Boundaries in Action : An Activity-theoretical Study of Development, Learning, and Change in Health Care Organization for Patients with Multiple and Chronic Illnesses

This study examines boundaries in health care organizations. Boundaries are sometimes considered things to be avoided in everyday living. This study suggests that boundaries can be important temporally and spatially emerging locations of development, learning, and change in inter-organizational activity. Boundaries can act as mediators of cultural and social formations and practices. The data of the study was gathered in an intervention project during the years 2000-2002 in Helsinki in which the care of 26 patients with multiple and chronic illnesses was improved. The project used the Change Laboratory method that represents a research assisted method for developing work. The research questions of the study are: (1) What are the boundary dynamics of development, learning, and change in health care for patients with multiple and chronic illnesses? (2) How do individual patients experience boundaries in their health care? (3) How are the boundaries of health care constructed and reconstructed in social interaction? (4) What are the dynamics of boundary crossing in the experimentation with the new tools and new practice? The methodology of the study, the ethnography of the multi-organizational field of activity, draws on cultural-historical activity theory and anthropological methods. The ethnographic fieldwork involves multiple research techniques and a collaborative strategy for raising research data. The data of this study consists of observations, interviews, transcribed intervention sessions, and patients' health documents. According to the findings, the care of patients with multiple and chronic illnesses emerges as fragmented by divisions of a patient and professionals, specialties of medicine and levels of health care organization. These boundaries have a historical origin in the Finnish health care system. As an implication of these boundaries, patients frequently experience uncertainty and neglect in their care. However, the boundaries of a single patient were transformed in the Change Laboratory discussions among patients, professionals and researchers. In these discussions, the questioning of the prevailing boundaries was triggered by the observation of gaps in inter-organizational care. Transformation of the prevailing boundaries was achieved in implementation of the collaborative care agreement tool and the practice of negotiated care. However, the new tool and practice did not expand into general use during the project. The study identifies two complementary models for the development of health care organization in Finland. The 'care package model', which is based on productivity and process models adopted from engineering and the 'model of negotiated care', which is based on co-configuration and the public good.

Environmental and health effects associated with Harmful Algal Bloom and marine algal toxins in China

The frequency and scale of Harmful Algal Bloom (HAB) and marine algal toxin incidents have been increasing and spreading in the past two decades, causing damages to the marine environment and threatening human life through contaminated seafood. To better understand the effect of HAB and marine algal toxins on marine environment and human health in China, this paper overviews HAB occurrence and marine algal toxin incidents, as well as their environmental and health effects in this country. HAB has been increasing rapidly along the Chinese coast since the 1970s, and at least 512 documented HAB events have occurred from 1952 to 2002 in the Chinese mainland. It has been found that PSP and DSP toxins are distributed widely along both the northern and southern Chinese coasts. The HAB and marine algal toxin events during the 1990s in China were summarized, showing that the HAB and algal toxins resulted in great damages to local fisheries, marine culture, quality of marine environment, and human health. Therefore, to protect the coastal environment and human health, attention to HAB and marine algal toxins is urgently needed from the environmental and epidemiological view.

Assessing the Oral Health Needs of Public Housing Residents

Objectives: “Tooth Smart Healthy Start” is a randomized clinical trial which aims to reduce the incidence of early childhood caries (ECC) in Boston public housing residents as part of the NIH funded Northeast Center for Research to Evaluate and Eliminate Dental Disparities. The purpose of this project was to assess public housing stakeholders' perception of the oral health needs of public housing residents and their interest in replicating “Tooth Smart Healthy Start” in other public housing sites across the nation. Methods: The target population was the 180 attendees of the 2010 meeting of the Health Care for Residents of Public Housing National Conference. A ten question survey which assessed conference attendees' beliefs about oral health and its importance to public housing residents was distributed. Data was analyzed using SAS 9.1. Descriptive statistics were calculated for each variable and results were stratified by participants' roles. Results: Thirty percent of conference attendees completed the survey. The participants consisted of residents, agency representatives, and housing authority personnel. When asked to rank health issues facing public housing residents, oral health was rated as most important (42%) or top three (16%) by residents. The agency representatives and housing authority personnel rated oral health among the top three (33% and 58% respectively) and top five (36% and 25% respectively). When participants ranked the three greatest resident health needs out of eight choices, oral health was the most common response. Majority of the participants expressed interest in replicating the “Tooth Smart Healthy Start” program at their sites. Conclusion: All stakeholder groups identified oral health as one of the greatest health needs of residents in public housing. Furthermore, if shown to reduce ECC, there is significant interest in implementing the program amongst key public housing stakeholders across the nation.

Randomized, controlled trial investigating short-term health-related quality of life with doxorubicin and paclitaxel versus doxorubicin and cyclophosphamide as first-line chemotherapy in patients with metastatic breast cancer: European Organization for Research and Treatment of Cancer Breast Cancer Group, Investigational Drug Branch for Breast Cancer and the New Drug Development Group Study.

