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PubMed2006

The impact of economic activity in Asturias on greenhouse gas emissions: consequences for environmental policy within the Kyoto Protocol framework.

Climate change is one of the major worldwide environmental concerns. It is especially the case in many developed countries, where the greenhouse gas emissions responsible for this change are mainly concentrated. For the first time, the Kyoto Protocol includes an international agreement for the reduction of the net emissions of these gases. To fulfil this agreement measures designed to reduce or limit current emissions have to be brought into force. Consequently, fears have arisen about possible consequences on competitiveness and future development of manufacturing activities and the need for support mechanisms for the affected sectors is obvious. In this paper, we carry out a study of the emissions of gases responsible for climate change in Asturias (Spain), a region with an important economic presence of sectors with intensive emissions of CO(2), the chief greenhouse gas. To be precise, in the first place, the volumes of direct emissions of the said gases in 1995 were calculated, showing that the sectors most affected by the Kyoto Protocol in Asturias are iron and steel and electricity production. Secondly, input-output analysis was applied to determine the direct and indirect emissions and the direct, indirect and induced emissions of the different production sectors, respectively. The results derived from the direct and indirect emissions analysis and their comparison with the results of the former allow us to reach some conclusions and environmental policy implications.

Air Pollution↗
PubMed2006

How much can treatment reduce national drug problems?

AIMS: Treatment of drug addiction has been the subject of substantial research and, in contrast to several other methods of reducing drug use, has been found to be both effective and cost-effective. This review considers what is known about how much a nation can reduce its drug problems through treatment alone and what is known at the aggregate level about the effectiveness of prevention and enforcement. METHODS: The literature on the effectiveness of treatment, prevention and enforcement are reviewed, and set in a policy analytical framework. FINDINGS: Many studies have found treatment to have large effects on individuals' consumption and harms. However, there is an absence of evidence that even relatively well-funded treatment systems have much reduced the number of people in a nation who engage in problematic drug use. For prevention, the scientific literature shows useful and modest effects at the individual level but there is little support for substantial aggregate effects. For enforcement, research has failed almost uniformly to show that intensified policing or sanctions have reduced either drug prevalence or drug-related harm. Nor-outside the UK-is there more than a modest effort to improve the evidence base for making decisions about the appropriate level of enforcement of drug prohibitions. CONCLUSIONS: Treatment can justify itself in terms of reductions in harms to individuals and communities. However, even treatment systems that offer generous access to good quality services will leave a nation with substantial drug problem. Finding effective complementary programs remains a major challenge.

Harm Reduction↗
PubMed1996

The chlorine controversy.

Environmental groups have called for a phaseout of the use of chlorine in industrial chemistry on the grounds that such use inevitably leads to the production of persistent, bioaccumulative toxins. This policy prescription is based on an application of the Precautionary Principle which holds that industry should demonstrate that its products and processes are safe before allowing releases of product or waste into the environment. The chemical industry has rejected the call to phaseout chlorine, and claims that available data on either the environmental exposure pathways or the toxicology of chlorinated compounds are inadequate to support responsible decision-making. Industry leaders have called for environmental policy to be based on sound science, comparative risk assessment, and cost-benefit analysis. The controversy over chlorine shows that the U.S. environmental policy-making framework may no longer be capable of producing solutions to environmental problems that satisfy important constituencies within our society.

Animals↗
PubMed2005

Training nurses and social workers in smoking cessation counseling: a population needs assessment in Hong Kong.

BACKGROUND: To achieve greater coverage of elderly smokers and to shift entire populations toward cessation, the provider-client interface could be broadened beyond physicians to include nurses and social workers, who can be formally trained to provide such services. We carried out a population-based training needs assessment of the latter two groups in Hong Kong. METHODS: Three thousand seven hundred eligible hospital-based nurses and 2,258 social workers who had elderly clients in Hong Kong were recruited in a knowledge, attitude, and practice (KAP) cross-sectional survey. We used multivariable logistic regression to identify predictors for two key outcomes-"initiation and advice" (ask and advise) and "follow-through" (assess, assist and arrange), based on the U.S. Agency for Health Care Policy Research framework. RESULTS: One thousand eight hundred forty-three (49.8%) nurses and 1,499 (66.4%) social workers responded. Nurses reported a much higher level of engagement in smoking cessation activities than social workers in all five steps of the AHCPR framework (P<0.001). Nurses (mean score=2.99+/-0.40 on a 4-point Likert scale) had more positive attitudes to tobacco control and smoking cessation counseling compared to social workers (mean score=2.79+/-0.41; P<0.001), whereas the latter group perceived themselves as more competent in handling such practice (mean score(nurses)=2.36+/-0.52, mean score(social workers)=2.51+/-0.39; P<0.001). Both attitudinal and self-perceived competence scores predicted incremental gains in the likelihood of offering "follow-through" interventions in addition to those observed for "initiation and advice" actions. CONCLUSION: Our findings highlight a large degree of unmet need in Hong Kong's hospital-based nurses and social workers who work with the elderly regarding smoking cessation service provision and training. Future research should focus on developing and evaluating programs that encourage nurses and social workers to provide cessation interventions to exert a much greater collective impact than doctors can alone.

