The quality of diabetes care in the community: practice, policy and culture

Aim: Diabetes is an important barometer of health system performance. This chronic condition is a source of significant morbidity, premature mortality and a major contributor to health care costs. There is an increasing focus internationally, and more recently nationally, on system, practice and professional-level initiatives to promote the quality of care. The aim of this thesis was to investigate the ‘quality chasm’ around the organisation and delivery of diabetes care in general practice, to explore GPs’ attitudes to engaging in quality improvement activities and to examine efforts to improve the quality of diabetes care in Ireland from practice to policy. Methods: Quantitative and qualitative methods were used. As part of a mixed methods sequential design, a postal survey of 600 GPs was conducted to assess the organization of care. This was followed by an in-depth qualitative study using semi-structured interviews with a purposive sample of 31 GPs from urban and rural areas. The qualitative methodology was also used to examine GPs’ attitudes to engaging in quality improvement. Data were analysed using a Framework approach. A 2nd observation study was used to assess the quality of care in 63 practices with a special interest in diabetes. Data on 3010 adults with Type 2 diabetes from 3 primary care initiatives were analysed and the results were benchmarked against national guidelines and standards of care in the UK. The final study was an instrumental case study of policy formulation. Semi-structured interviews were conducted with 15 members of the Expert Advisory Group (EAG) for Diabetes. Thematic analysis was applied to the data using 3 theories of the policy process as analytical tools. Results: The survey response rate was 44% (n=262). Results suggested care delivery was largely unstructured; 45% of GPs had a diabetes register (n=157), 53% reported using guidelines (n=140), 30% had formal call recall system (n=78) and 24% had none of these organizational features (n=62). Only 10% of GPs had a formal shared protocol with the local hospital specialist diabetes team (n=26). The lack of coordination between settings was identified as a major barrier to providing optimal care leading to waiting times, overburdened hospitals and avoidable duplication. The lack of remuneration for chronic disease management had a ripple effect also creating costs for patients and apathy among GPs. There was also a sense of inertia around quality improvement activities particularly at a national level. This attitude was strongly influenced by previous experiences of change in the health system. In contrast GP’s spoke positively about change at a local level which was facilitated by a practice ethos, leadership and special interest in diabetes. The 2nd quantitative study found that practices with a special interest in diabetes achieved a standard of care comparable to the UK in terms of the recording of clinical processes of care and the achievement of clinical targets; 35% of patients reached the HbA1c target of <6.5% compared to 26% in England and Wales. With regard to diabetes policy formulation, the evolving process of action and inaction was best described by the Multiple Streams Theory. Within the EAG, the formulation of recommendations was facilitated by overarching agreement on the “obvious” priorities while the details of proposals were influenced by personal preferences and local capacity. In contrast the national decision-making process was protracted and ambiguous. The lack of impetus from senior management coupled with the lack of power conferred on the EAG impeded progress. Conclusions: The findings highlight the inconsistency of diabetes care in Ireland. The main barriers to optimal diabetes management center on the organization and coordination of care at the systems level with consequences for practice, providers and patients. Quality improvement initiatives need to stimulate a sense of ownership and interest among frontline service providers to address the local sense of inertia to national change. To date quality improvement in diabetes care has been largely dependent the “special interest” of professionals. The challenge for the Irish health system is to embed this activity as part of routine practice, professional responsibility and the underlying health care culture.

Broadening public input into science policy decision making: can the democratic model for science communication influence scientific, innovation and technological trajectories?

