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PubMed2001

Ecological conceptual models: a framework and case study on ecosystem management for South Florida sustainability.

The Everglades and South Florida ecosystems are the focus of national and international attention because of their current degraded and threatened state. Ecological risk assessment, sustainability, and ecosystem and adaptive management principles and processes are being used nationally as a decision and policy framework for a variety of types of ecological assessments. The intent of this study is to demonstrate the application of these paradigms and principles at a regional scale. The effects-directed assessment approach used in this study consists of a retrospective, eco-epidemiological phase to determine the causes for the current conditions and a prospective predictive risk-based assessment using scenario analysis to evaluate future options. Embedded in these assessment phases is a process that begins with the identification of goals and societal preferences which are used to develop an integrated suite of risk-based and policy relevant conceptual models. Conceptual models are used to illustrate the linkages among management (societal) actions, environmental stressors, and societal/ecological effects, and provide the basis for developing and testing causal hypotheses. These models, developed for a variety of landscape units and their drivers, stressors, and endpoints, are used to formulate hypotheses to explain the current conditions. They are also used as the basis for structuring management scenarios and analyses to project the temporal and spatial magnitude of risk reduction and system recovery. Within the context of recovery, the conceptual models are used in the initial development of performance criteria for those stressors that are determined to be most important in shaping the landscape, and to guide the use of numerical models used to develop quantitative performance criteria in the scenario analysis. The results will be discussed within an ecosystem and adaptive management framework that provides the foundation for decision making.

Animals↗
PubMed2003

Moving towards integrated working in health and social care in Scotland: from maze to matrix.

The development of integrated working across health and social care has featured strongly in recent policy directives in both England and Scotland. This is part of a wider agenda of partnership and collaboration, with a range of options from the creation of unified structures as in the care trusts in England to localised arrangements for joint working between individual professionals. This article presents a detailed matrix of drivers and barriers to integrated working which has been developed through a number of case studies of community care practice pursued as part of work undertaken for the Joint Future Group of the Scottish Executive. Drivers and barriers in three key areas are highlighted: national policy frameworks, the local planning context, and operational factors. It is anticipated that the matrix should provide a useful framework for the detailed scrutiny and operationalisation of integrated working.

Delivery of Health Care, Integrated↗
PubMedDate not supplied

Nurse practitioner research: selected literature review and research agenda.

Selected literature is reviewed to illustrate current conceptual and methodological issues in nurse practitioner research. Concepts of style of practice, acceptance, satisfaction, and outcome are discussed. Methodological issues are linking process to outcome, complexity measures, use of existing data, and the effect of nurse practitioner education and experience on interpretation of findings. A research agenda with two objectives is proposed: studies designed to improve rather than evaluate practice and studies designed with a policy framework in mind.

Clinical Competence↗
PubMed2004

Addressing multiple behavioral risk factors in primary care. A synthesis of current knowledge and stakeholder dialogue sessions.

BACKGROUND: Addressing behavioral risk factors in primary care has become a pressing concern due to the increasing burden of behavioral risk factors on disease, healthcare costs, and public health. Risk factors considered include smoking, risky drinking, sedentary lifestyle, and unhealthy diet-singly or in combination. The already burdened primary care system needs a practical approach to efficiently and effectively address any combination of multiple risk factors. Multiple perspectives and broad insight are urgently needed to gain a deeper understanding of the interacting scientific, systems, and policy issues associated with multiple risk factor interventions (MRFIs). PURPOSE: This paper synthesizes findings from literature reviews, epidemiologic analyses, and structured interactive dialogue sessions, and includes a set of recommendations designed to stimulate further action. METHODS: Several papers were produced to document current knowledge, research evidence, and salient issues related to multiple risk factor assessment and intervention. Structured interactive dialogue sessions were then conducted with clinician, health system, and health policy leaders regarding what advantage or energy would be liberated by a multiple risk factor approach (rather than separate single risk factor approaches), and how to build a policy framework or constituency for MRFIs. This information is synthesized in this paper. RESULTS: There is a clear need to address MRFIs among multiple stakeholders, including patients, purchasers, payers, clinicians, health system leaders, and policy-level stakeholders. MRFIs need to bring with them a compelling value proposition for all stakeholders, and a vision of practical and systematic ways to make it a reality in already-pressed primary care practices. Involving stakeholders in dialogue aimed at helping them see the world through each other's eyes helps overcome discouragement and generates energy for jointly designing new approaches. Recommendations for further action include the creation of multistakeholder dialogue, creation of a policy agenda, development of a translation or integration agenda that connects researchers and practitioners in a two-way exchange, initiation of a series of demonstration projects around MRFIs, and support for research on multiple (rather than only single) risk factor interventions. CONCLUSIONS: The need to address multiple behavioral risk factors in primary care is increasingly urgent. Whereas stakeholders by themselves may be willing to address multiple risk factors, they agree that it can only be done successfully with a collaborative approach. Findings based on evidence reviews, hypotheses generation, and stakeholder dialogue provide guidance for appropriate further action that, based on what is known already, can be initiated right away.

