Roles of the non-medical prescribing leads within organisations across a Strategic Health Authority: perceived functions and factors supporting the role

Objectives Extending the roles of nurses, pharmacists and allied health professionals to include prescribing has been identified as one way of improving service provision. In the UK, over 50 000 non-medical healthcare professionals are now qualified to prescribe. Implementation of non-medical prescribing ( NMP) is crucial to realise the potential return on investment. The UK Department of Health recommends a NMP lead to be responsible for the implementation of NMP within organisations. The aim of this study was to explore the role of NMP leads in organisations across one Strategic Health Authority (SHA) and to inform future planning with regards to the criteria for those adopting this role, the scope of the role and factors enabling the successful execution of the role. Methods Thirty-nine NMP leads across one SHA were approached. Semi-structured telephone interviews were conducted. Issues explored included the perceived role of the NMP lead, safety and clinical governance procedures and facilitators to the role. Transcribed audiotapes were coded and analysed using thematic analytical techniques. Key findings In total, 27/39 (69.2%) NMP leads were interviewed. The findings highlight the key role that the NMP lead plays with regards to the support and development of NMP within National Health Service trusts. Processes used to appoint NMP leads lacked clarity and varied between trusts. Only two NMP leads had designated or protected time for their role. Strategic influence, operational management and clinical governance were identified as key functions. Factors that supported the role included organisational support, level of influence and dedicated time. Conclusion The NMP lead plays a significant role in the development and implementation of NMP. Clear national guidance is needed with regards to the functions of this role, the necessary attributes for individuals recruited into this post and the time that should be designated to it. This is important as prescribing is extended to include other groups of non-medical healthcare professionals.

Civilian casualties ��� do we really care? The failure of the revolution in military affairs of non-lethal weapons in the U.S., Russia and Israel

Causing civilian casualties during military operations has become a much politicised topic in international relations since the Second World War. Since the last decade of the 20th century, different scholars and political analysts have claimed that human life is valued more and more among the general international community. This argument has led many researchers to assume that democratic culture and traditions, modern ethical and moral issues have created a desire for a world without war or, at least, a demand that contemporary armed conflicts, if unavoidable, at least have to be far less lethal forcing the military to seek new technologies that can minimise civilian casualties and collateral damage. Non-Lethal Weapons (NLW) – weapons that are intended to minimise civilian casualties and collateral damage – are based on the technology that, during the 1990s, was expected to revolutionise the conduct of warfare making it significantly less deadly. The rapid rise of interest in NLW, ignited by the American military twenty five years ago, sparked off an entirely new military, as well as an academic, discourse concerning their potential contribution to military success on the 21st century battlefields. It seems, however, that except for this debate, very little has been done within the military forces themselves. This research suggests that the roots of this situation are much deeper than the simple professional misconduct of the military establishment, or the poor political behaviour of political leaders, who had sent them to fight. Following the story of NLW in the U.S., Russia and Israel this research focuses on the political and cultural aspects that have been supposed to force the military organisations of these countries to adopt new technologies and operational and organisational concepts regarding NLW in an attempt to minimise enemy civilian casualties during their military operations. This research finds that while American, Russian and Israeli national characters are, undoubtedly, products of the unique historical experience of each one of these nations, all of three pay very little regard to foreigners�� lives. Moreover, while it is generally argued that the international political pressure is a crucial factor that leads to the significant reduction of harmed civilians and destroyed civilian infrastructure, the findings of this research suggest that the American, Russian and Israeli governments are well prepared and politically equipped to fend off international criticism. As the analyses of the American, Russian and Israeli cases reveal, the political-military leaderships of these countries have very little external or domestic reasons to minimise enemy civilian casualties through fundamental-revolutionary change in their conduct of war. In other words, this research finds that employment of NLW have failed because the political leadership asks the militaries to reduce the enemy civilian casualties to a politically acceptable level, rather than to the technologically possible minimum; as in the socio-cultural-political context of each country, support for the former appears to be significantly higher than for the latter.

