The establishment and development of neurosurgery services in Papua New Guinea

BACKGROUND: Papua New Guinea (PNG) is a developing Pacific Nation of 7.3 million people. Although neurosurgery training was introduced to PNG in the year 2000, it was in 2003 that a neurosurgery service was established. Prior to this time, neurosurgery in PNG was performed by general surgeons, with some assistance from visiting Australian neurosurgeons. Neurosurgical training was introduced to PNG in 2000. The model involved a further 3 years of training for a surgeon who had already completed 4 years of general surgical training. We aim to review the output, outcomes and impact achieved by training the first national neurosurgeon. METHODS: The data on activity (output) and outcomes were collected prospectively from 2003-2012. Ongoing mentoring and continuing professional development were provided through annual neurosurgical visits from Australia. There were serious limitations in the provision of equipment, with a lack of computerized tomographic or MR imaging, and adjuvant oncological services. RESULTS: There were 1618 neurosurgery admissions, 1020 neurosurgical procedures with a 5.74 % overall mortality. Seventy percent of cases presented as emergencies. There were improved outcomes, particularly for head injuries, whilst hydrocephalus was managed with an acceptable morbidity and revision rate. CONCLUSIONS: The training of a neurosurgeon resulted in PNG patients receiving a better range of surgical services, with a lower mortality. The outcomes able to be delivered were limited by late presentations of patients and lack of resources including imaging. These themes are familiar to all low- and middle-income countries (LMICs) and this may serve as a model for other LMIC neurosurgical services to adopt as they consider whether to establish and develop neurosurgical and other sub-specialist surgical services.

Implementation of the diabetes and hypertension guideline lifestyle recommendations in urban Mongolia: A qualitative study of primary care providers

Abstract
Background: Hypertension and diabetes, key risk factors for cardiovascular disease, are significant health problems globally. As cardiovascular disease is one of the leading causes of mortality in Mongolia since 2000, clinical guidelines on arterial hypertension and diabetes were developed and implemented in 2011. This paper explores the barriers and enablers influencing the implementation of these guidelines in the primary care setting.
Methods: A phenomenological qualitative study with semi-structured interviews was conducted to explore the implementation of the diabetes and hypertension guidelines at the primary care level, as well as to gain insight into how practitioners view the usability and practicality of the guidelines. Ten family health centres were randomly chosen from a list of all the family health centres (n = 136) located in Ulaanbaatar City. In each centre, a focus group discussion with nurses (n = 20) and individual interviews with practice doctors (n =10) and practice managers (n= 10) were conducted. Data was analysed using a thematic approach utilising the Theoretical Domains Framework.
Results: The majority of the study participants reported being aware of the guidelines and that they had incorporated them into their daily practice. They also reported having attended guideline training sessions which were focused on practice skill development. The majority of participants expressed satisfaction with the wide range of resources that had been supplied to them by the Mongolian Government to assist with the implementation of the guidelines. The resources, supplied from 2011 onwards, included screening devices, equipment for blood tests, medications and educational materials. Other enablers were the participants’ commitment and passion for guideline implementation and their belief in the simplicity and practicality of the guidelines. Primary care providers reported a number of challenges in implementing the guidelines, including frustration caused by increased workload and long waiting times, time constraints, difficulties with conflicting tasks and low patient health literacy.
Conclusions: This study provides evidence that comprehensive and rigorous dissemination and implementation strategies increase the likelihood of successful implementation of new guidelines in low resource primary care settings. It also offers some key lessons that might be carefully considered when other evidence-based clinical guidelines are to be put into effect in low resource settings and elsewhere.

Implementation of clinical guidelines on diabetes and hypertension in urban Mongolia: a qualitative study of primary care providers' perspectives and experiences

BACKGROUND: Hypertension and diabetes, key risk factors for cardiovascular disease, are significant health problems globally. As cardiovascular disease is one of the leading causes of mortality in Mongolia since 2000, clinical guidelines on arterial hypertension and diabetes were developed and implemented in 2011. This paper explores the barriers and enablers influencing the implementation of these guidelines in the primary care setting.

