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The Fourth Quinquennial National Community Mental Health Nursing Census of England and Wales.

Within an increasingly articulate policy framework, changes to the United Kingdom National Health Service have taken place and these have impacted on mental health service provision. They have particular implications for the work of community mental health nurses (CMHNs). Since 1980, a five-yearly national census of CMHNs has been conducted. Selected findings from the latest census, commissioned by the Department of Health, are set within the context of data derived from the three previous studies. Substantive implications which flow from the changes detected in the practice, organisation and management, and education of community mental health nurses in England and Wales, are discussed.

Adult↗

Establishing cancer units.

The creation of effective cancer units is central to the implementation of the report A Policy Framework for Commissioning Cancer Services, produced by the Chief Medical Officers of England and Wales, recently issued by the Department of Health in April 1995. While cancer units are described in this report a range of important questions remain about their nature and how they should be developed. This paper addresses these issues in three ways. A definition of the cancer unit is suggested and its main implications spelt out. The problems of establishing cancer units are covered under three headings. Where should cancer units be? Which cancer sites should the unit cover? What is needed to establish the cancer unit? Finally two checklists are presented, describing the task from the perspectives of the district health authority and hospital(s) concerned. The underlying theme is that real changes in clinical practice and organisation are the goal, and these can only be achieved where there is extensive local dialogue in which the relevant issues are addressed in a structured and rigorous manner. Cosmetic changes in hospital designation will not achieve the consistent quality of cancer service that is the cornerstone of the 'Calman' policy.

Humans↗

Problems of cost recovery implementation in district health care: a case study from Niger.

This article describes and analyzes the impact of the introduction of a cost recovery system in 11 health centres of Tillabéri district, Niger, West Africa, between August 1997 and August 1999. The study is based on data collected by the health workers, observations of district activities and policy meetings and literature from similar programmes in the region. The central question addressed by this article is why a well-formulated programme, which was implemented accordingly, failed to succeed. The system described fits within the national health policy framework in Niger, which opted to introduce fixed attendance fees in health centres. The system was introduced as a part of a comprehensive package to improve the accessibility, quality and organization of the districts' health care. Discussed are the problems encountered in the functioning of the system, such as the unpredictability of the cost recovery rate, the drop in patients' attendance and the undermining effect of serious and regular shortages of essential generic drugs at the wholesale dealer. Further discussed are the supervision and control of the financial and drug administration and the participation of the population, which are identified as key areas of interest for sustainability of any cost recovery system.

Community Health Centers↗

Zambia moves towards reproductive health.

Several events in Zambia this year have marked the development of an integrated approach to reproductive health. A team met in March to draw up a national safe motherhood policy, plus strategies and guidelines. These were completed by April and are being distributed for comments. Clinical guidelines for safe motherhood in health centers have also been developed. These aim to reduce mortality and morbidity among mothers and infants by helping health workers to provide quality care to women at every stage of pregnancy and delivery. A reproductive health workshop was held in Ngwerere in May to create awareness of the concept of reproductive health, identify reproductive health problems in the area, propose solutions and outline activities. The 75 participants included community health workers, community leaders, teachers, youth leaders, and community members, as well as health workers and policymakers. The workshop was conducted in the local language so that those present were able to participate fully. June 1997 saw the official launch of Zambia's new policy framework, guidelines and strategy on family planning within reproductive health. The country's Minister of Health, Dr. Katele Kalumba, said the family planning guidelines were a sign of the government's commitment to providing a basic health care package for all Zambians. To promote widespread discussion of the whole concept of reproductive health, local newspapers printed feature articles with the headline "Let's talk reproductive health." The articles raised a variety of sensitive issues that ranged from safe sex and adolescent sexuality to safe motherhood and HIV prevention. Plans are going ahead in Zambia for drawing up a national training curriculum for safe motherhood and family planning. The curriculum for health workers will cover both pre-service and in-service training.

Africa↗

Building partnership capacity for the collaborative management of marine protected areas in the UK: a preliminary analysis.

This paper reports the findings of a preliminary analysis of 15 case studies of inshore marine protected areas in the UK. It draws on the common-pool resource (CPR) literature and is premised on the thesis that building partnership capacity amongst relevant authorities and resource users provides a critical basis for overcoming collective action problems (CAPs), through the development of incentive structures and social capital, in order to achieve strategic objectives. Particular attention is paid to the influence of statutory marine biodiversity conservation obligations to the European Commission for marine special areas of conservation (MSACs), as these are an important external contextual factor. The risks of imposition and parochialism are outlined and the challenges of taking a balanced approach are discussed. The challenges posed by the attributes of the marine environment are considered, as are those posed by the policy framework for MSACs. The findings are discussed in relation to three questions: (i) which partnership models appear to have the potential to overcome the CAPs posed by inshore MSACs? (ii) what CAPs had to be addressed during the early phase of development of the MSAC co-management regimes? (iii) what are the likely future CAPs for the collaborative management of MSACs that each partnership will need to address? These preliminary findings will form the basis for future studies to analyse the outcomes of these 15 initiatives, in order to assess the strengths, in various contexts, of different approaches for building resilient and balanced, thereby effective, institutions for the co-management of MSACs in the UK.