Adult↗
PubMed1999

From ministry orders towards constitutional debate: lessons drawn from the past 50 years of abortion laws in Hungary.

This article is an analytical and chronological review of the changing course of abortion law in Hungary since the end of the second world war. During that period, official attitudes toward abortion, and the legal and policy frameworks that give concrete expression to them, have changed several times, sometimes moving back and forth between restrictiveness and permissiveness. Prof. Sandor examines these developments and situates them within the larger context of Hungarian law and public policy, with a view to illuminating the issues at stake in the current abortion debates going on in Hungary.

Abortion, Illegal↗
PubMed1992

Doctors as managers: poachers turned gamekeepers?

Doctors in health care systems of different types are coming under increasing pressure to take on active roles in management. Mounting concern among governments over the escalating costs of health care, coupled with a desire to improve the quality of care and render services more responsive to user preferences has resulted in management being viewed as offering an effective means of tackling these issues. Until recently, the favoured strategy was to strengthen management in order to curb doctors' discretionary decision-making. There is now a shift towards creating managers out of doctors with all that this implies for the future shape of health services. There are also issues about the training and development required for a management role, the stratification of roles within the medical profession, and the future status of lay, or non-medical managers. The paper reviews the debate about doctors and managers and their distinctive value bases. It suggests that doctors can be involved in management as managers at two levels--meso and micro--and considers the issues raised at each level. The paper presents an analysis of the wider context in which the debate about doctors as managers is taking place. The main thesis put forward is that far from managers incorporating doctors, the end result may prove to be the other way round with 'provider capture' of the management agenda in health services a distinct possibility. In contrast to managers, doctors retain enormous public respect and support. As long as it is so doctors will remain powerful stakeholders in defining and controlling the shape and range of health services available. Their active involvement in management could lead to a strengthening of their position. It is argued that, paradoxically, this could make it more difficult for governments to challenge doctors' work practices. Medicine's traditional preoccupations and its resilience to change are likely to remain as strong as ever thereby disappointing advocates of a health and social care system located in a broader policy framework which emphasises health gain and a holistic approach to health.

Attitude of Health Personnel↗
PubMed1989

Privatization strategy: evolving roles of private sector in Japanese long-term care.

The rapidly increasing financial burden of an aging population and scarce public financial resources require a pragmatic response to reorganize and develop long-term care delivery systems in Japan. Privatization can be one of the most effective and influential countermeasures. Privatization of health providing systems, however, should be implemented in order to increase cost effectiveness and improve productivity. That is, the process of privatization should be designed to better induce the increased reliance on market incentives and management systems without impinging upon equity as a social objective. In an environment of fiscal constraints, market incentives and management systems are the two concepts that can facilitate effective privatization in the provision of quality long-term care. By examining demographic and financial impacts on long-term care, this work analyzes the lack of policy consistency that breaks down national health policy in pursuit of efficiency in macro domain into management systems of individual providers in micro domain. In order to synchronize the consistency of privatization policy with both micro and macro domains, it is necessary for Japanese health providers to change the out-dated management practices to more efficiency-oriented management systems. It is also imperative for policy makers to facilitate the management renewal among providers. Consequently, this paper provides a policy framework for integration of long-term care and the effective involvement of the private sector in the provision of privatization.