Adult↗
PubMed1986

Radiation protection programs in nuclear medicine.

The development of radiation protection programs in nuclear medicine has been stimulated by the greater degree of regulation that exists in this form of medical imaging. A program within an institution will depend on the amount and type of work to be undertaken, the resources available, and the commitment of the individuals involved. These factors may be part of a licensing program or exist within a broader framework. General policy may be set forth in a manual or guidelines distributed to all employees. The continuing review and development of policy is the function of the institutional committee on radiation. This review must consider patients and workers with the objective of reducing overall dose while obtaining the maximum amount of clinical information. The responsibility for radiation protection is shared by the institution, the licensee, and the individual employee.

Humans↗
PubMed1996

High technology near the end of life: setting limits.

High technology interventions near the end of life exact a high cost both in human and economic terms. Breathtaking advances in cardiology have helped to prolong life and improve its quality for many. For some, it has transformed the process of dying into a medical nightmare. The "do everything possible" attitude that prevailed during the past few decades is both inhumane and wasteful. In contrast, in the new era of managed care with its focus on profit, a well meaning physician may become suspect whenever he recommends against a medical intervention that he deems to be futile. More than ever before, there is a pressing need to develop rational guidelines for end of life medical interventions to ensure primacy of patients' best interests, protect the integrity of the doctor-patient relationship and affirm the duty of the medical establishment toward society at large. This weighty issue must not be relinquished to medical ethicists, health care alliances or the courts. It is the domain of physicians and the public at large. Medical futility should be defined as a treatment unlikely to affect the course of illness or that which has failed to achieve its desired effects. Rational guidelines for cardiopulmonary resuscitation and do not resuscitate orders should be formulated for both inhospital and out of hospital victims of cardiac arrest. These guidelines need to be developed through a process similar to those for the treatment of unstable angina, with involvement from all relevant medical specialities. Proposed guidelines must be negotiated, reviewed and ratified by the lay public. Appropriate legislation is necessary to establish the framework and policies to carry out agreed on recommendations. The focus of the "living will" should change so that it covers the last chapter of life rather than its terminal phase. The document should serve to express the person's wishes regarding specific medical interventions when the quality of life is seriously diminished beyond what is uniquely desirable for the particular patient. Living wills must be comprehensive, clear and specific. They must be honored. The Uniform Health Decisions Act, now pending legislation, should enhance the utility of the living will.

Ethics, Medical↗
PubMed2004

Induced abortion in Thailand: current situation in public hospitals and legal perspectives.

Abortion is illegal in Thailand unless the woman's health is at risk or pregnancy is due to rape. This study, carried out in 1999 in 787 government hospitals, examined the magnitude and profile of abortion in Thailand, using data collected prospectively through a review of 45,990 case records (of which 28.5% were classified as induced and 71.5% as spontaneous abortions) and face-to-face interviews with a sub-set of 1854 women patients. The estimated induced abortion ratio was 19.5 per 1000 live births. Almost half the induced abortions were in young women under 25 years of age, many of whom had little or no access to contraception. Socio-economic reasons accounted for 60.2% of abortions. Serious complications were observed in almost a third of cases, especially following abortions performed by non-health personnel. Government physicians' current provision of induced abortion went beyond the provisions of the law in almost half of cases, most commonly for intrauterine death and for congenital anomalies. The paper proposes a framework for policy discussions of the grey areas of maternal and fetal indications leading to legal reform, in order to facilitate safe abortion. A recommendation to amend the abortion law has been proposed to the Ministry of Public Health and the Thai Medical Council.

