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PubMed2003

Paradigms and progress in building research capacity in international environmental health.

Populations in low- and middle-income nations bear significant risks for poor health due to air, land and water contamination; natural resource depletion; deterioration of ecosystems; contaminated food supplies and other conditions related to poverty, including poor housing, crowding and inadequate nutrition and health care. These risks, related to rapid industrialization, increasing urbanization, poor land use, natural changes in ecology and other conditions, will only increase in the coming decades if current trends persist. The implications on populations' health include increased spread or emergence of disease, particularly those that impact children disproportionately, and added stress on already overburdened or weakened health care systems. To address environmental health conditions in a relevant manner in resource-poor settings, the training of scientists and health professionals from these settings is key to setting priorities and identifying cost-effective interventions. Training of professionals in a range of environmental health disciplines is a prerequisite for the establishment of effective national and international policies. Working to strengthen local expertise and scientific capacity is one of the most effective and lasting ways to affect positive policy change in environmental health. This paper describes four paradigms that support research training and research programs to meet the increasing and changing needs in this field. Factors influencing the development of the programs and their evolution are discussed as well as trends for the future.

Curriculum↗

PubMed2000

Sharing obstetric care: barriers to integrated systems of care.

OBJECTIVES: To map the provision of shared obstetric care in Victoria, and investigate the views of care providers about the ways in which current practice could be improved. METHOD: All Victorian public hospitals with > or = 300 births per annum and a purposive sample of hospitals with < 300 births per annum were mailed a questionnaire seeking information about current practice. Interviews with key informants (n = 32) were conducted at four case study sites. RESULTS: The response rate to the hospital survey was 98% (42/43). Fourteen different models of shared care were identified. Two-thirds of hospitals with > or = 300 births per annum (16/28) had three or more different models of shared care. Six hospitals (15%) had written guidelines for all models of shared care offered; 13 (32%) had written guidelines covering some models. Practice varied considerably in relation to: exclusion criteria, recommended schedule of visits and use of patient-held records. There was little consensus about the content of visits and responsibility for covering particular aspects of care. Few hospitals (6/42) had written information for women about shared care. Care providers expressed divergent views regarding the question of where ultimate responsibility lies for individual patient care and for the overall management of shared care. CONCLUSIONS: Current funding arrangements provide strong incentives to expand enrollment in shared obstetric care. Expansion of shared care has occurred without the development of formal, consultative and agreed arrangements between providers, or adequate provision for monitoring, evaluation and review. The variety, complexity and fluidity of models of shared care and lack of agreed procedures contribute to difficulties experienced by both providers and women participating in shared care. IMPLICATIONS: Detailed evidence-based agreed guidelines developed in consultation with hospital and community providers, and provision of improved information to women about what to expect in shared care arrangements are urgently required.

Attitude of Health Personnel↗

PubMed1999

Shared teaching in health care ethics: a report on the beginning of an idea.

In the majority of academic institutions nursing and medical students receive a traditional education, the content of which tends to be specific to their future roles as health care professionals. In essence, each curriculum design is independent of each course. Over the last decade, however, interest has been accumulating in relation to interprofessional and multi-professional learning at student level. With the view that learning together during their student training would not only encourage and strengthen future collaboration in practice settings but also enhance patient care, the University of Dundee decided to run a pilot study to explore shared teaching in ethics between medical and nursing students. This article presents a report on the reasons for selecting health care ethics as a precursor for shared teaching, the educational tool used for the sessions, and the results of student and facilitator evaluation of the short course. Overall, despite problems such as poor attendance by some students, and facilitation and timetable difficulties, most of the feedback from students and facilitators has been positive. In essence the 'idea' has gone from strength to strength and there are now three levels of shared teaching in ethics between nursing and medical students, with plans to include further sessions with students from other disciplines. Within the text, 'health care ethics' will be referred to as 'ethics'; nursing students/nurses encompasses midwifery students/midwives.

Attitude of Health Personnel↗

PubMed1993

Interorganizational exchanges as performance markers in a community cancer network.