Health in Brazil 2 Maternal and child health in Brazil: progress and challenges

In the past three decades, Brazil has undergone rapid changes in major social determinants of health and in the organisation of health services. In this report, we examine how these changes have affected indicators of maternal health, child health, and child nutrition. We use data from vital statistics, population censuses, demographic and health surveys, and published reports. In the past three decades, infant mortality rates have reduced substantially, decreasing by 5.5% a year in the 1980s and 1990s, and by 4.4% a year since 2000 to reach 20 deaths per 1000 livebirths in 2008. Neonatal deaths account for 68% of infant deaths. Stunting prevalence among children younger than 5 years decreased from 37% in 1974-75 to 7% in 2006-07. Regional differences in stunting and child mortality also decreased. Access to most maternal-health and child-health interventions increased sharply to almost universal coverage, and regional and socioeconomic inequalities in access to such interventions were notably reduced. The median duration of breastfeeding increased from 2.5 months in the 1970s to 14 months by 2006-07. Official statistics show stable maternal mortality ratios during the past 10 years, but modelled data indicate a yearly decrease of 4%, a trend which might not have been noticeable in official reports because of improvements in death registration and the increased number of investigations into deaths of women of reproductive age. The reasons behind Brazil`s progress include: socioeconomic and demographic changes (economic growth, reduction in income disparities between the poorest and wealthiest populations, urbanisation, improved education of women, and decreased fertility rates), interventions outside the health sector (a conditional cash transfer programme and improvements in water and sanitation), vertical health programmes in the 1980s (promotion of breastfeeding, oral rehydration, and immunisations), creation of a tax-funded national health service in 1988 (coverage of which expanded to reach the poorest areas of the country through the Family Health Program in the mid-1990s); and implementation of many national and state-wide programmes to improve child health and child nutrition and, to a lesser extent, to promote women`s health. Nevertheless, substantial challenges remain, including overmedicalisation of childbirth (nearly 50% of babies are delivered by caesarean section), maternal deaths caused by illegal abortions, and a high frequency of preterm deliveries.

LEARNING STUDY: ROZVOJ ŠKOLY SKRZE KOLEGIÁLNÍ UČENÍ UČITELŮ : Learning study: school development through collegial learning of teachers

The aim of this article is to describe how the Learning Study method (LS) was implemented in a Swedish upper secondary school, as well as how the principals and the teachers involved perceived this to affect teaching at, and the development of, the school. It is an empirical study that was conducted as an action research project over a period of three years. The project to implement the LS method was based on the assumption that proper training is the result of collegial activity that occurs when teachers learn from each other. The teachers in this study were, in general, positive about using the LS method. It created opportunities to meet and talk about teaching skills, developed better professional relationships between colleagues, and offered a systematic method for planning, implementing and monitoring teaching. However, working together requires that time be set aside to allow for implementation of the LS method. This is crucial, as the LS method is a rather expensive way to make school development work. This places heavy demands on principals to create the necessary conditions for the implementation of the LS method.

Improvement of heart rate variability after exercise training and its predictors in COPD

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Combining adapted Judo training and pharmacological treatment to improve bone mineral density on postmenopausal women: A two years study

Background & Study Aim: Physical activity has been an important factor to increase bone mineral density (BMD) and, consequently, to prevent and treat osteoporosis. The study aimed the effects of adapted Judo training on BMD in postmenopausal women, during pharmacological treatment. Material & Methods: Eighteen female volunteers participated in this study. They were separated into two groups: Adapted Judo training (AJT) (n=11; 52.2±5.3 years) and control group (CG) (n=7; 53.8±4.4 years). Lunar GE Dual Energy X-Ray Absorptiometry (DXA) measured BMD at lumbar L2-L4, femoral neck and trochanter sites. The training period for AJT was two years, comprised 12 mesocycles with different intensities. ANOVA compared 2 groups in 3 moments of testing and Scheffé Test allowed multiple comparisons between groups for the L2-L4 and femoral neck sites, but at trochanter was Fisher LSD. Results: ANOVA showed significant differences in the AJT group (F(2, 32)=15.187, p=0.000023). Scheffé Test showed significant increase on lumbar BMD after one year of AJT (Δ%=+8.9%, p=0.000017) and after two years this improvement stand still (p=0.33). The CG after one year presented significant decrease in BMD of femoral neck (Δ%=-6.9%, p=0.03) and trochanter (Δ%=-3.7%, p=0.0084). However, the CG recovered the loss of BMD of femoral neck (Δ%=+7.6%, p=0.02) and trochanter (Δ%=+3.8%, p=0.0079) after two years of study. Conclusions: Drug therapy, without the physical activity practice, can aid the maintenance of BMD. AJT may be considered as an efficient physical activity for postmenopausal women with low BMD in pharmacological treatment. © ARCHIVES OF BUDO | SCIENCE OF MARTIAL ARTS.