METHODS: A phenomenological qualitative study with semi-structured interviews was conducted to explore the implementation of the diabetes and hypertension guidelines at the primary care level, as well as to gain insight into how practitioners view the usability and practicality of the guidelines. Ten family health centres were randomly chosen from a list of all the family health centres (n = 136) located in Ulaanbaatar City. In each centre, a focus group discussion with nurses (n = 20) and individual interviews with practice doctors (n = 10) and practice managers (n = 10) were conducted. Data was analysed using a thematic approach utilising the Theoretical Domains Framework.

RESULTS: The majority of the study participants reported being aware of the guidelines and that they had incorporated them into their daily practice. They also reported having attended guideline training sessions which were focused on practice skill development. The majority of participants expressed satisfaction with the wide range of resources that had been supplied to them by the Mongolian Government to assist with the implementation of the guidelines. The resources, supplied from 2011 onwards, included screening devices, equipment for blood tests, medications and educational materials. Other enablers were the participants' commitment and passion for guideline implementation and their belief in the simplicity and practicality of the guidelines. Primary care providers reported a number of challenges in implementing the guidelines, including frustration caused by increased workload and long waiting times, time constraints, difficulties with conflicting tasks and low patient health literacy.

CONCLUSIONS: This study provides evidence that comprehensive and rigorous dissemination and implementation strategies increase the likelihood of successful implementation of new guidelines in low resource primary care settings. It also offers some key lessons that might be carefully considered when other evidence-based clinical guidelines are to be put into effect in low resource settings and elsewhere.

Fire affects microhabitat selection, movement patterns, and body condition of an Australian rodent (Rattus fuscipes)

Resource selection by animals influences individual fitness, the abundance of local populations, and the distribution of species. Further, the degree to which individuals select particular resources can be altered by numerous factors including competition, predation, and both natural- and human-induced environmental change. Understanding the influence of such factors on the way animals use resources can guide species conservation and management in changing environments. In this study, we investigated the effects of a prescribed fire on small-scale (microhabitat) resource selection, abundance, body condition, and movement pathways of a native Australian rodent, the bush rat (Rattus fuscipes). Using a before-after, control-impact design, we gathered data from 60 individuals fitted with spool and line tracking devices. In unburnt forest, selection of resources by bush rats was positively related to rushes, logs and complex habitat, and negatively related to ferns and litter. Fire caused selection for spreading grass, rushes, and complex habitat to increase relative to an unburnt control location. At the burnt location after the fire, rats selected patches of unburnt vegetation, and no rats were caught at a trapping site where most of the understory had been burnt. The fire also reduced bush rat abundance and body condition and caused movement pathways to become more convoluted. After the fire, some individuals moved through burnt areas but the majority of movements occurred within unburnt patches. The effects of fire on bush rat resource selection, movement, body condition, and abundance were likely driven by several linked factors including limited access to shelter and food due to the loss of understory vegetation and heightened levels of perceived predation risk. Our findings suggest the influence of prescribed fire on small mammals will depend on the resulting mosaic of burnt and unburnt patches and how well this corresponds to the resource requirements of particular species.

