R Evans, R.G. (1990), "Tension, Compression, and Shear: Directions,Stresses and Outcomes of Health Care Cost Control", Journal of HealthPolitics, Policy and Law 15(1):101-128. Originally released December,1988.HPRU 88:14R Evans, R.G., Robinson, G.C. and Barer, M.L. (1988), "Where Have All theChildren Gone? Accounting for the Paediatric Hospital Implosion", inR.S. Tonkin and J.R. Wright (eds.), Redesigning Relationships in ChildHealth Care, B.C. Children's Hospital, 63-76HPRU 89:10 Physician Utilization Before and After Entering a Long Term CareProgram: An Application of Markov Modell1ng. January 1989. (H.Krueger, A.Y. Ellencwelg, D. Uyeno, B. McCashln, N. Pagliccia)APRU 89:2R Hertzrnan, C., Pulcins, I.R., Barer, M.L., Evans, R.G., Anderson, G.M. andLomas, J. (1990) "Flat on Your Back or Back to your Flat? Sources ofIncreased Hospital Services Utilization Among the Elderly In BritishColumbia", Social Science and Medicine 30(7):819-828. Originallyreleased January, 1989.HPRU 89:3R BUhler, L., Glick, N. and Sheps, S.B. (1988), "Prenatal Care: AComparative Evaluation of Nurse-Midwives and Family Physicians",Canadian Medical Association Journal 139:397-403D =Discussion Paper R = Reprint2<::DISCUSSION PAPERS & REPRINTSHPRU 89:4R Anderson, G.M. and Lomas, J. (1989), "Recent Trends In CesareanSection Rates In OntarloN, Canadian Medical Association Journal141:1049-1053. Originally ,..Ieased February 1989.HPRU 89:50 The Canadian Health Care System: A King's Fund Interrogatory. March1989. (R.G. Evans)HPRU 89:6R Anderson, G.M., Spitzer, W.O.• Weinstein. M.C•• Wang. E•• Blackburn. J.L.and Bergman. U. (1990), NBenefits, Risks. and Costs of PrescriptionDrugs: A Scientific Basis for Evaluating Policy OptlonsN• ClinlcslPharmacology and Thsrapsutics 48(2):111-119. Originally released April,1989.HPRU 89:7R Evans. R.G. (1990). "The Dog In the Night Time: Medical PracticeVariations and Health Policy". In T.F. Andersen and G. Mooney (&ds.).The Challenges of Medical Practice Variations. The McMillan Press Ltd,London. 117-152. Originally released Juns 1989.HPRU 89:8R Evans, R.G. (1991), "Life and Death, Money and Power: The Politics ofHealth Care Finance". In T.J. Litman and L.S. Robins (eds.) HealthPolitics and Policy (2nd edition) Part 4(15):287-301. Originally relsasedJune, 1989.HPRU 89:9R Barer, M.L.• Nicoll. M.• Oiesendorf. M. and Harvey, R. (1990). "FromMedibank to Medicare: Trends In Australian Medical Care Costs and UseFrom 1976 to 1986". Community Health Studies XIV(1):8-18. Originallyreleased August 1989.HPRU 89:100 Cholesterol Screening: Evaluating Alternative Strategies. August 1989.(G. Anderson. S. Brinkworth. T. Ng)HPRU 89:11R Evans, R.G•• Lomas. J•• Barer. M.L., Labelle. R.J•• Fooks. C•• Stoddart,G.L., Anderson, G.M.• Feeny. D•• Gafnl. A•• Torrance. G.W. and Tholl.W.G. (1989). ·Controlling Health Expenditures - The Canadian Reality".New England Journal of Medicine 320(9):S71-snHPRU 89:120 The Effect of Admission to Long Term Care Program on Utilization ofHealth Services by the Elderly in British Columbia. November 1989.(A.Y. Ellencweig. A.J. Stark. N. Pagliccia. B. McCashin, A. Tourigny)HPRU 89:130 Utilization Patterns of Clients Admitted or Assessed but not Adm/tted toa Long Term Care Program - Characteristics and Dmerences. November1989. (A.Y. Ellencwelg. N. Pagliccls. B. McCsshln, A. Tourigny. A.J.Stark)o = Discussion Paper R = Reprint3;. . ': .