OBJECTIVE: This study examines how "strategic partnerships" between community-based consortia of oncologists and hospitals (CCOPs) and clinical cooperative groups emerge, develop, and influence patient accruals (i.e., the number of patients enrolled in clinical trials) over time. DATA SOURCES AND STUDY SETTING: Study analyses are based on 65 pairwise relationships that 38 CCOPs established with eight clinical cooperative groups in September 1983 and maintained through February 1989. Data are drawn from grantee applications and progress reports. STUDY DESIGN: The study examines how different types of CCOP-cooperative group exchange relate to one another and to CCOP patient accruals over six time points. Key independent variables include resource dependence, information exchange (i.e., meeting attendance and committee membership), and protocol exchange (i.e., the number of different protocols used). DATA COLLECTION METHODS: Data extracted from secondary sources were entered in a data base. PRINCIPAL FINDINGS: The number of CCOP physicians and support staff who attend cooperative group meetings during the first two years of a clinical research partnership has a significant influence on meeting attendance and protocol use in later years. Two-thirds or more of the variance in patient accruals at each time point can be explained by the number of different protocols used and the number of CCOP representatives serving on cooperative group committees (or attending cooperative group meetings). CONCLUSIONS: The findings highlight the importance of historical relationships and anticipated resource dependence in shaping initial exchange patterns. They also suggest that strategic partnerships need to emphasize structures and processes that encourage early involvement in collaborative activities and that reward participants for maintaining high levels of interaction.

Cancer Care Facilities↗

PubMed2002

Computer applications in the search for unrelated stem cell donors.

The majority of patients which are eligible for a blood stem cell transplantation from an allogeneic donor do not have a suitable related donor so that an efficient unrelated donor search is a prerequisite for this treatment. Currently, there are over 7 million volunteer donors in the files of 50 registries in the world and in most countries the majority of transplants are performed from a foreign donor. Evidently, computer and communication technology must play a crucial role in the complex donor search process on the national and international level. This article describes the structural elements of the donor search process and discusses major systematic and technical issues to be addressed in the development and evolution of the supporting telematic systems. The theoretical considerations are complemented by a concise overview over the current state of the art which is given by describing the scope, relevance, interconnection and technical background of three major national and international computer appliances: The German Marrow Donor Information System (GERMIS) and the European Marrow Donor Information System (EMDIS) are interoperable business-to-business e-commerce systems and Bone Marrow Donors World Wide (BMDW) is the basic international donor information desk on the web.

Bone Marrow Transplantation↗

PubMed2007

Introducing Health Impact Assessment: an analysis of political and administrative intersectoral working methods.

BACKGROUND: Intersectoral Action for Health (IAH) and its Health Impact Assessment (HIA) tool are built on collaboration between actors and sectors, requiring multidimensional and horizontal way of working. The study aims to analyse the enablers and barriers when such a new way of working and tool have been initiated to replace a traditional, vertical operation at the local level in Slovakia-a country in transition-in 2004. METHODS: Up to date, there are few studies that have analysed intersectoral initiatives in relation to politics. In this study the conceptual framework of Kingdon has been used by which the actual problems, the governmental actions (or non-actions) (politics) and the understanding, implementation and evaluation of the initiative (policy) could be analysed. All actors involved, civil servants, politicians, representatives of the local public health institute and researchers, were interviewed and made to answer a questionnaire. RESULTS: The results showed that there were a number of factors behind the initiation of HIA, which either delayed or accelerated the process. The problems identified were e.g. the prevailing traditional health care focus and the deteriorating health status of the population. There was a lack of multi-intersectoral knowledge, co-operation and function between sectors and actors. Enablers on the other hand were the membership of international organizations which called for new solutions, and the strong political commitment and belief that intersectorality would have a positive effect on health. CONCLUSION: The actors on the local level would have the capacity to work intersectorally to bring about policy change if HIA was to be more supported/institutionalized.

Community Health Planning↗

PubMedDate not supplied

Leadership development for rural health.

Leadership is the capacity to help transform a vision of the future into reality. Individuals who can and will exercise leadership are like a river's current--a part past where we now stand, a part yet to come. We have an ongoing need to remember and to look toward the next "generation." A key responsibility of those here now, is to mentor and to create structures for mentoring, in order to maximize the flow and effectiveness of tomorrow's leaders. When recruiting organizational leaders, the recruitment and interview process must seek individuals who in addition to technical competence, also have demonstrated leadership in their prior work and activities. To exercise effective leadership, we must work to know who we are, how we relate to others, and the environment around us. "Servant leadership" is a perspective held by many throughout the rural health community and offers a key set attributes of leadership useful to rural health. To implement the Institute of Medicine's recommendations in Through Collaboration: the Future of Rural Health, we must develop leaders skilled in collaboration, both internal to their organization and across organizations. The National Advisory Committee on Rural Health and Human Services had it right when they said to the Secretary and to the rest of us, "the best way to honor Jim is to consciously work to help develop the next generation of rural health leaders." There are, of course, a multitude of leadership institutes, programs, and courses throughout America; this is not a call for yet another separate entity. But it is a call to each of us in rural health to assure that we are deliberate in how we identify "emerging leaders from and for rural communities and provide them with the training and resources to play a lead role in ensuring access to quality healthcare in their states and communities." Let's get started.

