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PubMed2001

Managing challenging behaviour in the community: methods and results of interactive staff training.

A necessary condition for a high quality of community care in relation to challenging behaviour is staff training in appropriate methods. This paper describes the application of a practical 'interactive staff training' approach with n = 101 staff, featuring the use of focused and experiential learning in teams. The findings indicated that the course was socially acceptable to the participants, led to a significant improvement in their knowledge of nonphysical methods, and resulted in written guidelines for managing their own clients' challenging behaviour. Furthermore, agreements were clarified on how these guidelines would be implemented by each team following training. Implications are drawn for improved evaluation of this promising training programme, including developing the measures of learning and adding a generalisation assessment.

Adult↗

PubMed1998

Managed mental health care: problems and possibilities.

Case management has become an established organizational approach to mental health care. However, a recent development of case management, known as 'managed care' has received only limited attention in the UK and this has been confined to acute medical or surgical hospital care. The potential of managed care as applied to mental health care is uncertain. This paper clarifies the nature of managed care and discusses its relevance to mental health care, in particular to the care of people suffering from schizophrenia. The high incidence and heavy resource demands of this user group makes these people an ideal focus for managed care. However, there are conceptual and practical problems hindering its development and implementation, including: the variability and unpredictability of the disease process of schizophrenia; challenges of outcome measurement; and problems relating to the current organization of mental health care.

Case Management↗

PubMed2005

Having a "safe delivery": conflicting views from Tibet.

In the Tibetan Autonomous Region (TAR) of the People's Republic of China (PRC) maternal mortality ratios remain among the highest in the world. Although traditional Tibetan medical theory, practice, and pharmacology include information on maternal and child health care, Tibet is one of the few societies in the world that does not have traditional birth attendants or midwives. Using ethnographic methods, we gathered data from individual interviews with rural Tibetan women (N=38) about their beliefs and behaviors surrounding pregnancy and childbirth. Additional data were gathered through interviews with prefecture, county, and township health care providers. These data were used to develop a culturally appropriate village birth attendant training program in rural Tibet. We describe Tibetan women's perspectives of "having a safe delivery" in relation to concepts about "safe delivery" according to evidence-based medicine in the West. Our work also provides an example of the benefits and challenges that arise when ethnographic research methods are used to design and implement health care interventions.

Adult↗

PubMed2004

Trends in monitoring patients with aneurysmal subarachnoid haemorrhage.

After aneurysmal subarachnoid haemorrhage (SAH), the clinical outcome depends upon the primary haemorrhage and a number of secondary insults in the acute post-haemorrhagic period. Some secondary insults are potentially preventable but prevention requires prompt recognition of cerebral or systemic complications. Currently, several neuro-monitoring techniques are available; this review describes the most frequently used techniques and discusses indications for their use, and their value in diagnosis and prognosis. None of the techniques, when considered in isolation, has proved sufficient after SAH. Furthermore, the use of multi-modality monitoring is hampered by a lack of clinical studies that identify combinations of specific techniques in terms of clinical information and reliability. However, ischaemia at the tissue level can be detected by intracerebral microdialysis technique. Used together with the conventional monitoring systems, for example intracranial pressure measurements, transcranial Doppler ultrasound and modern neuro-imaging, direct assessment of biochemical markers by intracerebral microdialysis is promising in the advancement of neurointensive care of patients with SAH. A successfully implemented monitoring system provides answers but it also raises valuable new questions challenging our current understanding of the brain injury after SAH.

Cerebrovascular Circulation↗

PubMed2001

Behavioural interventions to prevent HIV infection: rapid evolution, increasing rigour, moderate success.

Behavioural interventions aim to alter behaviours that make individuals more vulnerable to becoming infected or infecting others with HIV. Research in this field has developed rapidly in recent years. Increased rigour in the design and conduct of evaluations and moderate successes in bringing about behaviour change in target populations are the key achievements so far. This paper reflects on these developments, addresses recent innovations and highlights likely areas for future work. Discussion focuses on maximising the potential effectiveness of new interventions, methodological issues relating to evaluation and implementation of interventions into practice. The paper concludes there is evidence that interventions deemed effective under evaluation conditions can be implemented in HIV prevention services and that this is the next major challenge. The immediate goal should be consolidation of the learning that has occurred, particularly efforts to maintain theoretical and evaluative rigour whilst encouraging increased collaborative partnerships between researchers, service providers and affected communities.

HIV Infections↗

PubMed2002

Nutritional status in dialysis patients: a European consensus.