Aged↗
PubMed2006

Clinical Governance and evidence-based laboratory medicine.

BACKGROUND: Clinical Governance is described as "a framework through which the NHS organisations are accountable to continue to improve the quality of the service and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish"; it is aimed to ensure continuous improvement in the overall standard of clinical care, ensuring that clinical decisions are based on the most up-to-date evidence in terms of effectiveness. METHODS: If Clinical Governance is a framework through which NHS organisations are accountable to continuously improve the quality of their services and safeguarding high standards of care, Clinical Effectiveness is a vital part of Clinical Governance. Clinical Effectiveness is a term that refers to measuring and monitoring the quality of care, and comprises various activities, including: Evidence-Based Practice, Research and Development, Clinical Audit, Clinical Guidelines, Integrated Care Pathways, and Total Quality Management. RESULTS: The application of evidence-based medicine (EBM) in laboratory medicine or evidence-based laboratory medicine (EBLM) aims to advance clinical diagnosis by researching and spreading new knowledge, combining methods from clinical epidemiology, statistics and social science with the traditional pathophysiological molecular approach. EBLM, by evaluating the role of diagnostic investigations in the clinical decision-making process, can help in translating the results of good quality research into everyday practice. CONCLUSIONS: If Clinical Governance is a framework through which organisations are accountable to improve the quality of care, health professionals should identify high quality standards, and systematically and rigorously monitor against them the process and outcomes that represent the diagnostic process. Within such a policy framework, practice guidelines are expected to play a major role, providing the basis to access the quality of care and guidance where clinical practice is found not in line with professional standards.

Clinical Laboratory Techniques↗
PubMed2004

Public participation in regional health policy: a theoretical framework.

How best to involve the public in local health policy development and decision-making is an ongoing challenge for health systems. In the current literature on this topic, there is discussion of the lack of rigorous evaluations upon which to draw generalizable conclusions about what public participation methods work best and for what kinds of outcomes. We believe that for evaluation research on public participation to build generalizable claims, some consistency in theoretical framework is needed. A major objective of the research reported on here was to develop such a theoretical framework for understanding public participation in the context of regionalized health governance. The overall research design followed the grounded theory tradition, and included five case studies of public participation initiatives in an urban regional health authority in Canada, as well as a postal survey of community organizations. This particular article describes the theoretical framework developed, with an emphasis on explaining the following major components of the framework: public participation initiatives as a process; policy making processes with a health region; social context as symbolic and political institutions; policy communities; and health of the population as the ultimate outcome of public participation. We believe that this framework is a good beginning to making more explicit the factors that may be considered when evaluating both the processes and outcomes of public participation in health policy development.

Canada↗
PubMed1998

Towards new partnerships for health development in developing countries: the contractual approach as a policy tool.

What roles for government but also for society's groups in the advancement of public health in developing countries? This paper focuses on the need to adopt the contractual approach as a powerful policy tool and sketches the contours of a policy framework for good contracting. A short historical review of health system changes leads up to a discussion of the current emergence of a multitude of actors, the forging of alliances between the various partners, examples on how significant health policy benefits might be secured through contracting, and the implications of building alliances, such as defining and assigning accountability to the contracting partners.

Developing Countries↗
PubMed2005

Tobacco control policies and the concurrent use of smokeless tobacco and cigarettes among men, 1992-2002.