Community Health Planning↗

PubMedDate not supplied

Integration of disaster mental health services with emergency medicine.

Despite limited resources, emergency medical settings will be called upon to play many roles in the context of disasters and terrorist attacks that are related to preparedness, surveillance, mental health services delivery, and staff care. Such settings are a central capture site for those individuals likely to be at highest risk for developing mental health and functional problems. Because much of the potential harm to survivors of disaster or terrorism (and their families) will be related to their mental health and role functioning, preparedness requires the active integration of behavioral health into emergency medicine in every component of disaster response. There are many challenges of doing this including: (1) finding ways to integrate activities of the medical care, emergency response, and public health systems; (2) determining whether an incident has actually occurred; (3) making differential diagnoses and managing other aspects of initial medical needs; and (4) coping with the risks associated with system overload and failure. Delivery of direct mental health care must include: (1) survivor and family education; (2) identification and referral of those requiring immediate care and follow-up; (3) group education and support services; and (4) individual counseling. In order for effective response to occur, the integration of psychosocial care into disaster response must occur prior to the disaster itself, and will depend on effective collaboration between medical and mental health care providers. At workplaces, emergency medical care centers must ensure that staff and their families are properly trained and supported with regard to their disaster functions and encouraged to develop personal/family disaster plans.

Disaster Planning↗

PubMed1981

Quality of institutional participation in multicenter clinical trials.

We studied the relation between an institution's degree of participation in a multicenter clinical trial and the quality of its participation. The quality of participation was judged on the basis of the percentage of patients entered into the trial who were in fact eligible, who were treated in accordance with the protocol, and for whom the appropriate forms were received. Those who satisfied these criteria were termed "valid" patients. Institutions were divided into two groups, "major participants" and "minor participants," according to the number of patients they entered in the trial. In a detailed analysis of a multicenter trial of chemotherapy for soft-tissue sarcoma, we found that major participants had a significantly higher percentage of valid patients than did minor participants (81 per cent vs. 39 per cent) and that the minor participants were actually detrimental to the study from both scientific and administrative viewpoints. These results suggest that institutions should not participate in multicenter studies unless they can enter some predetermined minimal number of patients per year.

Antineoplastic Agents↗

PubMedDate not supplied

A closer look at lay sponsorship. A CHA survey reveals some problems with two established models.

The private association of the Christian faithful (PACF) and private juridic person (PJP) are two lay sponsorship options for healthcare organizations that find traditional sponsorship unavailable. Today two questions relate to these models: Are the PACF and the PJP still realistic and attractive models of sponsorship? Can Catholic identity be maintained in them? Last summer CHA surveyed the seven member organizations that use either the PACF or the PJP as sponsorship models. In addition, CHA conducted four site visits, which corroborated the survey findings. Most respondents said their organizations had adopted the lay model as a means of remaining Catholic after their original sponsors withdrew. Most said they had a good relationship with the local diocese, although formal meetings with the diocesan leaders were infrequent. Each organization had a clearly articulated mission and reinforced their mission and values in various ways. Leadership development appeared somewhat weak. Some respondents spoke favorably of the PACF and PJP models of sponsorship, but others saw limitations, including isolation, lack of clarity in reporting mechanisms between the organization and the diocese, and lack of board education about the models. Even those who saw a future for lay sponsorship on the PACF and PJP models said that, although it is important for Catholic healthcare to develop lay leadership, these models are not promising steps in that direction.

Catholicism↗

PubMed2002

The disconnect of twin pillars: the growing rift in educational goals and methods between medical schools and the academic teaching hospitals.

Academic teaching hospitals (ATH) and medical schools are the two main components of the Academic Health Sciences Centre (AHSC) organization. They have traditionally worked in a symbiotic, f relatively unstructured and somewhat fluid relationship. Now changes in the medical school approach are creating stress on this traditional partnership. First, medical schools are being driven by external pressures to better respond to societal needs. Medical schools are increasingly decentralizing their educational process to help produce physicians with the values and skills needed to meet the diverse needs of Canadian society. Second, internally, the changing nature of medical knowledge and skill sets has led to differences in the educational process with more formal standards and educational goals. Within this second change is a difference in the trainees moving through the educational system - today's future doctors represent a different value set and demographic profile than their predecessors. These changes pose both a challenge and an opportunity for ATHs. ATHs are well positioned to be leaders and facilitators of these changes. Doing so would help strengthen the system, and would ultimately help ATHs fulfil their complex and often competing mandates. Unfortunately, there are also incentives for ATHs to fight these trends. The response of ATHs to their evolving relationship with medical schools and universities will have a large influence on the future shape and function of the AHSC.

