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PubMed1998

Contracting for health services in New Zealand: a transaction cost analysis.

The splitting of the functions of purchaser and provider in the New Zealand health system in 1993 necessitated the use of explicit contracts between the two parties. This paper examines contracting experiences during the first two years of operation. The study focuses on four services: rest homes, primary care clinics, surgical services, and acute mental health services. The insights of transaction cost economics form the theoretical framework. The objective of this study was to examine whether the transaction costs associated with contracting vary across the four different services, and whether different types of contracts and contractual relationships are emerging as transactors attempt to reduce these costs. Information was collected in a series of 53 interviews with purchasers and providers, together with any relevant documentation. The results suggest that the costs of contracting are indeed greater for some services than for others. Other variables such as the style of negotiations, the type and specificity of contracts and the degree of monitoring also differ across the four services. At this early stage of the reform process, there was little evidence that purchasers and providers were attempting to reduce transaction costs by negotiating more flexible, longer-term, relational contracts. The main benefit from contracting to date has been improved accountability of service providers.

Aged↗
PubMed2003

The multi-disciplinary evaluation of a national agri-environment scheme.

With an increasing amount of public funds being spent on agri-environmental schemes effective methods have to be developed to evaluate them. As many schemes have multiple objectives there is a need for a multi-disciplinary approach to any evaluation. A method was developed to assess the degree to which ecological, landscape, historical and access objectives for the Countryside Stewardship Scheme (CSS) in England have been met. The method used a sample of 484 agreements for which data were collected from surveys, a desk study and an interview with the agreement holder. These data were then evaluated by an expert team of an ecologist, landscape architect, landscape historian, and a social scientist specializing in rural affairs. The team were subsequently brought together with a Chair to discuss their findings for each agreement, allocating scores for each of five criteria: agreement negotiation; appropriateness, environmental effectiveness, compliance and side effects. The additionality that each agreement was likely to provide was also assessed. The results of this process suggest that in the majority of cases the CSS agreements should maintain or enhance the environment in terms of ecology, landscape, and landscape history and increase public enjoyment of the countryside. Thirty-six percent of agreements showed high additionality and 38% medium additionality which demonstrates that the CSS is likely to provide a benefit to society. Agreement negotiation, predicted environmental effectiveness and predicted compliance all improved significantly over the period 1996-98. Recommendations made from this project have been implemented by the Government department to improve the CSS. The multi-disciplinary method was successful and, with further development, could be used for assessment of any agri-environment scheme, or potentially any conservation project or broader 'rural development' scheme encompassing environmental, economic and social objectives. A key to success is the need for the criteria to be tailored for the project concerned and clearly established at the beginning.

Agriculture↗
PubMed1998

The influence of psychosocial factors, alcohol, drug use on African-American women's high-risk sexual behavior.

OBJECTIVE: The present study examines psychosocial and behavioral influences, particularly drug and alcohol use, as correlates of inconsistent condom use and having multiple sexual partners during the past months among African-American women. METHODS: The cross-sectional study, conducted between May and June 1996, recruited a convenience sample of 180 African-American women in Birmingham, Alabama. Women completed a face-to-face interview that assessed alcohol and drug use, sexual behaviors, depression, condom use, and negotiation skills. RESULTS: The majority of women, 51.6% (n = 93), had used either alcohol or drugs during the previous month. Many women, 31.1%, consumed alcohol, 18.3% used marijuana, and 8.3% had smoked crack within the past month. Nearly 42.7% of women used condoms inconsistently in the past month and 13.3% of women had multiple sexual partners within the past month. A logistic regression model predicting inconsistent condom use indicated that women were less likely to use condoms if they consumed alcohol between 20 and 30 days of the month (OR = 2.8, 90% CI = 1.3-5.9) and if they had not negotiated condom use (OR = 32.4, 90% CI = 7.9-131.6). The logistic regression model predicting multiple sexual partners indicated that women were more likely to have multiple sexual partners if they had smoked crack in the past month (OR = 5.3, 90% CI = 1.6-18.2). CONCLUSION: HIV sexual risk-reduction interventions for African-American women need to address the overlapping epidemics of drugs, alcohol, and STDs. Additionally, HIV sexual risk reduction efforts should be incorporated into existing drug and alcohol treatment programs and STD clinics.

Adult↗
PubMed1999

Public/private partners. Key factors in creating a strategic alliance for community health.