BACKGROUND: Malnutrition is common in dialysis patients and closely related to morbidity and mortality. Therefore, assessment of nutritional status and nutritional management of dialysis patients play a central role in everyday nephrological practice. METHODS: Achieving a consensus on key points relating to pathogenesis, clinical assessment, and nutritional management of dialysis patients. RESULTS: The assessment of nutritional status should be based on clinical assessment and biochemical parameters, including history of weight loss, per cent standard weight, body mass index, muscle mass, subcutaneous fat mass, and plasma albumin, creatinine, bicarbonate and cholesterol. Co-morbid conditions should be assessed and C-reactive protein (CRP) measured--as a marker of inflammation--as there is a close relation between malnutrition, on one side, and co-morbid conditions and inflammation on the other. For a more detailed assessment, subjective global assessment of nutritional status is a well-validated tool, and dual-energy X-ray absorptiometry (DEXA) is a useful method for routine assessment of lean body mass. Anthropometric methods are also useful. They are cheap and easy to apply, although less precise than DEXA. The recommended daily protein intake is at least 1.2 g/kg standard body weight and the energy intake 35 kcal/kg standard body weight (BW), in patients <60 years, and 30 kcal/kg standard BW in patients >60 years. The standard bicarbonate level should be at least 22 mmol/l. If CRP is >10 mg/l, it is important to seek and treat the underlying cause. Adequate dialysis (for haemodialysis: Kt/V >1.2) should be ensured and, although no definite evidence of the importance of dialysis water quality is available, the opinion of the authors is that the water quality should be high. The role of the biocompatibility of the dialysis membrane is still not clear. The dietitian plays a pivotal role in the nutritional care of dialysis patients, and patients should be provided with dietary counselling from the start of substitutive treatment in order to meet the recommended nutritional intakes. Dietary counselling can also play an important role in an integrated treatment of hyperphosphataemia, although most patients will also need phosphate binders if they have an adequate protein intake. CONCLUSION: Malnutrition assessment and treatment is a great challenge for nephrological care. Achieving evidence-based consensus can help in implementing the progress of knowledge in clinical practice.

Body Mass Index↗

PubMedDate not supplied

New approaches of organizing care and work: giving way to participation, mobilization, and innovation.

Quebec's health network has undertaken large-scale organizational changes to ensure the continuity, accessibility, and quality of health care and services for the population. This article describes the optimal approach for making changes to the organization of care and work for patients, health care workers, and organizations. This participative action research was carried out by means of interviews and document analysis. One hundred participants were involved, describing a total of 34 projects for significant organizational change. Results include an optimal approach broken down into 4 phases, each of which includes steps, facilitating factors, and potential difficulties. The phases of this approach are: (1) sharing the vision, mission, and values of the organization and identifying the purpose and need underlying the change; (2) building alliances and validating the involvement of the various players; (3) conceptualizing and planning the project; and (4) implementing changes and continuing evaluation. It is possible to rise to the challenge of finding new approaches to organize care and work by giving way to participation, mobilization, and innovation.

Cooperative Behavior↗

PubMed2001

Measuring the success of primary care organizations: is it possible?

Primary care in the UK has been the subject of numerous changes and reorganizations since 1990. Each innovation in organization, with the exception of fundholding, has been the subject of evaluation. However, the complexities of some innovations make the evaluation process problematic and this is further complicated by the trend towards central policy decision making being subject to local interpretation and implementation, by means of simultaneous devolution and centralization. This paper discusses the challenges and problems posed by attempting to evaluate these new organizations, particularly with regard to whether or not they can be considered to be "successful". It draws specifically on the national evaluation of the total purchasing pilots and indicates how the findings can be applied to primary care groups.

Contract Services↗

PubMed2002

A procedural evaluation of an analytic-deliberative process: the Columbia River Comprehensive Impact Assessment.

The U.S. Department of Energy's Columbia River Comprehensive Impact Assessment (CRCIA) was an ambitious attempt to direct its cleanup of the Hanford Nuclear Reservation toward the most significant risks to the Columbia River resulting from past plutonium production. DOE's approach was uncommonly open, including tribal, regulatory agency, and other Hanford interest group representatives on the board that was to develop the assessment approach. The CRCIA process had attributes of the "analytic-deliberative" process for risk assessment recommended by the National Research Council. Nevertheless, differences between the DOE and other participants over what was meant by the term "comprehensive" in the group's charge, coupled with differing perceptions of the likely effectiveness of remediation efforts in reducing risks, were never resolved. The CRCIA effort became increasingly fragmented and the role its products were to play in influencing future clean-up decisions increasingly ambiguous. A procedural evaluation of the CRCIA process, based on Thomas Webler's procedural normative model of public participation, reveals numerous instances in which theoretical-normative discourse disconnects occurred. These had negative implications for both the basic procedural dimensions of Webler's model-fairness and competence. Tribal and other interest group representatives lacked the technical resources necessary to make or challenge what philosopher Jurgens Habermas terms cognitive validity claims, while DOE and its contractors did not challenge normative claims made by tribal representatives. The results are cautionary for implementation of the analytic-deliberative process. They highlight the importance of bringing rigor to the evaluation of the quality of the deliberation component of risk characterization via the analytic-deliberative process, as well as to the analytic component.