Abortion, Induced↗
PubMed2001

Single-market regulation and innovation in Europe's medical devices industry.

In this article we analyze the influence of the legal regulatory framework in Europe, established by the two directives on medical devices and active implantable devices, on the performance of innovation in a single European market. First, we describe in general the possible influence of a single European market on innovation and the institutional features of the particular harmonization approach ("New Approach") we are looking at here. The empirical results presented derive from a survey investigation involving 150 firms that we defined as best innovators in the European medical devices industry from a pre-survey. The results confirm that the total impact of the New Approach regulation on firms' innovation in the long term is positive. However, it also becomes clear that the impact of regulation on innovation is limited if the factors are looked at individually and that there is a clear difference regarding short-term effects. To improve the regulatory framework, several policy actions are recommended.

Data Collection↗
PubMed2003

Restructuring a ministry of health - an issue of structure and process: a case study from Uganda.

This paper analyzes the recently undertaken restructuring of the Ministry of Health in Uganda, which was carried out because the previous structure did not comply well with the decentralization framework or policy. The Ministry was put under pressure by higher political levels, supported by the donor community, to restructure. The paper describes the principles that were guiding this operation, and assesses whether these principles relate to the final outcome and whether the outcome was actually as expected. This paper also analyzes the reasons for the achieved, or not achieved, results and suggests the way forward. The outcome of the restructuring procedure in terms of change in number of employees was small. The foundation, in terms of a certain structure, has been laid for the Ministry of Health to function in its new role as a coach more than a player, but the work to establish a functioning process is far from complete. The issue is to make actors at various levels relate to each other, and thereby establish appropriate processes within the existing structure that will help the Ministry develop into a dynamic body. The importance of finding forms for interaction, involving face-to-face relationships between the Ministry and service delivery level, is stressed.

Attitude of Health Personnel↗
PubMed2005

Quality-based payment: six case examples.

INTRODUCTION: The logic of paying more for high-quality care and less for low-quality resonates. Increasingly health system leaders worldwide acknowledge that payment reforms are needed to do just that, prompted no doubt by the growing body of evidence indicating that quality is not what it should be. PURPOSE: This review was undertaken to explore contexts in which quality-based payment appears feasible. The ultimate intent is to provoke thoughtful debate about whether and how quality-based payment might fit within a particular developing country's framework of policies to ensure and promote quality of care. METHODS: With guidance from key informants with first-hand knowledge of international quality-based payment schemes, a purposive sample of six quality-based payment schemes was assembled. Schemes were examined to identify environmental contexts and design features. RESULTS: Examples illustrate a variety of approaches and a breadth of contexts in which quality-based payment has been implemented. Contrary to what might be expected, implementation does not appear to be constrained to private-sector purchasers, private-sector providers, hospital settings, nor to any particular type of underlying payment system. Further, quality-based payment pioneers are using a variety of incentive structures, and are tapping a rich mix of structural, process, and outcome standards to benchmark quality. CONCLUSION: Despite significant operational challenges, quality-based payment has been implemented in developing as well as developed countries, albeit not frequently in either instance. What we do not know--what the literature is nearly silent on--relates to the sustainability and ultimate impact of alternative incentive schemes.

Benchmarking↗
PubMed2006

Clinician perceptions of personal safety and confidence to manage inpatient aggression in a forensic psychiatric setting.

Inpatient mental health clinicians need to feel safe in the workplace. They also require confidence in their ability to work with aggressive patients, allowing the provision of therapeutic care while protecting themselves and other patients from psychological and physical harm. The authors initiated this study with the predetermined belief that a comprehensive and integrated organizational approach to inpatient aggression was required to support clinicians and that this approach increased confidence and staff perceptions of personal safety. To assess perceptions of personal safety and confidence, clinicians in a forensic psychiatric hospital were surveyed using an adapted version of the Confidence in Coping With Patient Aggression Instrument. In this study clinicians reported the hospital as safe. They reported confidence in their work with aggressive patients. The factors that most impacted on clinicians' confidence to manage aggression were colleagues' knowledge, experience and skill, management of aggression training, use of prevention and intervention strategies, teamwork and the staff profile. These results are considered with reference to an expanding literature on inpatient aggression. It is concluded that organizational resources, policies and frameworks support clinician perceptions of safety and confidence to manage inpatient aggression. However, how these are valued by clinicians and translated into practice at unit level needs ongoing attention.