BACKGROUND: The rapidly evolving American health system creates economic and societal incentives for public and private health organizations to collaborate. Despite the apparent benefits of collaboration, there is a paucity of information available to help local agencies develop partnerships. This study, itself a collaboration between a school of public health (SPH) and a Georgia health district, was undertaken to identify critical factors necessary to successfully initiate and sustain a public/private community health collaboration. METHODS: Professional staff at the SPH conducted 26 standardized interviews involving participants from Cobb and Douglas counties Boards of Health; Promina Northwest (now known as Wellstar), a not-for-profit health system; and community stakeholders. Content analysis of each interview question was performed and comparisons were made both within each group and across groups. RESULTS: Trends were identified in the following key areas: vision of health care for Cobb and Douglas counties, forces driving collaboration, strengths of each organization, critical negotiating issues, and potential community gain resulting from the partnership. CONCLUSION: A shared vision between potential collaborators facilitates communication regarding strategies to achieve common goals. A previous history of working together in limited capacities allowed the partners to develop trust and respect for one another prior to entering negotiations. These factors, when taken in conjunction with each organization's strong leadership and knowledge of the community, build a strong foundation for a successful partnership.

Community Health Centers↗
PubMed2003

Automated monitoring of medical protocols: a secure and distributed architecture.

The control of the right application of medical protocols is a key issue in hospital environments. For the automated monitoring of medical protocols, we need a domain-independent language for their representation and a fully, or semi, autonomous system that understands the protocols and supervises their application. In this paper we describe a specification language and a multi-agent system architecture for monitoring medical protocols. We model medical services in hospital environments as specialized domain agents and interpret a medical protocol as a negotiation process between agents. A medical service can be involved in multiple medical protocols, and so specialized domain agents are independent of negotiation processes and autonomous system agents perform monitoring tasks. We present the detailed architecture of the system agents and of an important domain agent, the database broker agent, that is responsible of obtaining relevant information about the clinical history of patients. We also describe how we tackle the problems of privacy, integrity and authentication during the process of exchanging information between agents.

Artificial Intelligence↗
PubMed2001

Motion of the whole body's center of mass when stepping over obstacles of different heights.

Tripping over obstacles and imbalance during gait were reported as two of the most common causes of falls in the elderly. Imbalance of the whole body during obstacle crossing may cause inappropriate movement of the lower extremities and result in foot-obstacle contact. Thus, this study was performed to investigate the effect of obstacle height on the motion of the whole body's center of mass (COM) and its interaction with the center of pressure (COP) of the stance foot while negotiating obstacles. Six healthy young adults were instructed to perform unobstructed level walking and to step over obstacles of heights corresponding to 2.5, 5, 10, and 15% of the subject's height, all at a comfortable self-selected speed while walking barefoot. A 13-link biomechanical model of the human body was used to compute the kinematics of the whole body's COM. Stepping over the higher obstacles resulted in significantly greater ranges of motion of the COM in the anterior-posterior and vertical directions, a greater velocity of the COM in the vertical direction, and a greater anterior-posterior distance between the COM and COP. In contrast, the motion of the COM in the medial-lateral direction was less likely to be affected when negotiating obstacles of different heights.

Accidental Falls↗
PubMed2004

Characteristics of stepping over an obstacle in community dwelling older adults under dual-task conditions.

Previous research suggests that older adults may have difficulty attending to simultaneous tasks. This study was conducted to determine how concurrent performance of a secondary cognitive task influences walking and stepping over an obstacle in community dwelling older adults. Twenty-one men and women with a mean age of 73.4 years (S.D.=5.3) participated in the study. Subjects performed a gait task both alone (single-task condition) and in combination with a cognitive task that involved reciting numbers (dual-task condition). In the gait task, each subject walked at his/her fastest speed along a 10-m walkway and stepped over an obstacle designed to simulate a door threshold. Paired t-tests were used to compare gait parameters (10 m gait speed, gait speed during obstacle approach and negotiation, medial-lateral center of pressure excursion and velocity during obstacle negotiation, foot clearance over the obstacle, step length and foot position relative to the obstacle) and cognitive task performance under single and dual-task conditions. Toe-obstacle distance was greater and obstacle-heel distance was reduced under dual-task conditions. Performance of the remaining gait parameters did not change with the addition of a secondary cognitive task. Cognitive task performance decreased under dual-task conditions. These community dwelling older adults demonstrated minimal or no change in measured gait parameters during simultaneous performance of a cognitive task. The observed decrement in cognitive task performance suggests that subjects may have placed a higher priority on gait performance.