Controle de Qualidade em Raios X Odontológico Periapical

The purpose of this work is to provide quality control requirements and security in dental x-rays in order to obtain good quality image which allows the correct diagnosis, which reduces the dose to the patient, mainly due to the repetition of tests, and decreasing cost. The requirements apply to related activities to quality control and procedures using ionizing radiation for diagnostic imaging in dentistry by evaluating a minimum set of parameters to be tested or verified. Quality control follows the Ordinance No. 453 of the Ministry of Health of 06.01.1998, SS Resolution No. 625 of 12.14.1994 and Resolution No. 64 of the Health Surveillance Center – Department of Health of Sao Paulo and National Health Surveillance Agency – Ministry of Health of Brazil. This study was conducted in the city of Marilia, Sao Paulo, along with the Company P&R Consulting and Medical Physics, in a dental clinic of the University UNIMAR in the x-ray equipment used on that site. The physical parameters of the device were tested with the aid of ionization chambers to measure rates of radiation, electrometer to measure rates of time, kV and doses, radiographic films and positioning devices. Finally, this work demonstrates the need and importance of quality control, which one ensures the proper use of x-ray machines, maintaining efficiency and at the same time it reduces the risks to the patient, to the dentist and to the general public

Design and implementation of wireless sensor networks for impedance-based structural health monitoring using ZigBee and Global System for Mobile Communications

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Role of common mental and physical disorders in partial disability around the world

Background Mental and physical disorders are associated with total disability, but their effects on days with partial disability (i.e. the ability to perform some, but not full-role, functioning in daily life) are not well understood. Aims To estimate individual (i.e. the consequences for an individual with a disorder) and societal effects (i.e. the avoidable partial disability in the society due to disorders) of mental and physical disorders on days with partial disability around the world. Method Respondents from 26 nationally representative samples (n=61 259, age 18+) were interviewed regarding mental and physical disorders, and day-to-day functioning. The Composite International Diagnostic Interview, version 3.0 (CIDI 3.0) was used to assess mental disorders; partial disability (expressed in full day equivalents) was assessed with the World Health Organization Disability Assessment Schedule in the CIDI 3.0. Results Respondents with disorders reported about 1.58 additional disability days per month compared with respondents without disorders. At the individual level, mental disorders (especially post-traumatic stress disorder, depression and bipolar disorder) yielded a higher number of days with disability than physical disorders. At the societal level, the population attributable risk proportion due to physical and mental disorders was 49% and 15% respectively. Conclusions Mental and physical disorders have a considerable impact on partial disability, at both the individual and at the societal level. Physical disorders yielded higher effects on partial disability than mental disorders.

Brazilian Longitudinal Study of Adult Health (ELSA-Brasil): Objectives and Design

Although low- and middle-income countries still bear the burden of major infectious diseases, chronic noncommunicable diseases are becoming increasingly common due to rapid demographic, epidemiologic, and nutritional transitions. However, information is generally scant in these countries regarding chronic disease incidence, social determinants, and risk factors. The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) aims to contribute relevant information with respect to the development and progression of clinical and subclinical chronic diseases, particularly cardiovascular diseases and diabetes. In this report, the authors delineate the study's objectives, principal methodological features, and timeline. At baseline, ELSA-Brasil enrolled 15,105 civil servants from 5 universities and 1 research institute. The baseline examination (2008-2010) included detailed interviews, clinical and anthropometric examinations, an oral glucose tolerance test, overnight urine collection, a 12-lead resting electrocardiogram, measurement of carotid intima-media thickness, echocardiography, measurement of pulse wave velocity, hepatic ultrasonography, retinal fundus photography, and an analysis of heart rate variability. Long-term biologic sample storage will allow investigation of biomarkers that may predict cardiovascular diseases and diabetes. Annual telephone surveillance, initiated in 2009, will continue for the duration of the study. A follow-up examination is scheduled for 2012-2013.

Decentralization and regionalization: dynamics and conditioning factors for the implementation of the Health Pact in Brazil

Decentralization and regionalization represent constitutional guidelines for the organization of the Unified Health System, which in the last 20 years has required the adoption of mechanisms to coordinate and accommodate federative tensions in Brazil's healthcare sector. This paper analyzes the national implementation of the Health Pact between 2006 and 2010 involving a strategy that reconfigures intergovernmental relations in the sector. The study involved the analysis of documents, official data and interviews with federal, state and municipal managers in the Brazilian states. The content of the national proposal is initially discussed, including its implications for health policy. The different rhythms and degrees of implementation of the Health Pact are then reviewed, with respect to adherence by states and municipalities and the formation of Regional Management Boards. Lastly, the conditioning factors for the multiplicity of experiences observed in the country are identified and the challenges facing progress toward a decentralized and regionalized health system in Brazil are discussed.