Resource distribution influences positive edge effects in a seagrass fish

According to conceptual models, the distribution of resources plays a critical role in determining how organisms distribute themselves near habitat edges. These models are frequently used to achieve a mechanistic understanding of edge effects, but because they are based predominantly on correlative studies, there is need for a demonstration of causality, which is best done through experimentation. Using artificial seagrass habitat as an experimental system, we determined a likely mechanism underpinning edge effects in a seagrass fish. To test for edge effects, we measured fish abundance at edges (0-0.5 m) and interiors (0.5-1 m) of two patch configurations: continuous (single, continuous 9-m2 patches) and patchy (four discrete 1-m2 patches within a 9-m2 area). In continuous configurations, pipefish (Stigmatopora argus) were three times more abundant at edges than interiors (positive edge effect), but in patchy configurations there was no difference. The lack of edge effect in patchy configurations might be because patchy seagrass consisted entirely of edge habitat. We then used two approaches to test whether observed edge effects in continuous configurations were caused by increased availability of food at edges. First, we estimated the abundance of the major prey of pipefish, small crustaceans, across continuous seagrass configurations. Crustacean abundances were highest at seagrass edges, where they were 16% greater than in patch interiors. Second, we supplemented interiors of continuous treatment patches with live crustaceans, while control patches were supplemented with seawater. After five hours of supplementation, numbers of pipefish were similar between edges and interiors of treatment patches, while the strong edge effects were maintained in controls. This indicated that fish were moving from patch edges to interiors in response to food supplementation. These approaches strongly suggest that a numerically dominant fish species is more abundant at seagrass edges due to greater food availability, and provide experimental support for the resource distribution model as an explanation for edge effects.

End of life care - the importance of advance care planning

Background: Communication about end of life care may involve difficult conversations for patients, family members and health professionals. However, a lack of understanding of a person's wishes about their future care may result in a loss of dignity for the person, and additional distress for their family members and health professionals and burden to the healthcare system. Objective: This article discusses the barriers to advance care planning and provides some guidance for the general practitioner in undertaking advance care planning with patients and their families. Tips for initiating end of life discussions with patients and families utilising the 'PREPARED' acronym, and ensuring appropriate care delivery are included. Discussion: Involving patients and their family members in advance care planning may be challenging and time consuming for GPs. However, there are a number of resources to support this activity in relation to training, communication support and Medicare item funding.

The impact of coordinated care : Eyre region, South Australia 1997-1999

The SA HealthPlus Coordinated Care Trial in the Eyre Region began in fortuitous circumstances. First, it coincided with the completion of the Eyre Regional Health Service (ERHS) needs assessment in 1996, which highlighted outstanding health service needs and community concerns in relation to health care across the region. Second, although conceived as a formal trial, using standard research techniques, scientific processes and formal control groups to test significant differences between intervention and control groups, the trial did not conform strictly to the rules of social science or pure science and became more an exercise in action research. More significantly still, the Eyre Region became involved in the process, not so much as a way of proving a concept (the SA Health Plus hypotheses around utilisation, funding and health outcomes), but as a way of creating opportunities for change in the regional health system. If nothing else, the region stood to benefit from the implementation of the trial and involvement in the trial process. The present paper outlines the impact of the Eyre Coordinated Care Trial, not in terms of hypotheses and data analysis, but in terms of the impact of the trial processes on systems change and the evolution of an outcome-based health system. Such a system has the potential to deliver improved health outcomes to communities within existing financial resources and make much more effective use of resources by integrating care delivery and encouraging collaboration between health providers. In addition, the success of the change process in Eyre also supports the notion that change is not necessarily predicated upon scientific processes and research outcomes alone, but also upon the human and social structures associated with such endeavours. This perspective also contributes to the debate about the nature and role of science in the advancement of knowledge.