Aged↗
PubMed2004

Sexuality and women's rights in armed conflict in Sri Lanka.

The discourse of human rights in armed conflict situations is well adapted to respond to violence and violation, invoking internationally agreed principles of civil and political rights. However, in areas where the subject or domain of rights discourse is contested or controversial, human rights advocates appear less prepared to promote and defend such rights. Sexuality is one such domain. This paper explores the complex sexual choices women in Sri Lanka have had to negotiate, particularly widows and sex workers, within a context of ethnic conflict, militarisation and war. It argues that sexuality cannot be defined exclusively in terms of violation, even in a context dominated by violence, and that the sexual ordering of society may be subverted in such conditions. Newly widowed women and sex workers have had to negotiate self-determination as well as take responsibility for earning income and heading households, in spite of contrary community pressures. For women, political and economic rights are closely linked with the ability to determine their sexual and reproductive choices. The challenge to women's and human rights advocates is how to articulate sexual autonomy as a necessary right on a par with others, and strategise to secure this right during armed conflict and postwar reconstruction.

Adaptation, Psychological↗
PubMed2002

Psychosocial and behavioral correlates of refusing unwanted sex among African-American adolescent females.

PURPOSE: To identify psychosocial and behavioral correlates of refusing unwanted sex among African-American female adolescents. We hypothesized that greater power in relationships, less concern about negative emotional consequences, supportive family and peers, positive self-perceptions, greater perceived risk, and fewer sexual risk behaviors would be associated with increased odds of refusing unwanted sex. METHODS: Data regarding demographics, sexual behaviors, communication with parents, and psychosocial factors relevant to romantic and sexual partnerships were collected both via self-administered questionnaire and structured interview from a clinic- and school-based sample of 522 African-American adolescent females ages 14-18 years in Birmingham, Alabama. Adjusted odds ratios were calculated using logistic regression. RESULTS: Of those who had experienced pressure for unwanted sex (n = 366), 69% consistently refused to engage in unwanted sex. Adolescents with high safer sex self-efficacy and low perceived partner-related barriers (i.e., concerns about partners' negative emotional reactions) to condom negotiation were over 2.5 times more likely to consistently refuse unwanted sex than were those reporting low safer sex self-efficacy and high partner-related barriers. Adolescents who spoke more frequently with their parents about sexual issues were nearly twice as likely to consistently refuse unwanted sex than were those who spoke less frequently with their parents. CONCLUSIONS: Sexual-risk reduction efforts directed toward adolescent females should seek to build self-efficacy to negotiate safer sex and provide training in social competency skills that may help to reduce or eliminate partner barriers to condom use. Further, sexual risk-reduction programs may be more effective if they include parents as advocates of safer sexual behaviors.

Adolescent↗
PubMed2003

Religiosity and risky sexual behavior in African-American adolescent females.

PURPOSE: To examine the association between religiosity (defined by frequency of engaging in religious/spiritual activities) and African-American adolescent females' sexual behaviors, attitudes toward sex, and ability to negotiate safer sex. METHODS: Between December 1996 and April 1999, 1130 female adolescents were screened for eligibility in a sexually transmitted disease (STD)/human immunodeficiency virus (HIV) prevention trial. Data collection was achieved through a confidential self-administered questionnaire that examined religiosity and a structured interview regarding sexual behavior. Descriptive statistics were used to characterize the sociodemographics of the sample and logistic regression was used to measure the association between religiosity and the outcome variables. RESULTS: In the study sample (n = 522), 64% of the adolescents had higher religiosity scores based on a 4-item scale (alpha =.68). Results indicate that adolescents who had higher religiosity scores were significantly more likely to have higher self-efficacy in communicating with new, as well as steady male partners about sex; about STDs, HIV, and pregnancy prevention; and in refusing an unsafe sexual encounter. These adolescents were also more likely to have initiated sex at a later age, used a condom in the past 6 months, and possess more positive attitudes toward condom use. CONCLUSIONS: Results from this study indicate a relationship between religiosity and sexual behaviors, attitudes toward sex, and ability to negotiate safer sex.

Adolescent↗
PubMed1999

Is the societal perspective in cost-effectiveness analysis useful for decision makers?