Journal Article↗

PubMed2005

After adoption: sustaining the innovation. A case study of disseminating the hospital elder life program.

OBJECTIVES: To examine key factors that influence sustainability in the diffusion of the Hospital Elder Life Program (HELP) as an example of an evidence-based, multifaceted, innovative program to improve care for hospitalized older adults. DESIGN: Longitudinal, qualitative study between November 2000 and November 2003 based on 102 in-depth interviews every 6 months during HELP implementation. SETTING: Thirteen hospitals implementing HELP. PARTICIPANTS: Forty-two hospital staff members (physician, nursing, volunteer, and administrative staff) implementing HELP, conducted 102 interviews. MEASUREMENTS: Staff experiences sustaining the program, including challenges and strategies that they viewed as successful in addressing these challenges. RESULTS: Of the 13 hospitals studied, 10 were sustaining HELP at the end of the study period; three terminated the program (after 24 months, 12 months, and 6 months). Critical factors were identified as influencing whether the program was sustained: the presence of clinical leadership, the ability and willingness to adapt the original HELP protocols to local hospital circumstances and constraints, and the ability to obtain longer-term resources and funding for HELP. CONCLUSION: Recognizing the need for sustained clinical leadership and funding as well as the inevitable modifications required to sustain innovative programs can promote more-realistic goals and expectations for health services researchers, clinicians, and policy makers in their laudable efforts to translate research into practice.

Aged↗

PubMedDate not supplied

Performance improvement: one model to reduce length of stay.

Dedicated quality professionals are tired of quick fixes, Band-Aids, and other first-aid strategies that offer only temporary relief of nagging problems rather than a long-term cure. Implementing strategies that can produce permanent solutions to crucial problems is a challenge confronted by organizations striving for continuous performance improvement. One vehicle, driven by data and customer requirements, that can help to solve problems and sustain success over time is the storyboard. This article illustrates the use of the storyboard as the framework for reducing length of stay--one of the most important problems facing healthcare organizations today.

Data Display↗

PubMedDate not supplied

Mainstreaming during the early childhood years.

Issues surrounding the implementation of the integration imperative during infancy and early childhood present formidable challenges to education and community providers. Key among these issues is how professionals provide high-quality services to young children with disabilities in mainstream environments. This article explores current issues related to integration and reexamines the concept of "best practices" as it applies to mainstreaming during the early childhood years. The author recommends an integrated set of indicators for high-quality programs and describes an outcomes-based process for making administrative and pedagogical decisions.

Child, Preschool↗

PubMed2005

Involving students in learning and health promotion processes--clarifying why? what? and how?

The concept of student participation is currently a popular notion in health promoting schools as well as in general education. However, phrases such as 'involvement', 'participation', 'co-determination' and 'influence' are frequently used without careful definition. In this article two models, developed in the context of health promoting schools in two different cultures, are presented and discussed. The first model makes a fundamental distinction between token and genuine participation. Token participation in health promotion is characterised by focusing on prescribed knowledge, closed and convergent outcomes and targeting individuals isolated from the surrounding environment. In contrast, genuine participation stresses students' own construction of knowledge, open and divergent outcomes and targeting individuals in their context. Genuine participation is in accordance with a democratic health promoting school aiming at students' empowerment and action competence. The second model clarifies a number of different categories of students' participation in health promotion. The different categories illustrate how the teacher in various ways can play an active role in participatory approaches as a responsible professional. The more the students are involved in health projects, the more important it will be for the teacher to provide support, insight and knowledge to facilitate the learning processes. Furthermore, the different participation categories have to be related to a number of decisions which are normally included in a school health project. The model illustrates that participation should always be viewed in relation to the context and that it makes no sense to establish a single ideal way of working with participation in a health promoting school. The theoretical models are illuminated by concrete examples from health promoting schools. The overall conclusion is that participation is a complex term and rather than providing definitive answers, the models can be used as a framework for discussion among all stakeholders in planning, implementation, evaluation and managing projects involving student participation. Finally, specific implications and challenges for future health promoting schools are outlined. These are as follows: a participatory approach does not imply that health content should be regarded as vague or superfluous; teachers need flexible educational models and resources to manage participatory projects in health promoting schools; schools have to be acknowledged as cultural systems with firmly rooted rules and routines that are often difficult to change; a participatory approach has to influence all aspects of a democratic health promoting school rather than solely the teaching strategies.