PURPOSE: To compare health-related quality of life (HRQOL) in patients with metastatic breast cancer receiving the combination of doxorubicin and paclitaxel (AT) or doxorubicin and cyclophosphamide (AC) as first-line chemotherapy treatment. PATIENTS AND METHODS: Eligible patients (n = 275) with anthracycline-naive measurable metastatic breast cancer were randomly assigned to AT (doxorubicin 60 mg/m(2) as an intravenous bolus plus paclitaxel 175 mg/m(2) as a 3-hour infusion) or AC (doxorubicin 60 mg/m(2) plus cyclophosphamide 600 mg/m(2)) every 3 weeks for a maximum of six cycles. Dose escalation of paclitaxel (200 mg/m(2)) and cyclophosphamide (750 mg/m(2)) was planned at cycle 2 to reach equivalent myelosuppression in the two groups. HRQOL was assessed with the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire C30 and the EORTC Breast Module at baseline and the start of cycles 2, 4, and 6, and 3 months after the last cycle. RESULTS: Seventy-nine percent of the patients (n = 219) completed a baseline measure. However, there were no statistically significant differences in HRQOL between the two treatment groups. In both groups, selected aspects of HRQOL were impaired over time, with increased fatigue, although some clinically significant improvements in emotional functioning were seen, as well as a reduction in pain over time. Overall, global quality of life was maintained in both treatment groups. CONCLUSION: This information is important when advising women patients of the expected HRQOL consequences of treatment regimens and should help clinicians and their patients make informed treatment decisions.

Introducing e-learning in a large multisite academic health sciences centre: a case study of e-curriculum planning and educator support /

This qualitative study investigated how a team of 7 hospital educators collaborated to develop e-curriculum units to pilot for a newly acquired learning -r management system at a large, multisite academic health sciences centre. A case study approach was used to examine how the e-Curriculum Team was structured, how the educators worked together to develop strategies to better utilize e-leaming in their ovwi practice, what e-curriculum they chose to develop, and how they determined their priorities for e-curriculum development. It also inquired into how they planned to involve other educators in using e-leaming. One set of semistructured interviews with the 6 hospital educators involved in the project, as well as minutes of team meetings and the researcher's journal, were analyzed (the researcher was also a hospital educator on the team). Project management structure, educator support, and organizational pressures on the implementation project feature prominently in the case study. This study suggests that implementation of e-leaming will be more successful if (a) educators involved in the development of e-leaming curriculum are supported in their role as change agents, (b) the pain of vmleaming current educational practice is considered, (c) the limitations of the software being implemented are recognized, (d) time is spent leaming about best practice, and (e) the project is protected as much as possible from organizational pressures and distractions.

Partnership, politics and public administration: a case study of the Ontario Ministry of Natural Resources

Efforts to reform the public sector reflect the social, political and economic environment within which government must function. The recent demands by the public for more consensual decision-making, as well as more efficient, effective and responsive public service, have resulted in a number of reform initiatives, including an emphasis on partnership development. The purpose of this thesis is to examine partnership arrangements within the public sector. Specifically, the thesis will assess the value of partnerships and their impact on government by examining six partnership arrangements involving the Ontario Ministry of Natural Resources (OMNR). The OMNR, having recently been awarded the 1992 Institute of Public Administration of Canada Award for Innovative Management, on the theme of partnership development, is being lauded as an example for other government agencies considering similar alliances. The thesis begins by introducing the concept and practice of partnership within the public sector in general and the OMNR specifically. Descriptive analysis of six OMNR partnerships is provided and a number of criteria are used to determine the success of each of these arrangements. Special attention is paid to the political implications of partnerships and to those attributes which appear to contribute to the successful establishment and iii maintenance of partnership arrangements. The conclusion is drawn that partnerships provide the government with an opportunity to address public demands for greater involvement in decision-making while accommodating government's limited financial resources. However, few truly collaborative partnerships exist within the public sector. There are also significant political implications associated with partnerships which must be dealt with both at the political and bureaucratic levels of government. Lastly, it is argued that while partnerships within the OMNR are experiencing some difficulties, they constitute a genuine attempt to broaden the base of decision-making and to incorporate the concerns of stakeholders into resource management.

How health organizations can apply scenario based planning and analytic technologies to make strategic consequential decisions in a time of uncertainty

The magnitude of the cervical cancer problem, coupled with the potential for prevention with recent technological advances, made it imperative to step back and reassess strategic options for dealing with cervical cancer screening in Kenya. The purpose of this qualitative study was: 1) to explore the extent to which the Participatory Action Research (PAR) methodology and the Scenario Based Planning (SBP) method, with the application of analytics, could enable strategic, consequential, informed decision making, and 2) to determine how influential Kenyan decision makers could apply SBP with analytic tools and techniques to make strategic, consequential decisions regarding the implementation of a Cervical Self Sampling Program (CSSP) in both urban and rural settings. The theoretical paradigm for this study was action research; it was experiential, practical, and action oriented, and resulted in co-created knowledge that influenced study participants’ decision making. Action Africa Help International (AAHI) and Brock University collaborated with Local Decision Influencing Participants (LDIP’s) to develop innovative strategies on how to implement the CSSP. SBP tools, along with traditional approaches to data collection and analysis, were applied to collect, visualize and analyze predominately qualitative data. Outputs from the study included: a) a generic implementation scenario for a CSSP (along with scenarios unique to urban and rural settings), and b) 10 strategic directions and 22 supporting implementation strategies that address the variables of: 1) technical viability, 2) political support, 3) affordability, 4) logistical feasibility, 5) social acceptability, and 6) transformation/sustainability. In addition, study participants’ capacity to effectively engage in predictive/prescriptive strategic decision making was strengthened.