Canada↗

PubMed1992

Global considerations affecting the health agenda of the 1990s.

The author explains why global problems, both known and unknown and unpredictable, are going to affect the health sector in the next few decades even more than they do today. Five examples are given of global health-related dilemmas that must be faced: (1) the worldwide aging of the population and the changing morbidity trends and physician supply needs this creates; (2) rising worldwide poverty, which has a direct relation to health status and has some new causes in this century; (3) ethical dilemmas, such as those resulting from new reproductive and life-prolonging technologies; (4) the need for adequate and affordable health care systems (the Canadian system is described and several misconceptions about it are clarified); and (5) the need to allocate scarce resources to meet practically infinite health care demands. The author concludes by listing some of the important actions that must be taken if we are to deal effectively with the dilemmas fostered by global problems: (1) people must be taught that their health status is the result of many factors in addition to their health care (e.g., socioeconomic status, lifestyle, the environment); (2) medical education must be refocused to prepare physicians to deal with global challenges; (3) there must be greater international cooperation (e.g., working together to share research and implement strategies to control AIDS); (4) countries must invest in worldwide efforts, such as family planning and primary education; and (5) international partnerships must be created to develop worldwide strategies, such as a global drug strategy.

Aging↗

PubMed1997

An academic centre for gene therapy research with clinical grade manufacturing capability.

Huddinge University Hospital is a major teaching hospital affiliated with the Karolinska Institute in Southern Stockholm. For the past few years several groups have been working there in different areas of gene therapy relating to cancer, genetic and infectious diseases. However, a facility to produce clinical grade material under good manufacturing practice was lacking. To this end, Huddinge University Hospital has taken the initiative to open a Gene Therapy Research Center in 1996. This facility, which is unique of its kind in Scandinavia, is located in the Novum Research Park, Huddinge, and is a part of the existing Clinical Research Center. The newly built centre will allow clinicians and researchers to develop and produce vectors (viral and nonviral) for clinical trials and do basic research to understand the mechanisms of diseases. Although the centre will primarily serve the academic institutions it will also extend its facilities to other investigators in this field. The production unit is run in collaboration with the Faculty of Medicine, University of Lund. On-going projects include production of plasmid vectors for prevention of postangioplasty restenosis, DNA vaccine for HIV-1, cationic liposome DNA complexes for cystic fibrosis and retroviral vectors for HIV-1.

AIDS Vaccines↗

PubMedDate not supplied

Information partnerships--shared data, shared scale.

How can one company gain access to another's resources or customers without merging ownership, management, or plotting a takeover? The answer is found in new information partnerships, enabling diverse companies to develop strategic coalitions through the sharing of data. The key to cooperation is a quantum improvement in the hardware and software supporting relational databases: new computer speeds, cheaper mass-storage devices, the proliferation of fiber-optic networks, and networking architectures. Information partnerships mean that companies can distribute the technological and financial exposure that comes with huge investments. For the customer's part, partnerships inevitably lead to greater simplification on the desktop and more common standards around which vendors have to compete. The most common types of partnership are: joint marketing partnerships, such as American Airline's award of frequent flyer miles to customers who use Citibank's credit card; intraindustry partnerships, such as the insurance value-added network service (which links insurance and casualty companies to independent agents); customer-supplier partnerships, such as Baxter Healthcare's electronic channel to hospitals for medical and other equipment; and IT vendor-driven partnerships, exemplified by ESAB (a European welding supplies and equipment company), whose expansion strategy was premised on a technology platform offered by an IT vendor. Partnerships that succeed have shared vision at the top, reciprocal skills in information technology, concrete plans for an early success, persistence in the development of usable information for all partners, coordination on business policy, and a new and imaginative business architecture.

Economic Competition↗

PubMed2005

Improvement in neonatal intensive care in Northern Ireland through sharing of audit data.

