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PubMed1997

Collaboration with government leaders to promote sustainability, Cross River State, Nigeria. The Calabar PMM Team.

PRELIMINARY STUDIES: Focus group studies and facility reviews revealed poorly equipped and under-utilized emergency obstetric facilities in two rural communities in Cross River State, Nigeria. INTERUENTIONS: Beginning in late 1992, state and local government leaders were contacted to sensitize them to the problem of maternal mortality and enlist their cooperation in activities to upgrade obstetric services. RESULTS: A maternal health unit was created in the State Ministry of Health. Government officials were instrumental in upgrading hospital and polyclinic facilities, correcting staff shortages, repairing an ambulance, establishing a blood bank, granting leave to midwives for participation in skills workshops and facilitating dissemination of information. COSTS: Nineteen visits to government officials required approximately 33 person-days of the team's time. Transportation, communication and per diems were also paid. Government contributed a considerable amount in staff time and provided venues for workshops. CONCLUSIONS: A great deal can be achieved to improve emergency obstetric services through collaboration with government. Support and cooperation of government leaders can also enhance sustainability of interventions.

Community Health Centers↗

PubMed1998

Response of hostile individuals to stressful changes in their working lives: test of a psychosocial vulnerability model.

BACKGROUND: According to the psychosocial vulnerability model, the health of hostile individuals is at greater risk than that of non-hostile individuals, due partly to lesser ability of the former to cope with psychosocial stress situations. We examined whether hostile individuals were more vulnerable than others to health problems when faced with stressful changes in their working lives. METHODS: Hostility, sickness absence and psychosocial stressors in 866 local government employees over a 5-year period, which included severe economic decline, were investigated. Hostility was measured by a questionnaire. Data on medically certified sickness absence were obtained from the records of the local authority. Information about exposure to psychosocial stressors after assessment of hostility was also derived from these records, and from the subjects. RESULTS: Exposure to stressors during the period of economic decline was related to increased rates of sickness absence. In men, hostility increased risk of sickness absence after exposure to stressors only in cases of absence because of trauma. In women, hostility increased risk of absence through sickness overall and absence because of musculoskeletal disorders in individuals facing stressors such as severe organizational downsizing, high or increased levels of job demands or negative change in work. Findings were adjusted for sickness absence at the beginning of the decline, socio-economic background and behavioural risk factors. CONCLUSIONS: The psychosocial vulnerability model was partly supported. However, heightened vulnerability through hostility may differ between the sexes, since it was more evident in the women studied than in the men.

Absenteeism↗

PubMed2005

Trauma/critical care surgeon: a specialist gasping for air.

BACKGROUND: In the last 10 years, trauma/critical care has become less attractive because of the decreasing surgical caseload, the nocturnal work hours, and the economics of the practice. Nevertheless, during the same period, the number of verified trauma centers has significantly increased. This study assesses the economic drive behind this dichotomy. METHODS: Over a 1-year period, we collected financial data on 1,907 trauma patients for both Level I trauma centers and trauma/critical care surgeons. Financial data, including payor source, cost, reimbursement, margin, and reimbursement-to-charge and reimbursement-to-direct cost ratios, were calculated. RESULTS: For commercial- and government-insured patients, the reimbursement-to-direct cost ratio was 2-and 35-fold greater, respectively, for the trauma centers than for the trauma/critical care surgeons. For uninsured patients, the addition of local government funds allowed the trauma center to cover direct cost with no margin. In contrast, even with the addition of supplemental salary dollars from the institution, for every dollar in direct cost generated by the trauma/critical care surgeons in caring for uninsured patients, they recovered 55 cents, or a loss of 45 cents per direct cost dollar spent. CONCLUSION: The economic dichotomy that exists between trauma centers and trauma/critical surgeons is significant. It drives institutional growth and, at the same time, discourages surgeons from entering the subspecialty. As physician reimbursement decreases and the number of uninsured patients increases, this economic dichotomy will amplify. Over the next decade, without a significant adjustment, the subspecialty is in danger of extinction.