Cooperative Behavior↗

PubMed2000

The social and cultural context of risk and prevention: food and physical activity in an urban Aboriginal community.

One of the key public health challenges facing indigenous and other minority communities is how to develop and implement effective, acceptable, and sustainable strategies for the prevention of non-insulin-dependent diabetes mellitus (NIDDM). In this article, the authors describe how an ethnographic approach was used to contextualize the behavioral risk factors for NIDDM and applied to the development of a more meaningful and appropriate epidemiological risk factor survey instrument for an urban Aboriginal population in Australia. The overall research design comprised a mixture of qualitative and quantitative methods. The ethnographic study showed that the complex web of meanings that tie people to their family and community can and should be taken into account in any social epidemiology of health and illness if the findings are to have any effective and long-term potential to contribute to successful public health interventions targeting these behavioral risk factors.

Adult↗

PubMed1994

Risk-adjusted capitation: recent experiences in The Netherlands.

The market-oriented health care reforms taking place in the Netherlands show a clear resemblance to the proposals for managed competition in U.S. health care. In both countries good risk adjustment mechanisms that prevent cream skimming--that is, that prevent plans from selecting the best health risks--are critical to the success of the reforms. In this paper we present an overview of the Dutch reforms and of our research concerning risk-adjusted capitation payments. Although we are optimistic about the technical possibilities for solving the problem of cream skimming, the implementation of good risk-adjusted capitation is a long-term challenge.

Capitation Fee↗

PubMed2005

A history of microarrays in biomedicine.

The fundamental strategy of the current postgenomic era or the era of functional genomics is to expand the scale of biologic research from studying single genes or proteins to studying all genes or proteins simultaneously using a systematic approach. As recently developed methods for obtaining genome-wide mRNA expression data, oligonucleotide and DNA microarrays are particularly powerful in the context of knowing the entire genome sequence and can provide a global view of changes in gene expression patterns in response to physiologic alterations or manipulation of transcriptional regulators. In biomedical research, such an approach will ultimately determine biologic behavior of both normal and diseased tissues, which may provide insights into disease mechanisms and identify novel markers and candidates for diagnostic, prognostic and therapeutic intervention. However, microarray technology is still in a continuous state of evolution and development, and it may take time to implement microarrays as a routine medical device. Many limitations exist and many challenges remain to be achieved to help inclusion of microarrays in clinical medicine. In this review, a brief history of microarrays in biomedical research is provided, including experimental overview, limitations, challenges and future developments.

Animals↗

PubMed2003

[Regional variations in homicide mortality in Jalisco, Mexico].

The present study describes regional variations in homicide rates in Jalisco State, Mexico, in 1989-1991, 1994-1996, and 1999-2000, analyzing the trends by gender and socioeconomic stratum. Using mortality data generated by the National Institute for Statistics, Geography, and Information Technology, homicide rates adjusted by age and gender were calculated, along with rate/female rate ratios; rate ratios by socioeconomic stratum and 95% confidence intervals were also calculated. According to the results, the homicide rate showed: a downward trend in the 1990s; a regional homicide mortality pattern, with the highest rates in peripheral regions, considered among the poorest areas in the State; municipalities with the lowest socioeconomic conditions also presenting a statistically significant excess homicide mortality; and an evident over-mortality from homicide among males. The results point to tasks and challenges for public health and law enforcement institutions, including the need to implement different inter-institutional policies that take into consideration the characteristics of homicide and violent crime in Jalisco.

Cause of Death↗

PubMed2006

Training of evidence-based assessment and intervention approaches in cross-cultural contexts: challenges and solutions.

Dissemination of evidence-based assessment and intervention approaches for child and adolescent with behavioral and/or emotional problems is now a priority in the field worldwide. However, developing staff competence in evidence-based assessment and intervention approaches in different countries is complicated by some environmental and economic constraints. In this paper a distance training/supervision model is discussed. We describe seven specific challenges encountered and solutions used for overcoming the obstacles in order to implement evidence-based assessment and intervention approaches in different sites in Brazil, Egypt, Israel, and Lebanon.

Adolescent↗