Assessing the economic costs of parental mental illness

The economics discipline is broadly concerned with the allocation of scarce societal resources in the context of unlimited societal wants. Intrinsic to economics is the concept of choice – that is, how can we best use scarce societal resources when our wants are greater than the resources available to us. If we were able to satisfy all our wants and needs with our available resources, there would be no need for the discipline of economics! In most economies, markets are used to make these decisions. Markets are basically a mechanism whereby consumers and producers interact in such a way that the “best” allocation of resources is thought to occur. This “best” allocation of resources in economics is said to be an efficient allocation. Efficiency basically assumes that the correct types of services are being produced (allocative efficiency) in the least resource-intensive way (technical efficiency). Inherent within all these concepts is not just cost but also the benefit derived from the consumption of different goods and services. A central tenant of economics is the concept of opportunity cost whereby the true cost of any given action (or service) is the benefit which would have been attained if the resources used in providing that action or service were used in an alternative way. Therefore, both costs and benefits are central to the economic way of thinking. Contrary to much public perception, economics is not necessarily about cutting costs; rather, it is about using resources in the “best” possible way. Inherent within this idea of “best” is “value,” “benefit,” or “utility” (utility is the term most often seen in economics textbooks to refer to the value of using resources). Unfortunately, there are many assumptions which need to be met for markets to operate in an ideal way. One important assumption is that consumers of goods and services need to be aware of the full impact and consequences of all consumption choices. When market failures occur, governments can sometimes intervene in the operation of markets either because the markets are not working properly (largely because the assumptions underpinning the market mechanism are not met) or for social-justice or equity considerations (Rice and Unruh, 2009).

Modelled cost-effectiveness evaluation of bipolar disorder treatments to guide health policy

This analysis evaluates the cost-effectiveness of acute andmaintenance treatments for bipolar disorder (I and II) to assist inefficient allocation of resources to reduce the burden of this condition.

Transforming roles to support student development of academic literacies: a reflection on one team’s experience

Abstract: Social work is a discipline that attracts students from diverse academic backgrounds. Many are first in family to attend university, and come to university through alternative pathways such as vocational education. As a result, there are higher levels of attrition compared to other disciplines, especially in the first year. To address this, and in keeping with a commitment to provide accessible education, one school of social work undertook a project to embed academic literacies into the curriculum. This paper used Gibb’s reflective process to explore how this was experienced by team members. Data were collected via staff focus groups at two different points in time across the project and compared. The reflection unpacked a number of tensions experienced by team members, including concerns about potential loss of resources as a result of academics adopting new roles, and concerns about implementing what was seen as Westernised academic skills which may not fit with students’ ways of thinking and creating knowledge. Overfull curricula and constant change also appeared to be of concern. The reflection highlighted that to achieve effective and sustainable change, action was required at multiple levels.

Associations between parent-child relationship quality and obesogenic risk in adolescence: a systematic review of recent literature.

Adolescence is a period of significant cognitive, social and physiological change, presenting unique risk factors for weight gain. Childhood obesity research has traditionally focused on the influence of parent-level factors on children's eating and weight status. Increasingly, emphasis is turning towards the reciprocal nature of the parent-child relationship and its influence on health behaviour. A systematic literature review was conducted to investigate the relationship between parent-child relationship quality (defined as the felt emotional bond between parent and child) and obesogenic risk (weight status, eating attitudes and behaviours, level of physical activity and sedentary behaviour) in adolescence; 26 papers were included in the review. The results neither support nor challenge an association between parent-child relationship quality and weight, with study design flaws and limited measurement of the parent-child relationship precluding robust conclusions. The review does however suggests that several aspects of the parent-child relationship are important in understanding eating attitudes and behaviours, including the felt emotional bond between the parent and child, the child's perception of how much the parent cares for them and the mother's sensitivity towards the child. The need for further longitudinal research into the association between parent-child relationship quality and obesity risk across this developmental period is discussed.

Bellwether procedures for monitoring and planning essential surgical care in low- and middle-income countries: caesarean delivery, laparotomy and treatment of open fractures

BACKGROUND: Surgical conditions represent a significant proportion of the global burden of disease, and therefore, surgery is an essential component of health systems. Achieving universal health coverage requires effective monitoring of access to surgery. However, there is no widely accepted standard for the required capabilities of a first-level hospital. We aimed to determine whether a group of operations could be used to describe the delivery of essential surgical care.