Adaptation, Psychological↗
PubMed1999

Reimbursement to advanced practice nurses (APNs) through Medicare.

PURPOSE: To analyze why U.S. legislation for direct Medicare reimbursement to advanced practice nurses (APNs) was approved during the 105th congressional session. Help in understanding the complexities of policy making and in strategizing future policy activities is needed. Given their vast numbers, nurses are a formidable group with potential to influence policy. ORGANIZING CONSTRUCT: Kingdon's (1995) framework indicates that policy formation involves constant interaction among participants and the problem, its politics, and policy. When a policy is enacted into legislation, the three come together and an opportunity for policy formation exists, if even for a short period. Methods for data extraction included telephone interviews, information provided by the American Nurses Association (ANA), and information from the internet to access information. FINDINGS: Lack of access to health care by Medicare beneficiaries, tagging a policy proposal onto the Balanced Budget Act of 1997, the national mood to provide cost-effective quality care, and lobbying by interest groups helped to make direct Medicare reimbursement for advanced practice nurses a reality. CONCLUSIONS: When lobbying for the enactment of legislation, nurses should decrease their tendency to fragment. Nurses should be more effectively organized and concentrate on specific agendas. Working together can influence policy and change clinical situations to improve patient care.

Health Policy↗
PubMed2003

Bach to the future: response to: Extending preimplantation genetic diagnosis: medical and non-medical uses.

Professor Robertson sketches an elegant framework for policy evaluation and regulation of the use of preimplantation genetic diagnosis for various medical, medical related, and non-medical purposes. In criticism of his position, I argue that the distinction between policy and ethics upon which his argument relies is highly unstable, and the approach taken to ethical evaluation of particular parental interests leaves open many issues which the policy approach would hope to exclude. In conclusion I argue that while his position ultimately fails, the onus is on his critics to come up with a viable and satisfying alternative.

Attitude to Health↗
PubMed2005

[The conquest for non-smoking zones confronted with industry tactics: scientific misinformation and front groups. The Canadian experience].

"Cigarette smuggling: a wide scope phenomenon only there to serve the interests of big tobacco manuafacturers" uses industry officials' quotes and documents to describe how tobacco manufacturers are involved in the organisation of smuggling and how manufacturers use smuggling in two ways: on one hand, to flood markets with cheap cigarettes and defeat governements' efforts to reduce tobacco consumption by adopting one of the most efficient public health measures (ie: high taxation of tobacco products) and on the other hand, by using the false threat of increased contraband to scare politicians and prevent them from adopting strong fiscal policies. The Framework Convention on Tobacco Control (FCTC) with a protocol on smuggling and the collaboration between international agencies is a means to counter and defeat the tobacco industry attemps at sabotaging efficient public health measures.

Canada↗
PubMed2005

[Cigarette smuggling: a wide scope phenomenon only there to serve the interests of big tobacco manufacturers].

"Cigarette smuggling: a wide scope phenomenon only there to serve the interests of big tobacco manuafacturers" uses industry officials' quotes and documents to describe how tobacco manufacturers are involved in the organisation of smuggling and how manufacturers use smuggling in two ways: on one hand, to flood markets with cheap cigarettes and defeat governements' efforts to reduce tobacco consumption by adopting one of the most efficient public health measures (ie: high taxation of tobacco products) and on the other hand, by using the false threat of increased contraband to scare politicians and prevent them from adopting strong fiscal policies. The Framework Convention on Tobacco Control (FCTC) with a protocol on smuggling and the collaboration between international agencies is a means to counter and defeat the tobacco industry attemps at sabotaging efficient public health measures.

Commerce↗
PubMed2005

Emergency contraception for sexual assault victims: an advocacy coalition framework.

A bill was introduced into the Tennessee legislature in the 2005 session that would require emergency departments to offer and dispense emergency contraception to sexual assault survivors who are at risk of pregnancy. Several advocacy groups collaborated to form the Women's Health Safety Network for the purpose of communicating as one voice. The advocacy coalition framework of policy development is applied to the political system and is used as a model to discuss issues impacting policy development for this particular bill. Key actors, proponents, and opponents to this bill are presented along with constraints to policy acceptance. The challenge for emergency contraception advocates on a state and national level is to keep the focus on public health science, the health and well-being of women, and out of the abortion debate.

Catholicism↗