Conservation of Natural Resources↗

Review of policies and guidelines on infant feeding in emergencies: common ground and gaps.

Recent crises in regions where exclusive breastfeeding is not the norm have highlighted the importance of effective policies and guidelines on infant feeding in emergencies. In 1993, UNICEF compiled a collection of policy and guideline documents relating to the feeding of infants in emergency situations. In June 2000 Save the Children, UK, UNICEF and the Institute of Child Health undertook a review of those documents, updating the list and identifying the common ground that exists among the different policies. The review also analysed the consistency of the policy framework, and highlighted important areas where guidelines are missing or unclear. This article is an attempt to share more widely the main issues arising from this review. The key conclusions were that, in general, there is consensus on what constitutes best practice in infant feeding, however, the lack of clarity in the respective responsibilities of key UN agencies (in particular UNICEF, UNHCR and WFP) over issues relating to co-ordination of activities which affect infant-feeding interventions constrains the implementation of systems to support best practice. Furthermore, the weak evidence base on effective and appropriate intervention strategies for supporting optimal infant feeding in emergencies means that there is poor understanding of the practical tasks needed to support mothers and minimise infant morbidity and mortality. We, therefore, have two key recommendations: first that the operational UN agencies, primarily UNICEF, examine the options for improving co-ordination on a range of activities to uphold best practice of infant feeding in emergencies; second, that urgent attention be given to developing and supporting operational research on the promotion of optimal infant-feeding interventions.

Guidelines as Topic↗

Laboratory costs and utilization: a framework for analysis and policy design.

A conceptual framework is outlined as the basis for analysis and evaluation of laboratory test-ordering patterns. This framework highlights the input, process, and output phases of the laboratory inquiry system. Data are presented from a contemporary Canadian study to show that the cost of laboratory testing is escalating and represents a sizable proportion of hospital costs. Practical policy interventions intent on reducing the costs in this complex system will require thorough analysis within a conceptual framework such as is outlined here and will require ultimately sophisticated control programs at various levels in the laboratory inquiry system.

Clinical Laboratory Techniques↗

Hydropower, Adaptive Management, and Biodiversity

/ Adaptive management is a policy framework within which an iterative process of decision making is followed based on the observed responses to and effectiveness of previous decisions. The use of adaptive management allows science-based research and monitoring of natural resource and ecological community responses, in conjunction with societal values and goals, to guide decisions concerning man's activities. The adaptive management process has been proposed for application to hydropower operations at Glen Canyon Dam on the Colorado River, a situation that requires complex balancing of natural resources requirements and competing human uses. This example is representative of the general increase in public interest in the operation of hydropower facilities and possible effects on downstream natural resources and of the growing conflicts between uses and users of river-based resources. This paper describes the adaptive management process, using the Glen Canyon Dam example, and discusses ways to make the process work effectively in managing downstream natural resources and biodiversity. KEY WORDS: Adaptive management; Biodiversity; Hydropower; Glen Canyon Dam; Ecology

Journal Article↗

Looking back, looking beyond: revisiting the ethics of genome generation.

This paper will explore some of the ethical imperatives that have shaped strategic and policy frameworks for the use of new genetic technologies and how these play a role in shaping the nature of research and changing attitudes; with an attempt to conceptualize some theories of genetic determinism. I analyse why there is a need to put bioethical principles within a theoretical framework in the context of new technologies, and how, by doing so, their practical applications for agriculture, environment medicine and health care can be legitimized. There are several theories in favour of and against the use of genetic technologies that focus on genes and their role in our existence. In particular the theory of geneticisation is commonly debated. It highlights the conflicting interests of science, society and industry in harnessing genetic knowledge when the use of such knowledge could challenge ethical principles. Critics call it a 'reductionist' approach, based on arguments that are narrowed down to genes, often ignoring other factors including biological, social and moral ones. A parallel theory is that there is something special about genes, and it is this "genetic exceptionalism" that creates hopes and myths. Either way, the challenging task is to develop a common ground for understanding the importance of ethical sensitivities. As research agendas become more complex, ethical paradigms will need to be more influential. New principles are needed to answer the complexities of ethical issues as complex technologies develop. This paper reflects on global ethical principles and the tensions between ethical principles in legitimizing genetic technologies at the social and governance level.