This PhD thesis investigates the potential use of science communication models to engage a broader swathe of actors in decision making in relation to scientific and technological innovation in order to address possible democratic deficits in science and technology policy-making. A four-pronged research approach has been employed to examine different representations of the public(s) and different modes of engagement. The first case study investigates whether patient-groups could represent an alternative needs-driven approach to biomedical and health sciences R & D. This is followed by enquiry into the potential for Science Shops to represent a bottom-up approach to promote research and development of local relevance. The barriers and opportunities for the involvement of scientific researchers in science communication are next investigated via a national survey which is comparable to a similar survey conducted in the UK. The final case study investigates to what extent opposition or support regarding nanotechnology (as an emerging technology) is reflected amongst the YouTube user community and the findings are considered in the context of how support or opposition to new or emerging technologies can be addressed using conflict resolution based approaches to manage potential conflict trajectories. The research indicates that the majority of communication exercises of relevance to science policy and planning take the form of a one-way flow of information with little or no facility for public feedback. This thesis proposes that a more bottom-up approach to research and technology would help broaden acceptability and accountability for decisions made relating to new or existing technological trajectories. This approach could be better integrated with and complementary to government, institutional, e.g. university, and research funding agencies activities and help ensure that public needs and issues are better addressed directly by the research community. Such approaches could also facilitate empowerment of societal stakeholders regarding scientific literacy and agenda-setting. One-way information relays could be adapted to facilitate feedback from representative groups e.g. Non-governmental organisations or Civil Society Organisations (such as patient groups) in order to enhance the functioning and socio-economic relevance of knowledge-based societies to the betterment of human livelihoods.

The student bullying of teachers in Irish second level schools: exploring the influence of historical low state intervention in education on the development of contemporary policy responses in Ireland

The student bullying of teachers (SBT) is a distinct and complex form of bullying with a multiplicity of diverse, changeable and intersecting causes which is experienced by and affects teachers in a variety of ways. SBT is both a national and an international phenomenon which is under-recognised in academic, societal and political spheres, resulting in limited conceptual understanding and awareness of the issue. This study explores teachers’ experiences of SBT behaviours in Irish second level schools as well as teachers’ perceptions regarding training, policies and supports in Ireland to address the issue. Specifically, the study seeks to explore the influence of historical low State intervention in education on contemporary policies and supports to deal with SBT in Ireland. A mixed methods approach involving a survey of 531 second level school teachers and 17 semi-structured interviews with teachers, Year Heads and representatives from teacher trade unions and school management bodies was employed to collect and analyse data. Findings indicate that SBT behaviours are prevalent in many forms in Irish second level schools. The hidden nature of the phenomenon has simultaneously contributed to and is reinforced by limited understanding of the issue as well as teachers’ reluctance to disclose their experiences. Findings reveal that teachers perceive the contemporary policies, training and support structures in Ireland to be inadequate in equipping them to effectively deal with SBT. State intervention in addressing SBT behaviours to date, has been limited, therefore many teachers are forced to respond to the issue based on their own initiatives and assumptions rather than from an informed critically reflective approach, supported by national guidelines and sufficient State investment. This has resulted in a piecemeal, un-coordinated and ad-hoc approach to SBT in Irish schools both in terms of teachers’ management of SBT behaviours and with respect to the supports extended to staff. The potential negative consequences of SBT behaviours on teachers’ wellbeing and professional performance and thus, on the education system itself, underlines the need for a strategic, evidence-based, resourced and integrated approach which includes, as a pivotal component, consultation with teachers, whose contribution to the process is crucial.

Preserving patent policy space and securing access to medicines in developing countries: the role of states and pharmaceutical corporations

This thesis examines the tension between patent rights and the right to health and it recognizes patent rights on pharmaceutical products as one of the factors responsible for the problem of lack of access to affordable medicines in developing countries. The thesis contends that, in order to preserve their patent policy space and secure access to affordable medicines for their citizens, developing countries should incorporate a model of human rights into the design, implementation, interpretation, and enforcement of their national patent laws. The thesis provides a systematic analysis of court decisions from four key developing countries (Brazil, India, Kenya, and South Africa) and it assesses how the national courts in these countries resolve the tension between patent rights and the right to health. Essentially, this thesis demonstrates how a model of human rights can be incorporated into the adjudication of disputes involving patent rights in national courts. Focusing specifically on Brazil, the thesis equally demonstrates how policy makers and law makers at the national level can incorporate a model of human rights into the design or amendment of their national patent law. This thesis also contributes to the ongoing debate in the field of business and human rights with regard to the mechanisms that can be used to hold corporate actors accountable for their human rights responsibilities. This thesis recognizes that, while states bear the primary responsibility to respect, protect, and fulfil the right to health, corporate actors such as pharmaceutical companies also have a baseline responsibility to respect the right to health. This thesis therefore contends that pharmaceutical companies that own patent rights on pharmaceutical products can be held accountable for their right to health responsibilities at the national level through the incorporation of a model of civic participation into a country’s patent law system.