Accelerating the decline in smoking prevalence requires an understanding of changes in the concurrent use of and the substitution between different tobacco products, such as smokeless tobacco (SLT) and cigarettes. SLT could play an important role in reducing the toll of smoking-related illness and premature mortality. Research examining the role of tobacco control policies in explaining concurrent use of SLT and cigarettes has been minimal. Using the Current Population Survey Tobacco Use Supplements (CPS-TUS), we examined tobacco control policies in relationship with adult males' SLT use concurrent with smoking over the period 1992-2002. Consistent with the decline in smokeless-only and cigarette-only rates, concurrent use of SLT and cigarettes declined during the period. SLT users, faced with home or workplace smoking bans, are less likely to report smoking. Smokers with a home ban appear more likely to use SLT, but in more recent years, smokers with a workplace ban are less likely to use SLT. Tobacco excise taxes do not signal substitution between cigarettes and SLT products. Understanding current use patterns of the range of tobacco products, including their interaction with available policy levers, is vital in assessing whether changes that might promote substitution of arguably less toxic SLT products for highly toxic cigarettes are likely to lead to net public health gains or losses. Findings of the present study, in concert with other research about transitional probabilities between behavioral states, will inform the design of an effective policy framework that supports the objective of reducing tobacco-related death and disease.

Adult↗
PubMed2002

Law and policy in relation to the use of seclusion in psychiatric hospitals in Australia and New Zealand.

This paper discusses legal issues associated with the seclusion of acutely disturbed patients in psychiatric hospitals in Australia and New Zealand. There continues to be great variation in opinion and operational definition as to whether seclusion is a medical treatment, nursing intervention and management tool, or merely a form of situational restraint. Reflecting this lack of clarity, mental health acts and policies concerning the regulation and practice of seclusion lack consistency and focus across geographical boundaries and jurisdictions. Australian and New Zealand legislation and institutional policy is discussed in order to shed light on the contemporary issues highlighted by this controversial nursing practice. Mental health professionals must continue to review the practice of seclusion and to actively promote the use of acceptable alternatives. In addition nurses and other mental health professionals have a responsibility to understand current legislation and policy frameworks and to influence change where this is necessary to ensure the best practice possible in their clinical area.

Australia↗
PubMed2005

Pediatric use of complementary therapies: ethical and policy choices.

OBJECTIVE: Many pediatricians and parents are beginning to integrate use of complementary and alternative medical (CAM) therapies with conventional care. This article addresses ethical and policy issues involving parental choices of CAM therapies for their children. METHODS: We conducted a literature search to assess existing law involving parental choice of CAM therapies for their children. We also selected a convenience sample of 18 states of varying sizes and geographic locations. In each state, we inquired within the Department of Health and Human Services whether staff were aware of (1) any internal policies concerning these issues or (2) any cases in the previous 5 years in which either (a) the state initiated proceedings against parents for using CAM therapies for their children or (b) the department received telephone calls or other information reporting abuse and neglect in this domain. We asked the American Academy of Pediatrics and the leading CAM professional organizations concerning any relevant, reported cases. RESULTS: Of the 18 state Departments of Health and Human Services departments surveyed, 6 reported being aware of cases in the previous 5 years. Of 9 reported cases in these 6 states, 3 involved restrictive dietary practices (eg, limiting children variously to a watermelon or raw foods diet), 1 involved dietary supplements, 3 involved children with terminal cancer, and 2 involved religious practices rather than CAM per se. None of the professional organizations surveyed had initiated proceedings or received telephone calls regarding abuse or neglect concerning parental use of CAM therapies. CONCLUSIONS: Pediatric use of CAM therapies raises complex issues. Clinicians, hospitals, state agencies, courts, and professional organizations may benefit from a policy framework to help guide decision making.

Child↗
PubMed1996

Managerial responses to Medicaid prospective payment in the nursing home sector.

The United States must soon address long-term care policy. Policymakers have sought cost containment through reimbursement policies that contain incentives for efficiency. Nursing facility administrators were surveyed twice following a significant change in Maine's Medicaid reimbursement policy to determine the effects of the change on their managerial practices. The administrators responded to some of the policy changes as profit maximizers, including instituting cost controls and benefiting from incentives. In other areas, such as staffing, staff pay, and accepting heavy care patients, the administrators did not seem to behave entirely as expected. Insights from organizational theory are useful for explaining some of the other behaviors. As long-term care reform is undertaken, a policy framework should include aspects of the internal environment of nursing facilities, such as administrator goals and organizational structure and mission.