>,;.,·t;\b ISC:J S'SiON'PAPERS & RE'PRxlNTS··:'r~HEALTH 'POLICY RESEARCH UNIT'.. :.:..HPRU 89:14R Anderson, G.M., PUlclns, I.R., Barer, M.L, Evans, R.G. and Hertzrnan, C.(1990), "Acute Care Hospital Utilization Under Canadian National HealthInsurance: The BritiSh Columbia Experience from 1969 to 1988", InqUiry27: 352-358. Originally released Decsmber, 1989.HPRU 9O:1R Anderson, G.M., Newhouse, J.P. and Roos, L.L. (1989), "Hospital Carefor Elderly Patients with Diseases 01 the CircUlatory System. AComparison of Hospital Use In the United States and Canada", NewEngland Journal of Medicine 321:1443-1448HPRU 90:20 Poland: Health and Environment In the Context of Soclosconomlc_. Decline. January 1990. (C. Hertzman)HPRU 90:30 The Appropriate Use of Intrapartum Electronic Fetal Heart RateMonitoring. January 1990. (G.M. Anderson, O.J. Allison)HPRU 9O:4R Anderson, G.M., Brook, R. and Williams, A. (1991) "A Comparison ofCost-Sharing Versus Free Care in Children: Effects on the Demand forOffice-Based Medical Care", Medical Care 29(9):890-898. Originallyreleased January, 1990.HPRU 9O:5R Anderson, G.M., Brook, R., Williams, A. (1991) "Board Certification andPractice Style: An Analysis of Office-Based Care", The Journal of FamilyPractice 33(4):395-400. Originally released February, 1990. Originallyreleased February, 1990.HPRU 90:60 An Assessment of the Value of Routine Prenatal Ultrasound Screening.February 1990. (G.M. Anderson, D. Allison)HPRU 9O:7R Nemetz, P.N., Ballard, O.J., Beard, C.M., Ludwig, J., Tangalos, E.G.,Kokmen, E., Weigel, K.M., Belau, P.G., Bourne, W.M. and Kurland, L.T.(1989) "An Anatomy of the Autopsy, Olmsted County, 1935 through1985", MByO Clinic Proceedings 64:1055-1064HPRU 9O:8R Nemetz, P.N., Beard, C.M., Ballard, D.J., Ludwig, J., Tangalos, E.G.,Kokmen, E., Weigel, K.M., Belau, P.G., Bourne, W.M. and Kurland, L.T.(1989) "Resurrecting the Autopsy: Benefits and Recommendations",Mayo Clinic Proceedings 64:1065-1076HPRU 90:90 Technology Diffusion: The Troll Under the Bridge. A Pilot Study ofLow and High Technology In British Columbia. March 1990. (A.Kazanjian, K. Friesen)D = Discussion Paper R = Reprint4~~~;~;~~~A[Y~' (:!PO~18Y ~>ESEARCH;- '~N'IT<-..:::.;·: ' ~;~~bISCO~SION PAPERS & REPRINrSHPRU 9O:10R Sapphires In the Mud? The Export Potential of American Health CareFinancing. Enthoven, A.C. (1989), -What Can Europeans Learn fromAmerlcans?-, Evans, R.G., Barer, M.L. (1989), Comment Health CareFinancing Review, Annual Supplement 1989HPRU 90:11D Healthy Community Indicators: The Perils of the Search and the Paucityof the Find. March 1990. (M. Hayes, S. Willms)HPRU 9O:12D Use of HMRI Data In Ninet6Bn British Columbia Hospitals and FutureDirections for Case Mix Groups. April 1990. (K.M. Antioch)HPRU 9O:13R Evans, R.G. and Stoddart G.L. (1990) "Producing Health, ConsumingHealth Care". Social Science and Medicine 31(12) 1347-1363. Originallyreleased April, 1990.HPRU 90:14D Automated Blood Sample-Handling In the Clinical Laboratory. June1990. (W. Godolphln, K. Bodtker, D. Uyeno, L.