BACKGROUND: The U.S. Public Health Service's Panel on Cost-Effectiveness in Health and Medicine recommends that cost-effectiveness analyses (CEAs) intended to help allocate health resources in the public interest include a reference case analysis, conducted from the perspective of society as a whole. This perspective requires that an analysis measure all health effects and changes in resource use caused by an intervention. VALUE OF SOCIETAL CEAs: Tensions unavoidably arise among the parties to medical decisions--patients, their families and friends, clinicians, and third-party payers. One common approach to handling these tensions is to ignore some of them, to "solve" them by pretending they do not or should not exist. Patients do this when they demand the best care for themselves without regard to the cost to others, payers when they make coverage decisions that shift costs ot others. But by estimating all gains and losses, calculations that reflect the safety, effectiveness, and side effects of an intervention as well as its costs, societal CEAs can help resolve those tensions and provide the basis for decisions that are fair to all parties, an agenda for negotiating such decisions, and information essential for designing compensation and incentives to support them. MAKING BETTER USE OF SOCIETAL CEAs: Use of the societal perspective asks that all parties be aware of and consider the interests of others. Some process or procedure needs to be developed for presenting CEA information to the parties most likely to be affected by decisions, soliciting their views, and negotiating an acceptable decision. This process could be used by government decision makers or by managed care organizations, professional societies, or payers.

Attitude to Health↗
PubMed2004

Birth planning--is it beneficial to pregnant women?

The aim of this study was to investigate the experience of birth planning for pregnant women. Research in Australia and overseas has suggested that there are a number of conflicting issues with women's preparation and participation in childbirth. The researcher interviewed forty-two first time mothers in a variety of maternity settings around Victoria to ascertain the importance of birth planning in their approach to childbirth and the ways they went about making their plan and negotiating their needs with health professionals. The data from those interviews demonstrated that the means women used to negotiate their needs for childbirth with health professionals had little influence on their overall pregnancy and birth experience.

Australia↗
PubMed2006

Cost of an informatics-based diabetes management program.

OBJECTIVES: The relatively high cost of information technology systems may be a barrier to hospitals thinking of adopting this technology. The experiences of early adopters may facilitate decision making for hospitals less able to risk their limited resources. This study identifies the costs to design, develop, implement, and operate an innovative informatics-based registry and disease management system (POPMAN) to manage type 2 diabetes in a primary care setting. METHODS: The various cost components of POPMAN were systematically identified and collected. RESULTS: POPMAN cost 450,000 dollars to develop and operate over 3.5 years (1999-2003). Approximately 250,000 dollars of these costs are one-time expenditures or sunk costs. Annual operating costs are expected to range from 90,000 dollars to 110,000 dollars translating to approximately 90 dollars per patient for a 1,200 patient registry. CONCLUSIONS: The cost of POPMAN is comparable to the costs of other quality-improving interventions for patients with diabetes. Modifications to POPMAN for adaptation to other chronic diseases or to interface with new electronic medical record systems will require additional investment but should not be as high as initial development costs. POPMAN provides a means of tracking progress against negotiated quality targets, allowing hospitals to negotiate pay for performance incentives with insurers that may exceed the annual operating cost of POPMAN. As a result, the quality of care of patients with diabetes through use of POPMAN could be improved at a minimal net cost to hospitals.

Costs and Cost Analysis↗
PubMed2003

Impact of technical difficulties, choice of catheter, and the presence of blood on the success of embryo transfer--experience from a single provider.

PURPOSE: To investigate the impact of technical difficulties, choice of catheter, and the presence of blood during embryo transfer on the results of in vitro fertilization and ICSI. METHODS: A cohort of 784 consecutive cycles in 655 in vitro fertilization and ICSI patients were studied. RESULTS: Negotiating the cervix, using the volsellum, presence of blood on the catheter wall or on the cervix did not affect the results. Changing the catheter and blood on the catheter tip reduced the pregnancy (P < 0.05 and P < 0.05) and implantation rates (P < 0.001 and P < 0.01). The Ultrasoft catheter produced higher pregnancy (P < 0.0005) and implantation rates (P < 0.01) compared to the more rigid Frydman catheter. CONCLUSIONS: Negotiation of the cervix, the use of a volsellum, and the presence of blood on the catheter wall or on the cervix do not affect the results. Changing the catheter and blood on the catheter tip significantly diminish the pregnancy and implantation rates. Soft catheters perform better.

Blood Loss, Surgical↗
PubMed2002

The ground of dialogical bioethics.

