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PubMedDate not supplied

Nursing in the next millennium. Leadership skills for surviving and thriving.

Consider the following case study: The setting is an acute care facility with a large obstetrical service delivery (6,000 babies annually.) The year was 1989. A nurse leader had been appointed manager of Women's Services. Major job responsibilities included staffing, hiring, employee performance evaluations, developing policies and protocols, and managing daily operations issues. The reimbursement for the patient population was more than 50 percent fee for service.

Forecasting↗
PubMed1997

Diagnosis of severe growth hormone (GH) deficiency in young adults who received GH replacement therapy during childhood.

Between 20% and 87% of young adults who had completed growth hormone (GH) therapy in childhood for a putative diagnosis of GH deficiency (GHD) had normal GH responses to provocative tests when they were retested. Patients with isolated idiopathic GHD were more likely to exhibit normal GH responses at retest in young adult life than were patients with multiple pituitary hormone deficits. When determining which patients should receive GH therapy in adult life, those who have isolated GHD should undergo two tests of GH status, while those with multiple anterior pituitary hormone deficits require only one test. Most information is available for the insulin tolerance test, the arginine stimulation test and the glucagon stimulation test, but more recent methods, such as GH-releasing hormone in combination with pyridostigmine, are showing promise in the investigation of GHD. In young adults with childhood-onset GHD, the serum concentration of insulin-like growth factor I is a useful marker of GH status, and can be used in conjunction with a GH provocative test. The choice of GH provocative test should ultimately depend on the experience and policy developed at the centre performing the assessment. Whichever tests are chosen, each should be validated in subjects known to have hypothalamic-pituitary disease as well as in normal individuals.

Adult↗
PubMed2005

The dilemma of past success: insiders' views on the future of the international family planning movement.

Many observers believe that the international family planning movement has played a significant role in reducing fertility levels and slowing population growth in the developing world. Yet the perceived success of family planning programs recently has led some researchers to formulate questions about their relevance and future place on the development policy agenda. Within a framework derived from the sociological literature on social movements, we use interviews and focus-group discussions with insiders in the field of population studies to examine current perspectives on the status and future of the family planning movement, factors contributing to its declining international visibility, and possible responses from the family planning field. Informants cited four possible courses of action for the movement: (1) forming strategic alliances with other movements, specifically HIV/AIDS prevention; (2) redefining the family planning message to mobilize and strengthen support; (3) improving service delivery to broaden public acceptance and contraceptive method use; and (4) nurturing new leadership. The future course of the movement--whether it be one of cooptation by overlapping movements or revitalization--requires waiting until its full history can be written.

Family Planning Services↗
PubMed1998

Medication administration in schools: the Massachusetts experience.

In 1991, the School Health Unit of the Massachusetts Department of Public Health defined medication administration as a priority policy development area for school health. The decision was based on: a) the increased numbers of children requiring medications during the school day; b) a lack of consistent standards within Massachusetts schools; c) the need to update an outdated statute concerning psychotropic medications; and d) the more than 50 weekly telephone calls from school health personnel regarding this subject. This article describes the Massachusetts experience of developing medication administration regulations for public and private schools and implementing the regulations throughout the commonwealth. The Massachusetts experience may provide guidance to other states, cities, and towns as they address this important child health issue.

Drug Therapy↗
PubMed1999

Establishing networks for health promoting schools in South Africa.

South African schools were segregated by years of discriminatory practice. Apartheid policies adversely affected the health and social status of children in South Africa. The conceptual framework suggested by the health promoting schools movement was adopted in South Africa to address school health comprehensively. This approach provides a useful framework because it focuses not on the curriculum but on the school environment, community involvement, policy development, and appropriate health and social services. Currently, several initiatives in South Africa focus on developing networks of health promoting schools. Initiatives seen as a mechanism to address the historical inequities among children in South Africa are described.

Child↗
PubMed2006

Follow-up comparisons of intervention and comparison schools in a state tobacco prevention and control initiative.