Ford, Carter and Cambodia: US foreign policy and the Khmer Rouge

This thesis is an investigation into the US response to the Khmer Rouge regime in Cambodia between 1974 and 1981. It argues that the US experience in the Vietnam War acted as a causal factor in the formulation of its Cambodian policy during the presidencies of Gerald Ford and Jimmy Carter. From taking power in April 1975 to their removal by the Vietnamese in January 1979, the Khmer Rouge initiated a revolution unrivalled in the 20th Century for its brutality and for the total eradication of modern society. This thesis demonstrates that the Ford administration viewed Cambodia only as it pertained to their strategy in Vietnam and, following US disengagement from Indochina all but ignored the atrocities occurring there as they instead pursued informal relations with the Khmer Rouge as a means of punishing the Vietnamese. The Carter administration formulated a foreign policy based on human rights yet failed to adequately address the genocide that occurred in Cambodia due to its temporal and regional proximity to Vietnam. Instead, this collective reluctance to reengage with the region and the resulting anti-Vietnamese attitude reinforced Brzezinski’s broader global strategy that allied the US with China in support of an independent Cambodia to further isolate Hanoi. Thus this thesis argues that the distorting impact of the Vietnam War, as well as global Cold War calculations, undermined any appreciation of the Cambodian conflict and caused both administrations to pursue policies in Cambodia that ultimately supported the Khmer Rouge regime. This project incorporates declassified material from the Ford and Carter Presidential Libraries, supplemented by the material from the National Archives and Library of Congress, and relevant newspapers and periodicals. It demonstrates that the limitations placed upon US foreign policy by their experience in the Vietnam War may be used to reveal unexplored elements in US-Cambodian relations.

Accessibility, availability and affordability of anti-malarials in a rural district in Kenya after implementation of a national subsidy scheme.

BACKGROUND: Poor access to prompt and effective treatment for malaria contributes to high mortality and severe morbidity. In Kenya, it is estimated that only 12% of children receive anti-malarials for their fever within 24 hours. The first point of care for many fevers is a local medicine retailer, such as a pharmacy or chemist. The role of the medicine retailer as an important distribution point for malaria medicines has been recognized and several different strategies have been used to improve the services that these retailers provide. Despite these efforts, many mothers still purchase ineffective drugs because they are less expensive than effective artemisinin combination therapy (ACT). One strategy that is being piloted in several countries is an international subsidy targeted at anti-malarials supplied through the retail sector. The goal of this strategy is to make ACT as affordable as ineffective alternatives. The programme, called the Affordable Medicines Facility - malaria was rolled out in Kenya in August 2010. METHODS: In December 2010, the affordability and accessibility of malaria medicines in a rural district in Kenya were evaluated using a complete census of all public and private facilities, chemists, pharmacists, and other malaria medicine retailers within the Webuye Demographic Surveillance Area. Availability, types, and prices of anti-malarials were assessed. There are 13 public or mission facilities and 97 medicine retailers (registered and unregistered). RESULTS: The average distance from a home to the nearest public health facility is 2 km, but the average distance to the nearest medicine retailer is half that. Quinine is the most frequently stocked anti-malarial (61% of retailers). More medicine retailers stocked sulphadoxine-pyramethamine (SP; 57%) than ACT (44%). Eleven percent of retailers stocked AMFm subsidized artemether-lumefantrine (AL). No retailers had chloroquine in stock and only five were selling artemisinin monotherapy. The mean price of any brand of AL, the recommended first-line drug in Kenya, was $2.7 USD. Brands purchased under the AMFm programme cost 40% less than non-AMFm brands. Artemisinin monotherapies cost on average more than twice as much as AMFm-brand AL. SP cost only $0.5, a fraction of the price of ACT. CONCLUSIONS: AMFm-subsidized anti-malarials are considerably less expensive than unsubsidized AL, but the price difference between effective and ineffective therapies is still large.