Dialogical ethics are a procedural alternative to substantive ethics such as consequentialism, deontology, principlism, casuistry, virtue ethics and care ethics. Dialogical ethics are procedural in that they do not establish goods in advance, unlike substantive ethics, but rather determine goods through a procedure enacted by the actual parties involved (although some substantive notion of justice may still be required); and they are dialogical in that the procedure is that of dialogue, involving both empathic critical discussion and negotiation. A fundamental tenet of dialogical ethics may be the use of appropriate rules of order regulating dialogue among the parties involved. Some of the central characteristics of such rules of order are that they are reciprocally regulated by dialogue, that they override other ethical considerations, and that they institute empathic critical discussion and negotiation within the ethical dialogue. Dialogical bioethics are the application of dialogical ethics to ethical problems in medicine. The approach of dialogical bioethics has proven fruitful for resolving bioethical problems such as that of medical futility, where approaches of substantive ethics have reached an impasse. There is room for further study of special challengeswithin dialogical bioethics, such as the incompetence of some involved parties, conflicts of interests of third parties, and the cost-effectiveness of this ethical approach.

Bioethics↗
PubMed2004

Effects of alcohol and expectancies on HIV-related risk perception and behavioral skills in heterosexual women.

This experiment tested the effects of alcohol and expectancies on determinants of safer sex according to the information-motivation-behavioral skills model. Sixty heterosexual women attended 2 sessions. During Session 1, participants completed a set of descriptive measures; during Session 2 they were randomly assigned to 1 of 4 beverage conditions: control, alcohol-low (.35 gm alcohol/kg body weight), alcohol-moderate (.70 gm alcohol/kg body weight), or placebo. After beverage consumption, all participants completed measures of motivation to engage in risky sex and condom use negotiation skills. Results showed that the higher dose of alcohol and stronger alcohol expectancies were associated with greater motivation to engage in risky sexual behavior. However, perceived intoxication, rather than actual alcohol consumption or expectancies, was the best predictor of condom use negotiation skills. Integration of the findings with past research and their implication for the design of HIV-prevention programs are discussed.

Adult↗
PubMed1993

Recommendations concerning the costing and management for patients requiring domiciliary ventilation.

Reinstallation back in their own homes of severely disabled people who are ventilator dependent is increasingly becoming a viable trend. Such a development calls for detailed and imaginative planning and negotiations with several agencies. More than a decade of experience in Southport has highlighted the need for early and comprehensive negotiations to ensure that these profoundly disabled people are not denied a quality of life to which they are entitled and which advances in technology has made possible.

Costs and Cost Analysis↗
PubMed2001

Effects of endodontic instrument handle diameter on electromyographic activity of forearm and hand muscles.

AIM: To determine the influence of the handle diameter of endodontic instruments on forearm and hand muscle activity using electromyographic (EMG) recording. METHODOLOGY: Size 45 K-type files were fitted with four different handle diameters; 3.5, 4.0, 5.0, and 6.0 mm. Seven dentists then attempted to negotiate to the working length acrylic resin root canals with each of the four handle sizes using a reaming motion. EMG activities were recorded from the flexor pollicis brevis muscle (f.p.b.), the flexor carpi radialis muscle (f.c.r.), and the brachioradialis muscle (b) with bipolar surface electrodes. The time taken to negotiate the canals, the area of integrated EMG that corresponded to the amount of EMG activity required during penetration and the maximum amplitude of EMG were measured using the EMG data. Results were analysed statistically using a one-way factorial ANOVA test and multiple comparison tests. RESULTS: Reaming time and integrated EMG area of each muscle decreased with an increase in handle diameter. The most significant difference in time and area of integrated EMG was detected between handles of 6 mm and 3.5 mm diameter (time: P < 0.01, area of the f.p.b.: P < 0.01, area of the f.c.r. and b: P < 0.05), and between handles of 5 mm and 3.5 mm diameter (P < 0.05). Both 5 mm and 6 mm handles significantly decreased the maximum amplitude of EMG recorded from the f.p.b. compared with 3.5 mm handles (between 3.5 mm and 6 mm: P < 0.01, between 3.5 mm and 5 mm: P < 0.05). CONCLUSION: The results indicate that handle diameter has an effect on reaming time as well as on muscle activity. As a consequence, handle diameter influenced operator performance during instrumentation.

Acrylic Resins↗

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