This study provides information about prevention and control practices in intervention and comparison secondary schools 2 years after the start-up of the Texas Tobacco Prevention Initiative. The intervention, which was funded through the Texas Department of State Health Services, consisted of guidance, training, technical assistance, and reimbursement of approximately 2000 dollars per year for program expenses. Self-administered written surveys for Principals and Health Coordinators, based on the School Health Education Profile Tobacco Module, were designed for periodic assessment of the status of school programs. Surveys were sent in 2002 to intervention (n = 74) and comparison (n = 60) schools. Response to the Principal Survey was received from 109 (81%) schools, and response to the Health Coordinator Survey was received from 84 (63%) schools. Survey analysis showed that intervention schools more frequently (p <or= .05) reported: (1) being extremely or moderately active in student cessation support, teacher training, policy development, family involvement, and assessment of the prevention program; (2) using recommended curricula, offering more tobacco-related lessons, involving more teachers, and using more recommended teaching methods such as role-playing, simulations or practice, and peer educators; and (3) having more interest in staff development and more funding to purchase release time. Similarities across schools are provided, as well as recommendations for future planning.

Data Collection↗
PubMed1988

Protection of human subjects of biomedical research in the United States. A contrast with recent experience in the United Kingdom.

In the U.S., the development of extensive regulations for the protection of human subjects of research began in the 1960s and continued through the 1970s. The substance of these regulations reflects the American social and political climate of the time. There is a focus on rights--e.g., to be left alone, to be self-determining--reflected in elaborate requirements to assure the validity and documentation of informed consent. There is also a focus on systems of disinterested review and monitoring procedures to assure uniform adherence to the requirements of the regulations. To the extent that the U.S. has developed extensive regulations in this field, it may be viewed as more advanced than the U.K. And yet, it is apparent that there remain on both sides of the Atlantic very difficult and similar problems regarding the definition of responsible research. Such problems are illustrated by consideration of current controversies about the ethical justification of RCTs. There are some features of the U.S. regulatory system that I can commend to the attention of other nations as they develop policies for the protection of human research subjects. For example, a uniform requirement for informed consent and committee review appears to be responsive to some problems currently encountered in the conduct of RCTs in the U.K. A note of caution is in order, however. Some features of our regulatory policy and practices are excessively inflexible, wasteful of human resources, and occasionally counterproductive.

Clinical Trials as Topic↗
PubMed2000

Organizational approaches to the HIV/AIDS crisis.

The Centers for Disease Control and Prevention (CDC) has played a major role in controlling the HIV/AIDS epidemic in the United States. After implementation of perinatal zidovudine therapy in 1994, the efforts of the CDC and others produced a dramatic decline in perinatal HIV transmission. However, in recent years, approximately 300 perinatally infected infants have been born annually in the United States. To further reduce this number, the CDC has identified four prevention goals: improve prenatal care, recommend HIV testing, ensure treatment for HIV-infected pregnant women, and ensure follow-up care. To address these goals, the CDC launched a prevention plan consisting of surveillance, research, outreach strategies, grant programs, evaluation efforts, and policy development. Globally, the CDC tailors this plan to meet the needs of developing countries. The CDC provides technical assistance to international organizations to help develop, implement, and evaluate global prevention programs. Specific international sites are targeted for new research and programs to reduce perinatal HIV transmission.

Acquired Immunodeficiency Syndrome↗
PubMed2001

Moral problems in the use of coercion in dealing with nonadherence in the diagnosis and treatment of tuberculosis.

Coercion and detainment can be a morally acceptable strategy to fight the spread of tuberculosis, but these measures need to be placed into a much broader context than that of their short-term potential effectiveness. TB should be de-stigmatized by full acknowledgment that we all share the blame for its perpetuation. When coercion and detention are necessary, they should incorporate a strategy of optimum protection for minimum violation of autonomy. National and international health care programs should provide effective and nonthreatening treatments for TB and other related illnesses such as HIV and should develop policies to tackle the environmental causes of TB and provide support for vulnerable victims. Corporate pressures to continue world poverty must be undermined.

Civil Rights↗
PubMed1990

Oral health education and promotion in maternal and child health: a position paper.

Oral health education and promotion are the connecting mechanisms among prevention, policy development and program implementation, maintenance and evaluation. Given the preventive procedures available today, all focus populations of women and children should have access to accurate information about such procedures as well as access to the procedures themselves. Furthermore, appropriate methodologies need to be utilized for community oral health education and these methods differ from those commonly used for individual education. In the context of maternal and child health there are unprecedented opportunities for new accomplishments in oral health. The health education model most appropriate for these groups is the public health model, an approach designed to empower as well as inform, and one that fosters shared decision making among community members and health professionals. Dental professionals have the responsibility to address this challenge, and to help correct the health information inequities that prevail, especially among the traditionally informationally disenfranchised subfocus populations discussed in this paper.