Prioritization of knowledge needs for sustainable aquaculture: a national and global perspective

Aquaculture is currently the fastest expanding global animal food production sector and is a key future contributor to food security. An increase in food security will be dependent upon the development and improvement of sustainable practices. A prioritization exercise was undertaken, focusing on the future knowledge needs to underpin UK sustainable aquaculture (both domestic and imported products) using a ‘task force’ group of 36 ‘practitioners’ and 12 ‘research scientists’ who have an active interest in sustainable aquaculture. A long list of 264 knowledge needs related to sustainable aquaculture was developed in conjunction with the task force. The long list was further refined through a three stage process of voting and scoring, including discussions of each knowledge need. The top 25 knowledge needs are presented, as scored separately by ‘practitioners’ or ‘research scientists’. There was similar agreement in priorities identified by these two groups. The priority knowledge needs will provide guidance to structure ongoing work to make science accessible to practitioners and help to prioritize future science policy needs and funding. The process of knowledge exchange, and the mechanisms by which this can be achieved, effectively emerged as the top priority for sustainable aquaculture. Viable alternatives to wild fish-based aquaculture feeds, resource constraints that will potentially limit expansion of aquaculture, sustainable offshore aquaculture and the treatment of sea lice also emerged as strong priorities. Although the exercise was focused on UK needs for sustainable aquaculture, many of the emergent issues are considered to have global application.

Making modelling count - increasing the contribution of shelf-seas community and ecosystem models to policy development and management

Marine legislation is becoming more complex and marine ecosystem-based management is specified in national and regional legislative frameworks. Shelf-seas community and ecosystem models (hereafter termed ecosystem models) are central to the delivery of ecosystem-based management, but there is limited uptake and use of model products by decision makers in Europe and the UK in comparison with other countries. In this study, the challenges to the uptake and use of ecosystem models in support of marine environmental management are assessed using the UK capability as an example. The UK has a broad capability in marine ecosystem modelling, with at least 14 different models that support management, but few examples exist of ecosystem modelling that underpin policy or management decisions. To improve understanding of policy and management issues that can be addressed using ecosystem models, a workshop was convened that brought together advisors, assessors, biologists, social scientists, economists, modellers, statisticians, policy makers, and funders. Some policy requirements were identified that can be addressed without further model development including: attribution of environmental change to underlying drivers, integration of models and observations to develop more efficient monitoring programmes, assessment of indicator performance for different management goals, and the costs and benefit of legislation. Multi-model ensembles are being developed in cases where many models exist, but model structures are very diverse making a standardised approach of combining outputs a significant challenge, and there is a need for new methodologies for describing, analysing, and visualising uncertainties. A stronger link to social and economic systems is needed to increase the range of policy-related questions that can be addressed. It is also important to improve communication between policy and modelling communities so that there is a shared understanding of the strengths and limitations of ecosystem models.

The African National Congress and its Critics: 'Predatory Liberalism', Black Empowerment and Intra-Alliance Tensions in Post-Apartheid South Africa

Post-apartheid South Africa is characterized by centralized, neo-liberal policymaking that perpetuates, and in some cases exaggerates, socio-economic inequalities inherited from the apartheid era. The African National Congress (ANC) leadership’s alignment with powerful international and domestic market actors produces tensions within the Tripartite Alliance and between government and civil society. Consequently, several characteristics of ‘predatory liberalism’ are evident in contemporary South Africa: neo-liberal restructuring of the economy is combined with an increasing willingness by government to assert its authority, to marginalize and delegitimize those critical of its abandonment of inclusive governance. A new form of oligarch power, combining entrenched economic interests with those of a new ‘black bourgeoisie’ promoted by narrowly implemented Black Economic Empowerment policies, diminishes prospects for broad-based socio-economic transformation. Because the new policy environment is failing to resolve tensions between global market demands for increasing market liberalization and domestic popular demands for poverty-alleviation and socio-economic transformation, the ANC leadership is forced increasingly to confront ‘ultra-leftists’ who are challenging its credentials as defender of the National Democratic Revolution which was the cornerstone in the anti-apartheid struggle.