Ethics, Medical↗

Quality management in orthodontics.

The introduction of modern quality thinking to orthodontic care should be a continuing effort on the part of the orthodontic profession. The strategy for the development of a European quality management system in orthodontic care was developed from 1993 to 2000 during the EURO-QUAL project. During the project's first stage, the basic prerequisites were identified for a general model of quality management in orthodontic care. A supra-national agreement was reached on policy statements for orthodontic care in Europe. The essential components of an orthodontic quality management system are: linking orthodontic care to population need, patient partnership, clinical accountability, and containing costs.Value-based health care and "TQM", the philosophy of total quality management, are basic principles applied in accordance with the recommendations of the European Health Committee of September 1997 and the "Health-for-All" policy framework of the World Health Organization.

European Union↗

What about the carers?: Exploring the experience of caregivers in a chemotherapy day hospital setting.

Interest in the concerns of cancer patients' carers has been growing steadily over the last decade reflected in key cancer service policy documents [DOH, 1995. A Policy Framework for Commissioning Cancer Services (Calman-Hine Report). London, HMSO; DOH, 2002. The NHS Cancer Plan]. Despite this acknowledgement, it can be argued that less is known about carers' experience in the cancer treatment context. Carers can be defined as someone who shares the experience of cancer with the patient. The aim of this study was to explore the lived experience of caregivers in a chemotherapy day hospital and how this compared with their experience of inpatient care. Using a phenomenological approach, face-to-face interviews were conducted with a purposive sample of ten caregivers. Data were analysed using Polkinghorne's [1995. Narrative Knowing & the Human Sciences. University of New York Press, Albany] two stages of narrative analysis. The findings indicated that the caregivers experienced similar transitions to the patients with regards to health-illness transition and organisational transitions. The caregivers adopted various roles in the day hospital such as Companion 'being with' their relative, Protector 'keeping an eye'; Practical Caregiver and assuming an Advocate Role. The findings of this study are important for cancer nursing practice as health professionals need to acknowledge the role of carers in the chemotherapy day hospital setting and facilitate their involvement in care.

Adaptation, Psychological↗

Drought planning and water allocation: an assessment of local capacity in Minnesota.

Water allocation systems are challenged by hydrologic droughts, which reduce available water supplies and can adversely affect human and environmental systems. To address this problem, drought management mechanisms have been instituted in jurisdictions around the world. Historically, these mechanisms have involved a crisis management or reactive approach. An important trend during the past decade in places such as the United States has been a shift to a more proactive approach, emphasizing drought preparedness and local involvement. Unfortunately, local capacity for drought planning is highly variable, with some local governments and organizations proving to be more capable than others of taking on new responsibilities. This paper reports on a study of drought planning and water allocation in the State of Minnesota. Factors facilitating and constraining local capacity for drought planning were identified using in-depth key informant interviews with state officials and members of two small Minnesota cities, combined with an analysis of pertinent documentation. A key factor contributing to the effectiveness of Minnesota's system is a water allocation system with explicit priorities during shortages, and provisions for restrictions. At the same time, the requirement that water suppliers create Public Water Supply Emergency Conservation Plans (PWSECP) clarifies the roles and responsibilities of key local actors. Unfortunately, the research revealed that mandated PWSECP are not always implemented, and that awareness of drought and drought planning measures in general may be poor at the local level. From the perspective of the two cities evaluated, factors that contributed to local capacity included sound financial and human resources, and (in some cases) effective vertical and horizontal linkages. This analysis of experiences in Minnesota highlights problems that can occur when senior governments establish policy frameworks that increase responsibilities at the local level without also addressing local capacity.

Conservation of Natural Resources↗

Combined use of GIS and environmental indicators for assessment of chemical, physical and biological soil degradation in a Spanish Mediterranean region.