Career Choice↗

PubMed1999

Ergonomic strategies for improving working conditions in some developing countries in Asia.

Ergonomic action is growing in Asia in response to increasing local needs. Recent studies in some developing countries in Asia commonly developed and applied widely-applicable measures for assessing local needs in field conditions including small enterprises and agriculture. For this purpose, carefully examining the actual workplace conditions of the local people was essential. Consequently, a number of field studies could contributed to improving the working conditions of the local people in materials handling, workstation design, work organization and work environment by using available local resources. Building on local capacity and practice, action-oriented ergonomics training has also been developing and spreading into many workplaces. Various non-expert human resources including local government units, trade unions, industrial associations and the agricultural sectors have been mobilized to act as participatory trainers in the action-oriented ergonomic training programmes. Training tools such as action checklists, good local examples and group work dynamics have been developed and applied to such training activities. Learning from local achievements and focusing on locally available resources, ergonomists have facilitated these local action processes by developing action-oriented training tools and training local trainers. It was confirmed that a number of ergonomic improvements could be formulated by the self-help initiative of the local people when participatory action tools and training were provided. Developing flexible and dynamic ergonomic research and training methods to meet the diversifying needs of the local people will continuously be important. Ergonomists' efforts to cover the wider population and workplaces need to be strengthened and accelerated.

Asia↗

PubMed2004

Governance in gridlock in the Russian health system; the case of Sverdlovsk oblast.

Epidemiological, demographic and environmental crises, transition to a new political regime and exceptionally severe economic crises were powerful stimuli to health sector reform in Russia. The Russian Federation responded by introducing medical insurance whilst decentralising public administration. Yet despite intense contextual pressures to do so and a new policy climate, Russian hospitals found it difficult to reprofile services and reallocate their resources. A case study analysing governance structures in Sverdlovsk oblast reveals that medical insurance created incentives to reduce costs by reducing bed-days, but if hospitals did so they would lose money under the formulae through which decentralised local government still allocated around three-quarters of hospital income. If instead hospitals tried to increase budgetary income by increasing numbers of bed-days, the insurance system would penalise them. This specific form of policy mess can be called 'governance in gridlock'. The juxtaposition of two overlapping but incompatible sets of governance structures practically immobilised official hospital management systems. It is as one-sided to blame residues of the Soviet system for this gridlock as it is to blame the medical insurance system. Gridlock resulted from the interaction of the two, a problem to which all health system reform is potentially vulnerable.

Bed Occupancy↗

PubMedDate not supplied

[Psychiatric planning in Schleswig-Holstein].

The new Land government of Slesvick Holstein has resolved to reorganize psychiatric care in a manner that care centres work and are managed in districts that are geographically situated near provincial towns or in county areas where local supervision is rendered easier by their proximity to the seat of local government and to out-patients' domiciles. The article describes the present structure of care, the update state of planning activities and the outlook to the future.

Community Mental Health Services↗

PubMed2006

Community perspectives on the impact of policy change on linking social capital in a rural community.

Understanding what undermines or builds social capital is important when estimating the impact that changes in social capital have on people's lives. The aim of this paper is to illustrate how the consequences of neo-liberal policy initiatives have impacted on linking social capital in one small and vibrant rural community in Australia. Policy changes affecting all levels of government and various commercial agencies have undermined people's capability for a range of actions which bring personal and community-wide social and economic returns. Rationalisation and regionalisation of services and commercial agencies, including local government amalgamation, and increased workloads have undermined people's capabilities for community engagement. Policy outcomes are at odds with the stated policy agenda of building community capacity.

Adult↗

PubMed2002

Alcohol-related violence and the role of oral and maxillofacial surgeons in multi-agency prevention.