Child↗
PubMed1992

An evaluation of dietary guidance graphic alternatives: the evolution of the eating right pyramid.

The pyramid graphic was found to be most effective in conveying the messages of moderation and proportionality. The pyramid design might be further strengthened in conveying the total moderation message by including both FOS pictures and symbols in the same graphic. The pyramid also has considerable strength in promoting the message of variety. More important, the pyramid graphic did not convey misinformation about variety, proportionality, and moderation or about the importance of consuming foods in adequate amounts from all the major food groups to achieve a healthful diet. The bowl design was found to be far less effective in promoting the moderation and proportionality messages, but did illustrate the variety message somewhat better than the pyramid. Although respondents indicated a preference for the bowel shape, it is important to note that even in the groups where preference for the bowl was the strongest (i.e., younger, less educated, ethnic minority, and low-income respondents), the pyramid was more likely to be identified as the graphic that suggested the moderation-of-fat message most clearly. Further, preference for the bowl was not linked to effectiveness of intended messages in those groups. In this study, the shape a respondent preferred was of less importance to policy development than the amount of intended information conveyed by each graphic.

Adolescent↗
PubMed1991

Mortality in Pacific island countries around 1980: geopolitical, socioeconomic, demographic and health service factors.

Inhabitants of Pacific island countries experience a wide range of levels and cause structures of mortality. Data on socioeconomic, geopolitical and demographic variables have been analysed here to identify correlates and determinants of mortality in Pacific island countries circa 1980. The mortality data used in the study were the best available for the period and are reasonably accurate; descriptive data were derived from recognised sources. Political status was a major correlate, with independence positively associated with mortality. However, the influence of political status was partly accounted for by economic and social variables. Economic indices, particularly imports per capita, were major inverse correlates of mortality. Disparities in life expectancy occurred between malarious and nonmalarious countries, and these were not explicable by other factors. Melanesians, especially women, experienced high mortality rates. Education and doctor availability were both associated with increased life expectancy. Intercorrelation and confounding need to be taken into account in the interpretation of this analysis. The results have ramifications for policy development in the Pacific island countries themselves, and for investment and aid programs from major donor nations and organisations.

Cross-Sectional Studies↗
PubMed2005

Comparison of complementary and alternative medicine use: reasons and motivations between two tertiary children's hospitals.

AIMS: To compare prevalence, reasons, motivations, initiation, perceived helpfulness, and communication of complementary and alternative medicine (CAM) use between two tertiary children's hospitals. METHODOLOGY: A study, using a face-to-face questionnaire, of 500 children attending the University Hospital of Wales, Cardiff, UK was compared to an identical study of 503 children attending the Royal Children's Hospital, Melbourne, Australia. RESULTS: One year CAM use in Cardiff was lower than Melbourne (41% v 51%; OR = 0.67, 95% CI 0.52-0.85), reflected in non-medicinal use (OR = 0.41, 95% CI 0.29-0.58) and general paediatric outpatients (OR = 0.38, 95% CI 0.21-0.67). Compared to Melbourne, factors associated with lower CAM use in Cardiff included families born locally (father: OR = 0.58, 95% CI 0.44-0.77) or non-tertiary educated parents (mother: OR = 0.54, 95% CI 0.38-0.77). Cardiff participants used less vitamin C (OR = 0.31, 95% CI 0.18-0.51) and herbs (OR = 0.49, 95% CI 0.34-0.71), attended less chiropractors (OR = 0.25, 95% CI 0.06-0.37) and naturopaths (OR = 0.08, 95% CI 0.02-0.33), but saw more reflexologists (OR = 3.33, 95% CI 1.08-10.29). In Cardiff, CAM was more popular for relaxation (OR = 1.92, 95% CI 1.03-3.57) but less for colds/coughs (OR = 0.4, 95% CI 0.27-0.73). Most CAM was self-initiated (by parent) in Cardiff and Melbourne (74% v 70%), but Cardiff CAM users perceived it less helpful (OR = 0.46, 95% CI 0.31-0.68). Non-disclosure of CAM use was high in Cardiff and Melbourne (66% v 63%); likewise few doctors/nurses documented recent medicinal CAM use in inpatient notes (0/21 v 2/22). CONCLUSIONS: The differences in CAM use may reflect variation in sociocultural factors influencing reasons, motivations, attitudes, and availability. The regional variation in use and poor communication highlights the importance of local policy development.