METHODS: We convened an expert panel to identify procedures that might indicate the presence of resources needed to treat an appropriate range of surgical conditions at first-level hospitals. Using data from the World Health Organization Emergency and Essential Surgical Care Global database, collected using the WHO Situational Analysis Tool (SAT), we analysed whether the ability to perform each of these procedures-which we term "bellwether procedures"-was associated with performing a full range of essential surgical procedures.

FINDINGS: The ability to perform caesarean delivery, laparotomy, and treatment of open fracture was closely associated with performing all obstetric, general, basic, emergency, and orthopaedic procedures (p < 0.001) in the population that responded to the WHO SAT Survey. Procedures including cleft lip, cataract, and neonatal surgery did not correlate with performing the bellwether procedures.

INTERPRETATION: Caesarean delivery, laparotomy, and treatment of open fractures should be standard procedures performed at first-level hospitals. With further validation in other populations, local managers and health ministries may find this useful as a benchmark for what first-level hospitals can and should be able to perform on a 24/7 basis in order to ensure delivery of emergency and essential surgical care to their population. Those procedures which did not correlate with the bellwether procedures can be referred to a specialized centre or collected for treatment by a visiting specialist team.

Analysis of interacting uncertainties in on-site and off-site activities: Implications for hybrid construction

Interaction and integration of uncertainties in on-site and off-site project activities often result in the risk of delays and schedule overruns in hybrid construction projects. To address this problem, a holistic risk analysis approach that assesses the integrating impact of uncertainties on completion times is proposed. The results of the analysis show that growth in project size and work quantities intensifies pair and group interconnection of tasks within and between groups of on-site and off-site activities, resulting in lengthened completion times and deviations from project plans. Unavailability of resources, risk seeking attitudes, and workflow variability are other major contributors to the risk of late completion in hybrid construction. While project managers often analyze on-site and off-site uncertainties separately, practical implications of the research results suggest adoption of a holistic approach in which risk management practices in the two environments are integrated. This approach significantly improves tangible performance measures in projects.

Psychosocial research with children in Iraq : current health practice and policy in a context of armed conflict

There is a need to show how psychosocial issues affect children in conflict areas like Iraq. Raising knowledge and awareness of children’s mental health status in Iraq has been difficult and the knowledge base has been limited by the shortage of resources, international sanctions and the isolation of Iraqi scholars. Many obstacles to research in Iraq exist but an agenda should be developed emphasising the need for high-quality contextualised psychosocial research. Health researchers in the country need to clarify basic population parameters and to provide culturally appropriate, evidence-based interventions for practitioners.

Spatial variation in reproductive effort of a southern Australian seagrass

In marine environments characterised by habitat-forming plants, the relative allocation of resources into vegetative growth and flowering is an important indicator of plant condition and hence ecosystem health. In addition, the production and abundance of seeds can give clues to local resilience. Flowering density, seed bank, biomass and epiphyte levels were recorded for the temperate seagrass Zostera nigricaulis in Port Phillip Bay, south east Australia at 14 sites chosen to represent several regions with different physicochemical conditions. Strong regional differences were found within the large bay. Spathe and seed density were very low in the north of the bay (3 sites), low in the centre of the bay (2 sites) intermediate in the Outer Geelong Arm (2 sites), high in Swan Bay (2 sites) and very high in the Inner Geelong Arm (3 sites). In the south (2 sites) seed density was low and spathe density was high. These regional patterns were largely consistent for the 5 sites sampled over the three year period. Timing of flowering was consistent across sites, occurring from August until December with peak production in October, except during the third year of monitoring when overall densities were lower and peaked in November. Seagrass biomass, epiphyte load, canopy height and stem density showed few consistent spatial and temporal patterns. Variation in spathe and seed density and morphology across Port Phillip Bay reflects varying environmental conditions and suggests that northern sites may be restricted in their ability to recover from disturbance through sexual reproduction. In contrast, sites in the west and south of the bay have greater potential to recover from disturbances due to a larger seed bank and these sites could act as source populations for sites where seed production is low.