The maxillofacial region is by far the most frequently selected target in assaults on adults. There is a causal link between alcohol intoxication and injury. Therefore, oral and maxillofacial surgery is, in effect, the lead speciality for those injured in violence and has a responsibility to orchestrate holistic care that takes into account mental health needs. Recent years have also seen a determined effort by oral and maxillofacial surgeons to get involved in wider issues of prevention, exemplified by the national UK BAOMS Facial Injuries Awareness Week. Multi-agency prevention, not just with mental health professionals in the case of individual patients, but also with emergency medicine, public health, local government, the police and the voluntary sector is key to success. Given the potential complexity of collaborations like this, it is important to understand what works in multi-agency prevention. This paper reviews successful interventions: their rationale and how oral and maxillofacial surgeons can contribute to local injury prevention.

Adolescent↗

PubMedDate not supplied

Corporatization as a means of improving water quality: the experience in Victoria, Australia.

Factors including fragmentation, a lack of direction, poor accountability, poor water quality, and a sizable state government subsidy contributed to the rural water industry in Victoria, Australia, in 1993. In 1993 the state government set out parameters for reform to change the size, structure, performance, and culture of the water industry. The path taken was not privatization, but corporatization. Tools used included amalgamation of organizations; separating water provisions from local government; changing the composition and reporting mechanisms of the boards; establishing clear benchmarks and performance criteria; making information publicly available; and providing a commercial orientation. The outcomes of the reforms were to be a focus on water quality and effluent management. In 2001, 15 water authorities were in place. There were significant improvements in accountability, finances, and performance. The authorities provided information on performance to both the state and the public. Reductions of operating costs have been in the range of 20-35%, with savings put back into new infrastructure. Water quality has significantly improved in a number of parameters and effluent management has also improved. This paper describes the challenges faced before the reform process, the reforms initiated, and the outcomes. It argues that privatization is not the only path to improvement: Developing a corporate structure and accountability can also deliver substantial improvements.

Benchmarking↗

PubMed1988

Perinatal and infant mortality in Wales: inter-district variations and associations with socio-environmental characteristics.

Stillbirth rates, perinatal death rates, early and late neonatal death rates and (post-neonatal) infant death rates are reported for Wales since local government and NHS reorganization in 1974. The time trends in these rates show declining mortality, in full weight and in low birthweight babies. Analysis of average rates for the period 1974-81 inclusive in the 37 local authority districts within Wales demonstrate wide variations, with PMRs ranging from 11.5 to 22.5 per 1000. Many highly statistically significant associations were evident between socioeconomic characteristics of the districts and stillbirth rates but few with neonatal death rates and none with infant death rates.

Environment↗

PubMed2001

Towards integrated catchment management, Whaingaroa, New Zealand.

The paper examines progress towards integrated catchment management and sustainable agriculture at Whaingaroa (Raglan), New Zealand. Application of the Canadian "Atlantic Coastal Action Program" model (ACAP) has been only partially successful within New Zealand's bicultural setting. Even before the introduction of the ACAP process there existed strong motivation and leadership by various sectors of the community. A merging of resource management planning and implementation processes of the larger community and that of the Maori community has not occurred. Research carried out by Crown Research Institutes has clearly shown the actions required to make pastoral farming more sustainable. There are difficulties in the transference to, and uptake of, these techniques by farmers. An examination of the socio-economic context is required. There has been a requirement on local government bodies to tighten their focus as part of recent reform. This has occurred concurrently with a widening of vision towards integrated and sustainable forms of management. This (as well as a clear belief in empowerment of local communities) has lead to Council reliance on voluntary labour. There is a need to account for the dynamic interaction between social and political history and the geological and biophysical history of the area. As part of a re-examination of sustainable development, New Zealand needs to reconcile the earning of the bulk of its foreign income from primary production, with the accelerating ecological deficit that it creates. A sustainability strategy is required linking consumer demand, property rights and responsibilities.

Agriculture↗

PubMed2006

Development knowledge and experience--from Bangladesh to Afghanistan and beyond.