Cost Control↗
PubMed1985

Current ethical issues in IVF.

This article has briefly reviewed the range of public policy issues and ethical questions raised with respect to IVF. It then discussed selected issues that are now under policy debate and decision. Given the wide acceptance of IVF as a medical procedure for married couples, what variants might also be ethically defensible? IVF for unmarried couples appears defensible under specific conditions that are equally applicable to married couples. Involvement of third parties (gamete donation and gestational surrogacy) is more complex and needs case by case examination. Sperm donation appears to generate little that is ethically new when coupled with IVF but requires the same care and concern as AID. Egg or embryo donation, however, does raise new ethical questions that need close attention and continuing analysis. Freezing of human embryos also breaks new ethical ground, particularly in the options it generates beyond a narrowly defined medical domain. Certain of these options are better not undertaken without further public policy decision. Improvement of current procedures and techniques through effective clinical trials can be ethically carried out in terms of scientific and medical perspectives. However, efforts in this direction will be more effective if undertaken within a public policy framework that clearly defines acceptability during a transitional period of confidence-building.

Adoption↗
PubMed2007

[Preimplantation genetic diagnosis. Ethical, social and legal aspects].

Preimplantation genetic diagnosis (PGD) undertakes an examination of an embryo outside the mother's womb subsequent to artificial insemination in order to identify a potential genetic and chromosomal impairment of that embryo. PGD is not being practiced in the Federal Republic of Germany since it cannot be reconciled with the provisions of the Embryo Protection Law. Objections have been raised against PGD based on ethical, religious and feminist arguments as well as on the grounds of legal framework policy. The essence of those objections relates to the fact that this method relativises the inviolability of the embryo in its early stages. Even human dignity itself is considered in danger. However, those objections have themselves caused demur. A variety of ethical reasons make it appear conceivable to allow PGD under narrowly defined conditions in medically founded cases. PGD can be used to the benefit of the health of both the pregnant mother and the expected children. In case PGD should be permitted, it would have to be within the framework of medical and sociopsychological counselling.

Embryo Research↗
PubMedDate not supplied

Physical Activity Policy Development: a synopsis of the WHO/CDC Consultation, September 29 through October 2, 2002, Atlanta, Georgia.

Physical activity is an important part of the World Health Organization's integrated approach to the prevention and control of noncommunicable disease and the promotion of health, and, in particular, to the evolving World Health Organization Global Strategy on Diet and Physical Activity. To assist in these efforts, a joint World Health Organization/Centers for Disease Control and Prevention Consultation on Physical Activity Policy Development took place in Atlanta, Georgia, from September 29 through October 2, 2002. This article summarizes the context and outcomes of the consultation. It also includes elaboration of a Comprehensive Physical Activity Policy Framework developed as a product of the meeting.

Centers for Disease Control and Prevention, U.S.↗
PubMed1986

Evaluation of the European strategy for Health for All by the Year 2000.

For the first time ever, Europe has a concrete, comprehensive and forward-looking health policy framework. Forming part of the worldwide movement for Health for All (HFA) by the Year 2000, the European regional HFA strategy, embodied in 38 specific targets. has been developed by the 33 Member States of the WHO European Region. Completed in 1985, the first evaluation of overall progress in implementing this new health policy has shown that the regional targets may be ambitious but they are viable and realistic. Certain countries have already achieved some of the targets, but even in these countries efforts are still needed to improve equity among social groups. Performance in key areas such as orientation towards primary health care and the provision of safe water and adequate sanitary facilities, although improving, is still not at the levels hoped for and these remain priority items. Even more serious difficulties are apparent in other areas such as healthy lifestyles and the quality of care. The quality of the information available, even in an area as developed as Europe, also leaves much to be desired. The gaps and weaknesses identified must be tackled urgently if the goal of HFA is to be achieved, but there are encouraging signs that the HFA movement in Europe has now really started.

Europe↗