-O. Goh)HPRU 9O:15R Anderson, G., Sheps, S.B., Cardiff, K., (1990) "Hospital-based UtilizationManagement: a Cross-Canada Survey", Canadian Medical AssociationJournal 143 (10):1025-1030. Originally released June, 1990.HPRU 9O:16D Hospital-Based Utilization Management: A Literature Review. June1990. (5. Sheps. G.M. Anderson. K. Cardiff)HPRU 9O:17D Reflections on the Financing of Hospital Capital: A CanadianPerspective. June 1990. (M.L. Barer. R.G. Evans)HPRU 9O:18R Evans. R.G. Barer, M.L. and Hertzrnan, C. (1991), "The 2G-YearExperiment: Accounting For. Explaining. and Evaluating Health CareCost Containment in Canada and the United States ", Annual Review ofPublic Health 12:481-518. C1rlglnally released September, 1990.HPRU 9O:19D Accessible, Acceptable and Affordable: Financing Health Care InCanada. September 1990. (R.G. Evans)HPRU 9O:20D Hungary Report. October 1990. (C. Hertzman)HPRU 90:21D Unavailable for Circulation.D =Discussion Paper R = Reprint5~:'=h .:':,:. " • . :- . . ;(:;;.. \::",:.• : . . ~. ..-. . , -. . < . . . . i:~;:C :,",;tHEALTH':,POLICY RESEARCH ,UNIT.~;lr~~J~S;bN PAP~RS ·& ':REPRIN~~:..~.;~ . :-::-~ . ... . ....HPRU 9O:22R Anderson, G.M., PUlclns, I. (1991), MRecent trends In acute care hospitalutilization In Ontario for diseases or the circulatory system-, CMAJ145(3):221-226. Originally released October, 1990. .HPRU 90:230 Environment and Health In Czechoslovak/a. December 1990. (C.Hertzman)HPRU 90:240 Perceptions and Realities: Med/csl and Surgical ProClKlure Variation ALiterature Review. January 1991. (S. Sheps, S. Scrivens, J. Galt)HPRU 91:1R Nemetz, P.N., Tangalos, E.G. and Kurland, L.T. (1990), -rhe Autopsy andEpidemiology - Olmsted County, Minnesota and Malmo, Sweden", APMIS98:765-785HPRU 91:20 Putting Up or Shutting Up: Interpreting Health Status Indicators FromAn Inequities Perspective. May 1991. (C. Hertzman, M. Hayes)HPRU 91:3R Barer, M.L. (1991), "Controlling Medical Care Costs in Canada"(Editorial), Journal of the American Medical Association 265(18):2393­2394HPRU 91:40 The Meeting of the Twain: Managing Health Care Capital, Capacity andCosts in Canada. June 1991. (M.L. Barer, R.G. Evans)"HPRU 91:5R Barer, M.L., Welch, W.P. and Antioch, L. (1991) "Canadian-AmericanHealth Care Comparisons: Reflections On The HIAA'S Analysis", HealthAffairs 10(3):229-239. Originally released June, 1991.HPRU 91:60 Toward Integrated Medical Resource Policies for Canada: BackgroundDocument. June, 1991. (M.L. Barer, G.L. Stoddart) Cost: $45.00HPRU 91:70 Toward Integrated Medical Resource Policies for Canada: Appendices.June, 1991. (M.L. Barer, G.L. Stoddart) Cost: $30.00""" N~te: :Jf you aTe ordering 91:60or 91:7D, plea~~""'i/ maJce your cheque payable to "The UniverSity of .British Columbia and enclose it with this Jist.o = Discussion Paper R = Reprint6HPRU 91:80 Bulgaria: The Public Health Impact of Environmental Pollution. August,1991. (C. Hertzman)HPRU 91:9D Reflections on the Revolution in Sweden. september, 1991. (R.G.Evans) .HPRU 91:10D The Canadian Health Care System: Where are We; How Did We GetHere? October,1991. (R.G. Evans, M.M. Law)HPRU 92:1D On Being Old and Sick: The Burden of Health Care for the Elderly InCanada and the United States. December, 1991. (M.L. Barer, C.Hertzman, R. Miller, M.V. Pascali)HPRU 92:2R Manson Willms, S. (1992) "Housing for Persons with HIV Infection inCanada: Health, Culture and Context", Western Geographic Series Vol.26:1-22.HPRU 92:30 Environment and Health in the Baltic Countries. April, 1992.(C. Hertzman)HPRU 92:4R Barer, M.L., Evans, R.G. (1992) "Interpreting Canada: Models, Mind-Sets,and Myths", Health Affairs 11(1):44-61(File: t>; =Discussion Paper R = Reprint7


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