Family Health Support Centers: challenges and opportunities from the perspective of primary care professionals in the city of Sao Paulo, Brazil

Family Health Support Centers (NASF) were created in Brazil to increase the case-resolution capacity of primary healthcare. Prior to their implementation in the West Side of the city of Sao Paulo, Brazil, a series of workshops were held for primary healthcare professionals to prepare a proposal for such centers. Hermeneutic analysis was used to study the transcribed material. The thematic categories were: role, constitution, and functioning of the NASF, relationship with family health teams, and interdisciplinarity. The participants' expected the NASF to be an empowering device for comprehensiveness of care, intervening in an existing culture of unnecessary referrals while fostering linkage with other levels of care. The participants also expected the NASF to contribute to the discussion on health professionals' training and stimulating reflection with policy-makers on health indicators based exclusively on the number of consultations. These indicators fail to reflect the impact on the services' activities and the quality of care offered to the population in the coverage area.

Evaluation of Viral Load Thresholds for Predicting New World Health Organization Stage 3 and 4 Events in HIV-Infected Children Receiving Highly Active Antiretroviral Therapy

Background: This study evaluated a wide range of viral load (VL) thresholds to identify a cut-point that best predicts new clinical events in children on stable highly active antiretroviral therapy (HAART). Methods: Cox proportional hazards modeling was used to assess the adjusted risk for World Health Organization stage 3 or 4 clinical events (WHO events) as a function of time-varying CD4, VL, and hemoglobin values in a cohort study of Latin American children on HAART >= 6 months. Models were fit using different VL cut-points between 400 and 50,000 copies per milliliter, with model fit evaluated on the basis of the minimum Akaike information criterion value, a standard model fit statistic. Results: Models were based on 67 subjects with WHO events out of 550 subjects on study. The VL cut-points of >2600 and >32,000 copies per milliliter corresponded to the lowest Akaike information criterion values and were associated with the highest hazard ratios (2.0, P = 0.015; and 2.1, P = 0.0058, respectively) for WHO events. Conclusions: In HIV-infected Latin American children on stable HAART, 2 distinct VL thresholds (>2600 and >32,000 copies/mL) were identified for predicting children at significantly increased risk for HIV-related clinical illness, after accounting for CD4 level, hemoglobin level, and other significant factors.

Essays in Applied Health Economics: Evidence on Health and Health Care in Italy and UK

This thesis is the result of my experience as a PhD student taking part in the Joint Doctoral Programme at the University of York and the University of Bologna. In my thesis I deal with topics that are of particular interest in Italy and in Great Britain. Chapter 2 focuses on the empirical test of the existence of the relationship between technological profiles and market structure claimed by Sutton’s theory (1991, 1998) in the specific economic framework of hospital care services provided by the Italian National Health Service (NHS). In order to test the empirical predictions by Sutton, we identify the relevant markets for hospital care services in Italy in terms of both product and geographic dimensions. In particular, the Elzinga and Hogarty (1978) approach has been applied to data on patients�� flows across Italian Provinces in order to derive the geographic dimension of each market. Our results provide evidence in favour of the empirical predictions of Sutton. Chapter 3 deals with the patient mobility in the Italian NHS. To analyse the determinants of patient mobility across Local Health Authorities, we estimate gravity equations in multiplicative form using a Poisson pseudo maximum likelihood method, as proposed by Santos-Silva and Tenreyro (2006). In particular, we focus on the scale effect played by the size of the pool of enrolees. In most of the cases our results are consistent with the predictions of the gravity model. Chapter 4 considers the effects of contractual and working conditions on selfassessed health and psychological well-being (derived from the General Health Questionnaire) using the British Household Panel Survey (BHPS). We consider two branches of the literature. One suggests that “atypical” contractual conditions have a significant impact on health while the other suggests that health is damaged by adverse working conditions. The main objective of our paper is to combine the two branches of the literature to assess the distinct effects of contractual and working conditions on health. The results suggest that both sets of conditions have some influence on health and psychological well-being of employees.