PROBLEM: Ten percent of infants born will require admission to a neonatal facility. Coordinated activity to monitor and improve the quality of care for this high risk, high cost group of infants is considered a high priority. At the time of initiation of this project no system for collection and analysis of neonatal data existed in Northern Ireland. DESIGN: In 1994 an ongoing prospective centralised data collection system was implemented to facilitate quality improvement and research in neonatal care. We aim to ascertain if there has been a demonstrable improvement in the quality of care provided since the initiation of this system. SETTING: All nine Northern Ireland neonatal intensive care units returned prospectively collected socioeconomic, obstetric and neonatal episode data. KEY MEASURES FOR IMPROVEMENT: Achievement of the agreed quality indicators relating to transfer patterns, thermoregulation, antenatal steroid administration, and timing of administration of surfactant during the period 1 April 1999 to 31 March 2000 were compared with data for the period 1 April 1994 to 31 March 1996. STRATEGIES FOR CHANGE: Monitoring included audit and annual feedback of timely clear and relevant data where results were provided confidentially as standardised reports, together with anonymised comparisons with other similar sized units. Draft recommendations were made at regional level and units were asked to adopt finalized consensus guidelines at the local level and to implement changes to clinical practice. EFFECTS OF CHANGE: The proportion of transfers taking place in utero increased from 26% to 42% and antenatal steroid administration from 68% to 82%. Normothermia on first admission improved from 66% to 71% for inborn infants. The proportion of infants receiving surfactant where the first dose was given within an hour of birth increased from 13% to 66%. LESSONS LEARNT: A multi-professional regional care network can facilitate the development of agreed standards and a culture of regular evaluation leading to quality improvement.

Body Temperature Regulation↗

PubMed1990

Sponsorship in evolution.

Sponsorship appears to be evolving from an original model in which the sponsoring religious institute related to its facilities in a manner resembling a family business, to a model of sponsorship akin to a franchise, to a ministerial partnership. Factors leading to this evolution include tremendous changes within the religious institute itself, including decreases in the number of members and financial stability. Changes within healthcare itself--such as greater competition and declining revenues-have forced hospitals to diversify. One result of these developments has been a radical change in the "rules" of the game. Historically independent entities--hospitals, sponsors, physicians--now have to value interdependence and mutuality. In the family-run model the family (sponsor) had special privileges, as though they "owned" the business. When the number of family members dropped below that necessary to govern, administer, and staff the institute's facilities, they began to move away from the family model to the franchise model, which has more open communication, greater input to decision making by non-family members, and a shift in the family's attention from actual operations to oversight and accountability. Eventually, the franchise model began to give way to the ministerial partnership, characterized by mutuality. Both family and others have roles not only in carrying out the mission, but in actually shaping and forming it.

Catholicism↗

PubMed2004

[Clinical research in the "acute and chronic leukemias"competence network ].

Goal of the network is the construction of an exemplary cooperative leukemia network for the improvement of medical care and of health related research in acute and chronic leukemias. This is achieved by improved mechanisms of cooperation among all major groups in Germany that deal with the leukemias in research and in patient care. In practice, cooperation between clinical groups and scientists in research institutes is mediated by various instruments that improve communication, flow of information and interdisciplinary cooperation and also increase information transfer from top research institutions to clinical translation. The network comprises more than 1400 participants in about 400 university centers, large community hospitals and specialty practices with functional communication structures, interdisciplinary cooperation and nation-wide logistics. The improved cooperation and the accelerated information transfer from the bench to the "bedside" results in an added value that ultimately results in improved survival results of patients and in superior competitiveness of involved research workers and clinicians. Sustainability is addressed by establishing a leukemia foundation to support long term financial coverage of the network and by negotiating a proposal for a European Network of Excellence against leukemia within the Sixth Framework Programme of the European Union.

Acute Disease↗

PubMed2005

Multi-agency working in services for disabled children: what impact does it have on professionals?

Whilst agencies in many sectors have been encouraged to work together to better meet the needs of service users, multi-agency working is now a central feature of government policy. In relation to children's services, the National Service Framework, the English green paper, 'Every Child Matters' (DfES, 2003) and the Children Bill (DfES 2004) give a high priority to an integrated approach to service provision. This paper focuses on multi-agency working for disabled children with complex health-care needs, a group of children who, perhaps even more than most, require the many professionals who support them and their families, to work more closely together. Drawing on the findings from a 3-year qualitative research study, this paper examines the impact of working in a multi-agency service on professionals. Interviews with 115 professionals concluded that staff were overwhelmingly positive about working as part of a multi-agency service. They reported improvements to their working lives in areas such as professional development, communication, collaboration with colleagues, and relationships with families with disabled children. However, whilst professionals felt that they were able to offer families a more efficient service, there was concern that the overall impact of multi-agency working on disabled children and their families would be limited.

Adolescent↗