Soil is one of the main non-renewable natural resources in the world. In the Valencian Community (Mediterranean coast of Spain), it is especially important because agriculture and forest biomass exploitation are two of the main economic activities in the region. More than 44% of the total area is under agriculture and 52% is forested. The frequently arid or semi-arid climate with rainfall concentrated in few events, usually in the autumn and spring, scarcity of vegetation cover, and eroded and shallow soils in several areas lead to soil degradation processes. These processes, mainly water erosion and salinization, can be intense in many locations within the Valencian Community. Evaluation of soil degradation on a regional scale is important because degradation is incompatible with sustainable development. Policy makers involved in land use planning require tools to evaluate soil degradation so they can go on to develop measures aimed at protecting and conserving soils. In this study, a methodology to evaluate physical, chemical and biological soil degradation in a GIS-based approach was developed for the Valencian Community on a 1/200,000 scale. The information used in this study was obtained from two different sources: (i) a soil survey with more than 850 soil profiles sampled within the Valencian Community, and (ii) the environmental information implemented in the Geo-scientific map of the Valencian Community digitised on an Arc/Info GIS. Maps of physical, chemical and biological soil degradation in the Valencian Community on a 1/200,000 scale were obtained using the methodology devised. These maps can be used to make a cost-effective evaluation of soil degradation on a regional scale. Around 29% of the area corresponding to the Valencian Community is affected by high to very high physical soil degradation, 36% by high to very high biological degradation, and 6% by high to very high chemical degradation. It is, therefore, necessary to draw up legislation and to establish the policy framework for actions focused on preventing soil degradation and conserving its productive potential.

Agriculture↗

Challenges of genomic testing for patients and clinicians in Latin America: Foundations of a qualitative multi-country study.

Genomic medicine is expanding across Latin America (LATAM), yet access to essential ancillary services such as genetic counselling remains limited. 'Latin-SEQ' is a study that provides whole exome sequencing (WES) for neuromuscular diseases across 18 countries, aiming to improve diagnostic rates and generate region-specific genetic insights. However, funding constraints exclude genetic counselling and cascade testing, raising concerns about equitable and harm-free care. This paper reports early findings from 'Latin-SEQ Plus,' a mixed-methods study exploring patient and healthcare practitioner (HCP) perspectives on WES and genetic counselling. Data were generated via surveys with patients and HCPs, and participatory workshops with HCPs across six countries. We found that patients strongly valued genetic testing for diagnostic clarity, improved care, and family planning. HCPs acknowledged the diagnostic benefits of WES but highlighted absence of local genetic counselling services, inconsistent pre and post-test practices, and uncertainty in managing incidental findings and variants of uncertain significance (VUS). Psychological impacts related to WES results are not always addressed, underscoring risks of psychological and emotional harm for patients. Access to WES and genetic counselling is limited in LATAM due to financial hardship and the absence of a clear genetic counselling infrastructure. Our findings also reveal a mismatch between patient expectations and HCPs' capacity to deliver comprehensive genomic care. We argue for urgent investment in genetic counselling infrastructure, HCP training, culturally tailored resources, and policy frameworks to support equitable implementation of genomic medicine in LATAM.

Humans↗

Balancing risks.

Regulatory policies designed to reduce the health risk of environmental and/or synthetic chemicals generally aim for zero or negligible levels. Foods, on the other hand, especially those with a long history in the human diet, have been treated as essentially safe, even though they too contain various chemicals including nutrients. The recent debate on the presence in food of acrylamide, a possible human carcinogen, is likely to shake up the traditional paradigm held by regulatory agencies on chemical health risks. The current stance on the safety of acrylamide in food seems to be an extension of the traditional approach to assessment of environmental and/or synthetic chemicals. However, even foods which have long been a part of the human diet contain components that do not necessarily meet the safety margins applied to environmental and/or synthetic chemicals. In the future, a greater understanding of the effect of these agents on biological systems as well as the development of analytical methods for testing will result in many questions being raised concerning chemicals in foods, such as acrylamide which is under scrutiny today. Regulatory policies currently employ various standards for controlling chemical risk. These standards are dependent upon the labeling of the chemical in question, e.g., whether carcinogenic or non-carcinogenic, synthetic or natural, or whether a food or industrial chemical. Regardless of labeling, all chemicals to which we are exposed should be evaluated on an equal footing. Then, according to the level of the identified health risk, regulations could or could not be applied based on local circumstances, e.g., public acceptance, voluntary risk vs. involuntary risk, etc. In order to create a standardized system for chemical risk assessment, the introduction of uniform measures is essential. Loss of life expectancy (LLE) is one possible measure to assess chemical health risk. When LLE has been used, animal toxicity data have indicated that an ad libitum diet intake has considerably more impact on health risk than the acrylamide concentration of the ingested food. Reassessing the health effects of chemicals with a system of uniform measures could reveal many risks that need to be preferentially addressed above and beyond keeping minor toxicants to zero or negligible levels. Recognition of such risks may result in changes that conflict with existing regulations. In any case, whether consciously or unconsciously, people have always been exposed to a certain degree of chemical risk in their daily life. Based on the premise that the public can accept some degree of chemical risk in balance with other risks in their lives, regulatory bodies should be able to take a flexible and effective approach. In order to efficiently and comprehensively maximize the protection of our health against potential harm from chemicals using limited public resources, it is now time for regulatory agencies to restructure their policy frameworks across categories for controlling chemical health risks.