Adolescent↗
PubMed1999

Evaluation of a national surveillance unit.

AIM: The Australian Paediatric Surveillance Unit (APSU) facilitates national active surveillance of uncommon childhood conditions. This study assessed whether it fulfilled its objectives and satisfied criteria established by the Centers for Disease Control and Prevention (CDC) for evaluating surveillance systems. METHODS: Anonymous questionnaires were sent to users of the system, individual studies were reviewed, and data were collected from independent sources. RESULTS: Seven hundred and sixty six clinicians, 48 investigators, and 15 public health professionals responded to the questionnaires. Clinicians reported that the APSU was useful, 33% saying information provided by the APSU informed or changed their clinical practice. Most (88%) reported that completing monthly report cards was not a burden. Impact on policy development was limited by suboptimal dissemination of information to public health professionals. Flexibility and timeliness were limited by design. Estimated sensitivity of APSU studies ranged from 92% (congenital rubella) to 31% (drowning/near drowning). Positive predictive value of notified cases was over 70% for most studies. CONCLUSION: The APSU fulfils most of its objectives and meets CDC criteria salient to these. Ways in which the APSU could be improved have been identified, as have methodological challenges and limitations in applying CDC guidelines to this type of unit.

Australia↗
PubMed1996

Outlook for survivors of childhood in sub-Saharan Africa: adult mortality in Tanzania. Adult Morbidity and Mortality Project.

OBJECTIVE: To measure age and sex specific mortality in adults (15-59 years) in one urban and two rural areas of Tanzania. DESIGN: Reporting of all deaths occurring between 1 June 1992 and 31 May 1995. SETTING: Eight branches in Dar es Salaam (Tanzania's largest city), 59 villages in Morogoro rural district (a poor rural area), and 47 villages in Hai district (a more prosperous rural area). SUBJECTS: 40,304 adults in Dar es Salaam, 69,964 in Hai, 50,465 in Morogoro rural. MAIN OUTCOME MEASURES: Mortality and probability of death between 15 and 59 years of age (45Q15). RESULTS: During the three year observation period a total of 4929 deaths were recorded in adults aged 15-59 years in all areas. Crude mortalities ranged from 6.1/1000/year for women in Hai to 15.9/1000/year for men in Morogoro rural. Age specific mortalities were up to 43 times higher than rates in England and Wales. Rates were higher in men at all ages in the two rural areas except in the age group 25 to 29 years in Hai and 20 to 34 years in Morogoro rural. In Dar es Salaam rates in men were higher only in the 40 to 59 year age group. The probability of death before age 60 of a 15 year old man (45Q15) was 47% in Dar es Salaam, 37% in Hai, and 58% in Morogoro; for women these figures were 45%, 26%, and 48%, respectively. (The average 45Q15s for men and women in established market economies are 15% and 7%, respectively.) CONCLUSION: Survivors of childhood in Tanzania continue to show high rates of mortality throughout adult life. As the health of adults is essential for the wellbeing of young and old there is an urgent need to develop policies that deal with the causes of adult mortality.

Adolescent↗
PubMed2000

Measuring the costs and benefits of heart disease monitoring.

OBJECTIVE: To evaluate the costs and benefits of alternative systems of coronary heart disease monitoring in Scotland. DESIGN: An option appraisal was conducted to evaluate the costs and benefits of implementing a coronary heart disease monitoring system. This involved a review of existing Scottish datasets and relevant reports, specification of options, definition and weighting of benefit criteria by key stakeholders, assessment of options by experts, and costing of options. The options were assessed by 33 stakeholders (grouped as cardiologists, patient representatives, general practitioners, public health physicians, and policy makers), plus 13 topic experts. SETTING: Scotland (population 5.1 million). RESULTS: Between group mean benefit weights were: mortality rates and case fatality (10.6), quality of life (9.8), patient function (8.8), hospital activity (7.8), primary care activity (9.25), prescribing (5.72), socioeconomic impact (4.0), risk factors (7.4), prevalence (5.0), incidence (6.0), case registration (6.82), international comparability (4.2), breadth of coverage (8.8), and frequency (5.8). Differences between group weights were significant for prevalence (p = 0.048) and international comparability (p = 0.032). Four monitoring options were identified: a community epidemiology model, based on MONICA (monitoring trends and determinants in cardiovascular disease) study methodology applied to a series of eight representative communities, had the highest benefits, at an average annual discounted cost of approximately pound 360,000; models based on the Australian cardiovascular disease monitoring scheme and on enhanced routine data offered fewer benefits at discounted average annual costs ranging from pound 165,000 to pound 195,000; finally, a coronary heart disease registry modelled on the Scottish Cancer Registry scheme would have had fewer benefits and substantially higher costs than the other options. CONCLUSIONS: The most beneficial coronary heart disease monitoring system is the community epidemiology model, based on MONICA methodology. Option appraisal potentially offers an explicit and transparent methodology for evidence based policy development.