PROBLEM: In Afghanistan the challenges of development are daunting, mainly as a result of many years of conflict. The formation of a new government in 2001 paved the way for new initiatives from within and outside the country. BRAC (formerly Bangladesh Rural Advancement Committee), a Bangladeshi nongovernmental organization with a long history of successful work, extended its development model to Afghanistan in 2002. LOCAL SETTING: Provincial Afghanistan. APPROACH: BRAC has implemented programmes in Afghanistan in the areas of health, education, microfinance, women's empowerment, agriculture, capacity development and local government strengthening, and has taken many of these programmes to scale. RELEVANT CHANGES: With a total staff of over 3000 (94% Afghan and the rest Bangladeshis), BRAC now works in 21 of the country's 34 provinces. BRAC runs 629 non-formal primary schools with 18 155 students, mostly girls. In health, BRAC has trained 3589 community workers who work at the village level in preventive and curative care. BRAC runs the largest microfinance programme in the country with 97 130 borrowers who cumulatively borrowed over US$ 28 million with a repayment rate of 98%. LESSONS LEARNED: Initial research indicates significant improvement in access to health care. Over three years, much has been achieved and learned. This paper summarizes these experiences and concludes that collaboration between developing countries can work, with fine-tuning to suit local contexts and traditions.

Afghanistan↗

PubMedDate not supplied

[Health promotion and education: a diagnosis of sanitation conditions using participatory research and community education (São João dos Queiróz - Quixadá/Ceará, Brazil)].

This study was conducted in a rural community, São João dos Queiróz, a township in the county of Quixadá, Ceará, Brazil, using a combination of participatory research and community education in compliance with the health promotion reference and principles of the 1986 Ottawa Charter. The project was joined by representatives of several local government institutions and organizations from the grassroots community movement. The theme generating the research, as defined by an assembly meeting of the community association, was a diagnosis of sanitation conditions in the community. The starting point was the assessment of local conditions. Results showed adverse local conditions in sanitation, literacy, income, and employment. Suggestions for solving the problems were organized so as to be included in the planning agenda for local health policies. Evaluation was procedural and enriched with daily research activities. The problem-solving pedagogical approach developed during the educational process contributed to a critical reconstruction, appropriation, and sharing of the resulting knowledge.

Adolescent↗

PubMed2006

Pandemic planning.

Recent trends of hospital ED overcrowding, ambulance diversion and the persistent "dire straits" of emergency medical systems can be expected to be exacerbated under the conditions a pandemic influenza will present. Partners of community healthcare systems must come together to solve these problems as they develop their pandemic influenza response plans. The solution must involve EMS, hospitals, public health and other healthcare partners, as well as local government. Limited surge capacity, overwhelming numbers of citizens requiring and demanding care, and the worried well will simply compound the challenges EMS responders will face. EMS must get proactive and tap the preparedness resources being marshaled at federal, state and local levels. These preparations will not be complete without an exercise that probes for weaknesses in the response plan. EMS agencies are encouraged to join up with other components of the healthcare system, such as hospitals, community health centers and public health, and conduct joint exercises. And we must not forget the coroners, whose plans must include a mass-fatality plan that details the management of what may become an overwhelming number of deceased.

Disaster Planning↗

PubMed2000

Protein synthesis in axons and terminals: significance for maintenance, plasticity and regulation of phenotype. With a critique of slow transport theory.