Acrylamides↗

The National Emergency Medical Extranet project.

The National Emergency Medical Extranet (NEME) project was a collaborative multi-center effort to create a plan for a networked system to improve emergency clinical care through real-time information support, and simultaneously provide benefit through information support for public health initiatives. This article presents a review of the NEME project and its recommendations, which are particularly relevant given the desire for improved communication and surveillance systems in today's healthcare and public health environments. Participants in the NEME project performed an environmental assessment and a proposed conceptual architecture for NEME. A consensus conference was held to review the NEME concept to obtain feedback and delineate priorities for future development and testing. The NEME consensus conference used a modified version of the nominal group method. Recommendations for the following areas were established: Business/Organizational Issues [1) create a compelling provider driven NEME model, 2) provide a comprehensive policy framework, 3) address economics]; Clinical/Caregiver Issues [1) develop a NEME system that is integrated with Emergency Medicine workflow, 2) provide incentives to caregivers, 3) generate a critical mass of participation for maximum benefit]; Technical Issues [1) incorporate a robust security and confidentiality architecture, 2) utilize a master person index, where appropriate, 3) evaluate or adopt existing data standards]; Heart Attack Alert Functional Priorities for NEME [1) continuous quality improvement and research, 2) regional electrocardiogram server, 3) past medical history and medication server]; Next Generation Internet Functional Priorities for NEME [1) real time epidemiology/surveillance, 2) patient education, 3) real time clinical alerting]. In conclusion, issues and consensus recommendations in the planning of a NEME are documented. These recommendations should be considered in future efforts to design, develop and implement wide area information networks to support Emergency Medicine. A review of current activities evolving from NEME is presented, and further research and development is encouraged to create and implement NEME systems.

Computer Communication Networks↗

The impact of decentralisation on sexual and reproductive health services in Ghana.

This paper analyses the impact of decentralisation on the political organisation, management and provision of sexual and reproductive health services in Ghana. It draws on qualitative research and interviews with key informants from the Ministry of Health, donors, NGOs, regional and district health management teams, local government and community leaders. Within a national reproductive health policy framework, previously disparate family planning, maternal and child health, STI and HIV/AIDS programmes have become more integrated, and donors have pooled or co-ordinated their funding. Some decision-making about resource allocation is meant to happen at district and regional level but in practice, this remains centrally controlled, which may be a necessary safeguard for sexual and reproductive health services. Earmarked donor funds still ensure a regular supply of contraceptives and STI drugs. However, paying for these is problematic at local level. Sexual and reproductive health staff make up a large proportion of primary health care staff, but especially in rural areas they experience poor working conditions, and there is high turnover and vacancies. District and sub-district level links are working well in this new system, but clarity is still needed on how different national sexual and reproductive health bodies relate to each other and to regional and district health authorities. The development of formal mechanisms for priority setting and advocacy at local levels could help to secure benefits for sexual and reproductive health care.

Attitude of Health Personnel↗

[Family health nursing in Germany: a process of consensus finding as basis].

The "Project design- and consensus phase for implementation of the Family Health Nurse in Germany" ordered by the German professional association for nurses (DBfK) was realized by the Institute of Nursing Science at the University of Witten/Herdecke. Aim of this study was to find out if there is a consensus between eleven stakeholders from ten different institutions of the German health care system before starting the real "pilot project for the feasibility of the Family Health Nurse in Germany", which should strengthen the prevention and the health promotion in Germany corresponding to the WHO's policy framework "Health 21". The investigation included also the identification of the need and the complexity of the new role for nurses and midwives. Furthermore, a statement should be made about the virtual feasibility. Methodically, multi-level analyses were used. First, the stakeholders were interviewed about the possible role of the Family Health Nurse in Germany. All their statements were determined by qualitative content analyses. From these results different areas of responsibilities for the Family Health Nurse in Germany were developed by using the scenario technique. These scenarios were discussed by the stakeholders in focus groups and revised several times until five consented scenarios could be developed. The contents of the scenarios were generalized and structured to according the variables target group, reason for care, need, access, skills, settlement and financing. Like that, the characteristic features of the new areas of responsibilities for the Family Health Nurse in Germany could be defined. Finally, all stakeholders formulated the consensus for the implementation of the planned pilot project with an integrated educational course for nurses and midwives, which immediately has started in autumn 2005 with an accompanying research evaluation.

Family Nursing↗