Safe and exciting science : a pack of training activities on health and safety for science departments in secondary schools and colleges and for initial teacher training.

Es un recurso formativo elaborado en respuesta a diversas solicitudes de escuelas para ayudar a éstas en los servicios de salud y actividades de formación en seguridad. Este material puede ser utilizado por los profesores en las prácticas realizadas en los laboratorios escolares con un riesgo mínimo. Va dirigido a asesores científicos, profesores, consultores y formadores de docentes.

The Assault on Human Rigths and the Resilience of the Andean Dream: Health Inequities in Ecuador. IV Annual Distinguished Lecture sponsored by the Center for Research on Ethnicity, Culture and Health; School of Public Health; University of Michigan

The point of departure for these reflections is life, since its protection is the central purpose encouraging the defense of human rights and of public health. Life in the Andes has an exceptional diversity. Particularly in Ecuador, my country, this diversity constitutes a characteristic sign that is expressed in two main forms: natural megadiversity and multiculturalism. Indeed, Ecuador’s small territory synthesizes practically all types of lifezones that exist on Earth, having received the gift of high average rates of solar energy and abundant nutritional sources, which have facilitated the natural reproduction of countless species that show their beautiful vitality in the variety of ecosystems that compose the Andean mountain range, the tropical plains, the Amazon humid forests, and the Galapagos Islands. But besides being a highly biodiverse country, it is also a plurinational and multi-cultural society, in which the activity of human beings, organized into social conglomerates of different historical and cultural backgrounds, have formed more than a dozen nations and peoples. Regrettably this natural and human wealth has not been able to bear its best fruits due to the violent operation of a deep social inequity – unfortunately also one of the highest in the Americas—which conspires against life and is reproduced in national and international inequitable relations. This structural inequity has changed its form throughout the centuries and currently has reached its highest and most perverse level of development.

Improving the health forecasting alert system for cold weather and heat-waves in England: a proof-of-concept using temperature-mortality relationships

Objectives In this study a prototype of a new health forecasting alert system is developed, which is aligned to the approach used in the Met Office’s (MO) National Severe Weather Warning Service (NSWWS). This is in order to improve information available to responders in the health and social care system by linking temperatures more directly to risks of mortality, and developing a system more coherent with other weather alerts. The prototype is compared to the current system in the Cold Weather and Heatwave plans via a case-study approach to verify its potential advantages and shortcomings. Method The prototype health forecasting alert system introduces an “impact vs likelihood matrix” for the health impacts of hot and cold temperatures which is similar to those used operationally for other weather hazards as part of the NSWWS. The impact axis of this matrix is based on existing epidemiological evidence, which shows an increasing relative risk of death at extremes of outdoor temperature beyond a threshold which can be identified epidemiologically. The likelihood axis is based on a probability measure associated with the temperature forecast. The new method is tested for two case studies (one during summer 2013, one during winter 2013), and compared to the performance of the current alert system. Conclusions The prototype shows some clear improvements over the current alert system. It allows for a much greater degree of flexibility, provides more detailed regional information about the health risks associated with periods of extreme temperatures, and is more coherent with other weather alerts which may make it easier for front line responders to use. It will require validation and engagement with stakeholders before it can be considered for use.

Breastfeeding knowledge and practice of health professionals in public health care services

Objetivou-se avaliar conhecimentos e práticas sobre aleitamento materno de profissionais que atendem lactentes em unidades de atenção básica, ou maternidades públicas, de município do interior paulista, Brasil. É estudo epidemiológico, sendo a população composta por 89 enfermeiros e médicos. Suas respostas a um questionário estruturado foram analisadas no total e segundo o local de trabalho, aplicando-se o teste de diferença de proporções (qui-quadrado), considerando-se p<0,05 como nível crítico. Como parâmetros de acertos foram consideradas as recomendações do Ministério da Saúde. As diferenças significativas para conhecimentos e práticas, segundo o local de trabalho, foram restritas a alguns aspectos, com resultados discretamente melhores dos escores médios de acertos dos profissionais das unidades de atenção básica. Independente do local de trabalho, verificou-se desempenho regular e ruim em diferentes aspectos estudados, indicando que possíveis intervenções para a capacitação nessa temática deverão incluir profissionais de todos os níveis de atenção à saúde.

Algunos aspectos de salud mental en relación al fenómeno de urbanización = Psychological and mental health problems of urbanization based on case studies in Peru

Los documentos del Seminario fueron publicados por UNESCO en 1961 con el título: La urbanización en América Latina/Urbanization in Latin America