This article focuses on local protein synthesis as a basis for maintaining axoplasmic mass, and expression of plasticity in axons and terminals. Recent evidence of discrete ribosomal domains, subjacent to the axolemma, which are distributed at intermittent intervals along axons, are described. Studies of locally synthesized proteins, and proteins encoded by RNA transcripts in axons indicate that the latter comprise constituents of the so-called slow transport rate groups. A comprehensive review and analysis of published data on synaptosomes and identified presynaptic terminals warrants the conclusion that a cytoribosomal machinery is present, and that protein synthesis could play a role in long-term changes of modifiable synapses. The concept that all axonal proteins are supplied by slow transport after synthesis in the perikaryon is challenged because the underlying assumptions of the model are discordant with known metabolic principles. The flawed slow transport model is supplanted by a metabolic model that is supported by evidence of local synthesis and turnover of proteins in axons. A comparison of the relative strengths of the two models shows that, unlike the local synthesis model, the slow transport model fails as a credible theoretical construct to account for axons and terminals as we know them. Evidence for a dynamic anatomy of axons is presented. It is proposed that a distributed "sprouting program," which governs local plasticity of axons, is regulated by environmental cues, and ultimately depends on local synthesis. In this respect, nerve regeneration is treated as a special case of the sprouting program. The term merotrophism is proposed to denote a class of phenomena, in which regional phenotype changes are regulated locally without specific involvement of the neuronal nucleus.

Animals↗

PubMed2004

The pharmaceutical industry's responsibility for protecting human subjects of clinical trials in developing nations.

Pharmaceutical companies increasingly perform clinical trials in developing nations. Governments of host nations see the trials as a way to provide otherwise unaffordable medical care, while trial sponsors are drawn to those countries by lower costs, the prevalence of diseases rare in developed nations, and large numbers of impoverished patients. Local governments, however, fail to police trials, and the FDA does not monitor trials in foreign countries, resulting in the routine violation of international standards for the protection of human subjects. This Note proposes independent accreditation of those institutions involved in clinical trials--the institutional review boards which oversee trial protocol; the organizations, such as pharmaceutical companies, which sponsor the trials; and the research organizations that conduct the trials. Accreditation, similar to that used in the footwear and apparel industries, would increase the transparency of pharmaceutical trials and would enable the United States government and consumers to hold trial sponsors accountable for their actions.

Accreditation↗

PubMed2001

Breaking the camel's back: multicenter clinical trials and local institutional review boards.

Clinical research has undergone remarkable and beneficial expansion in the past 25 years, but with this growth has come an unprecedented increase in workload for the human subjects protection system. Recently, a major change in federal oversight of local institutional review boards (IRBs) became evident. Although it was not announced publicly, in 1998 and 1999 federal regulatory actions against local IRBs increased threefold. Particularly notable was the marked increase in regulatory actions taken against the IRBs of academic medical centers (1 in 1997 compared with 14 in 1999). Ironically, this apparent federal crackdown began at the same time that two federal review panels called for major changes in the regulations governing local IRBs. A key factor in the current crisis in the function of local IRBs is the ascendance of multicenter clinical trials as the dominant form of clinical research. Local IRBs were not designed to handle the initial evaluation and ongoing review required by the rapidly increasing number of multicenter clinical trials. Furthermore, local IRB review of the thousands of safety reports from multicenter clinical trials monopolizes resources without promoting patient safety. Instead of rigid enforcement of outmoded regulations that do not contribute to patient safety, the responsibilities of the local IRB in the oversight of multicenter clinical trials must be systematically evaluated.

Academic Medical Centers↗

PubMed2006

Towards active community participation in dengue vector control: results from action research in Santiago de Cuba, Cuba.

Community participation is advocated as essential for attaining effective dengue prevention, but knowledge of how to foster this is limited. In Santiago de Cuba, multiple small task forces were created at the neighbourhood level that included all stakeholders in the control of Aedes aegypti. The task forces assessed the perceived needs and elaborated action plans to promote specific behavioural change and to reduce environmental risks through social communication strategies and intersectoral local government activities. We monitored five dimensions of the participation process and assessed behavioural and environmental results and entomological outcomes. Participation was weak to good. At the household level, uncovered water storage containers decreased from 49.3% to 2.6% between 2000 and 2002, and removing larvicide from them dropped from 45.5% to 1%. There was a reduction of 75% in the absolute number of positive containers and a significant decrease from 1.23% to 0.35% in the house index. Local task forces, in which the interests of householders as well as vector control workers are directly represented, can lead to effective government-community partnerships that resolve problems of mutual concern.

Animals↗