Coronary Disease↗
PubMed2006

Classifying undetermined poisoning deaths.

OBJECTIVE: To classify poisoning deaths of undetermined intent as either suicide or unintentional and to estimate the extent of underreported poisoning suicides. METHODS: Based on 2002 statewide death certificate and medical examiner data in Utah, the authors randomly selected one half of undetermined and unintentional poisoning deaths for data abstraction and included all suicides. Bivariate analyses assessed differences in demographics, death characteristics, forensic toxicology results, mental health history, and other potentially contributing factors. Classification and regression tree (CART) analysis used information from unintentional and suicide poisoning deaths to create a classification tree that was applied to undetermined poisoning deaths. RESULTS: The authors analyzed 41 unintentional, 87 suicide, and 84 undetermined poisonings. Undetermined and unintentional decedents were similar in the presence of opiates, physical health problems, and drug abuse. Although none of the undetermined decedents left a suicide note, previous attempt or intent to commit suicide was reported for 11 (13%) of these cases. CART analysis identified suicidal behavior, drug abuse, physical health problems, depressed mood, and age as discriminating between suicide and unintentional poisoning. It is estimated that suicide rates related to poisoning are underreported by approximately 30% and overall suicide rates by 10%. Unintentional poisoning death rates were underreported by 61%. CONCLUSIONS: This study suggests that manner of death determination relies on circumstance dependent variables that may not be consistently captured by medical examiners. Underreporting of suicide rates has important implications in policy development, research funding, and evaluation of prevention programs.

Adult↗
PubMed1999

What is the cost utility of screening for hepatitis C virus (HCV) in intravenous drug users?

OBJECTIVES: To model the likely cost utility of the prevalence round of a screening programme for hepatitis C (HCV) in intravenous drug users (IVDUs) in contact with services in the South and West health region of the UK. METHODS: Information on the prevalence of HCV, performance of diagnostic tests, and effectiveness of interferon alpha (IFN alpha) for treatment of chronic hepatitis were brought together with estimates of the costs of service provision. A simple spreadsheet model was used to estimate cost utility (cost/quality adjusted life year (QALY)). Assumptions (including use of ribavirin plus IFN alpha combination therapy) were tested by a one way sensitivity analysis. RESULTS: About 5600 IVDUs live in the region. A combination of enzyme linked immunosorbent assay (ELISA) and polymerase chain reaction (PCR) testing has high sensitivity and specificity for detecting HCV. There is excellent evidence that IFN alpha is effective in producing sustained normalisation of liver function and, by inference, eradicating HCV. Evidence for long term benefits comes from modelling studies based on progression of HBV or non-A, non-B hepatitis and is considerably less robust. The cost of the prevalence round of screening in IVDUs would be about 700,000 Pounds and is likely to identify about 1400 people, of whom about 270 would be eligible for treatment and 20 would respond to IFN alpha. This gives a cost/QALY of 9300 Pounds for the screening programme. However, much uncertainty around the estimates used to inform the cost utility calculation limits confidence in the value of screening IVDUs for HCV. Sensitivity analysis shows a range of possible cost utility from 3333 Pounds to 81,438 Pounds. Estimates are particularly sensitive to adherence to liver biopsy and treatment and to discounting of benefits. CONCLUSIONS: Although potentially cost effective, many important uncertainties surround the assumptions used to estimate the long term effectiveness of screening and treatment. There is insufficient evidence to inform policy development and further research is required in this rapidly changing field.

Comorbidity↗