Contact as a Policy Mechanisim in Integrated schools in Israel and Northern Ireland

Policy initiatives in inter-group education evolved in Northern Ireland and Israel at around the same
time. In each jurisdiction, the emphasis is on improving relations between protagonist groups in
ethnically divided societies. Central to this objective and at the core of integrated education
(Northern Ireland) and bilingual/bi-national education (Israel) is sustained contact in a shared
learning environment. Based on qualitative research in four schools, this paper examines the nature
of the contact experience in two integrated schools in Northern Ireland and two bilingual/binational
schools in Israel. Through comparative analysis, and with reference to contact theory, it
illuminates some of the contextual and process variables that seemingly mediate the quality and
moderate the effectiveness of contact in each school setting.

'National Antiquities' and the Law

National museums, housing â??national antiquities', were a nineteenth-century cultural phenomenon throughout Europe. In the United Kingdom, they afforded the Treasury a means of preserving relics of antiquity claimed as treasure trove. While satisfying the desire of the scientific community for the preservation of archaeological finds, and national sentiment in Scotland and Ireland, Treasury practice undermined the British Museum's eponymous mission. This paper traces the development and legal consequences of the Treasury policy of national allocation of treasure trove, including the discussion in the Museums Committee of 1898â??99 of the â??nationality' of objects and artefacts, and considers the potential wider significance of â??national antiquity' in the context of changing constitutional arrangements in the United Kingdom in the 1920s, and in the future.

Education and the 'universalist' idiom of empire: Irish National School Books in Ireland and Ontario

This paper compares the founding of the elementary school systems of Ireland and Ontario in the nineteenth century. The systems shared a common set of textbooks that had originated in Ireland. Using examples from a number of these books, which were part of a series that had been specially prepared for the Irish national school system, founded in 1831, and information from archive sources on policy and administration in both countries, the paper argues that there was a common, ‘universalist’, imperialist ideology being promulgated in both systems. The article focuses on these ‘universalist’ principles rather than undertaking a detailed analysis of the textbooks.

Implementing a resuscitation policy for patients at the end of life in an acute hospital setting: qualitative study

Objective : To explore attitudes and experiences of doctors and nurses regarding cardiopulmonary resuscitation for patients with end stage illness in an acute hospital. Design : Qualitative study; thematic analysis of two audio-taped focus groups and four semi-structured interviews. Setting : Acute district hospital, Northern Ireland. Participants : Seven nurses and nine doctors; varying nationality, gender and years of professional experience; involved in cardiopulmonary resuscitation decision-making. Results : Participants reported different interpretations of resuscitation policy and of what do not attempt to resuscitate (DNAR) decisions meant in relation to practical care for patients. This confusion in translating policy into practice contributed to communication difficulties in initiating, documenting and implementing cardiopulmonary resuscitation decisions. Participants were aware of how clinical conditions could change and reported uncertainty in determining end stage illness; they expressed fears of potential consequences of DNAR decisions for patients' care. The more disease-centred approach of doctors to patients' management, compared to nurses' more patient-centred approach, contributed to inter-professional conflict within teams. Doctors identified training needs in applying resuscitation policy and ethical principles in `real life' and nurses identified a need for ongoing professional support, which was perceived as being less available to junior doctors. Personal relationships between staff and patients, cultural reluctance to address sensitive issues and local community expectations of relatives being involved in decisions added to policy implementation difficulties. Conclusions : The findings indicate a need for ongoing staff support and training in applying resuscitation policy to decisions for patients with end stage illness in an acute hospital. They support suggestions that reviews of local resuscitation policy and of national guidelines should be undertaken with openness and honesty regarding the goals, opportunities and difficulties involved in trying to deliver good end of life care in local settings. Palliative Medicine 2007; 21 : 305—312 Key Words: do not attempt resuscitation (DNAR) • end stage illness • inter-professional • policy • resuscitation decisions