The Barriers to the Integration of the Uterine Balloon Tamponade into South Africa and Ghana's Health Systems for the Management of Postpartum Hemorrhage

Background

Postpartum hemorrhage is the most significant contributor to maternal mortality globally, claiming 140,000 lives annually. Postpartum hemorrhage is a leading cause of maternal death in South Africa, with the literature indicating that 80 percent of the postpartum hemorrhage deaths in South Africa are avoidable. Ghana, as of 2010, witnesses 2700 maternal deaths annually, primarily because of poor quality of care in health facilities and services being difficult to access. As per WHO recommendations, uterotonics are integral to treating postpartum hemorrhage as soon as it is diagnosed. In case of persistent bleeding or limited availability of uterotonics, the uterine balloon tamponade (UBT) can be used as a second line of defense. If both these measures are unable to counter the bleeding, providers must perform surgical interventions. Literature on the UBT, as one tool in the protocol to address postpartum hemorrhage, has shown it to have success rates ranging from 60 to 100 percent. Despite the potential to lower the number of postpartum hemorrhage deaths in South Africa and Ghana, the UBT has not been incorporated widely in South Africa and Ghana. The aim of this study is to describe the barriers involved with integrating the UBT into South Africa and Ghana’s health systems to address postpartum hemorrhage.

Methods

The study took place in multiple sites in South Africa (Cape Town, Johannesburg, Durban and Mpumalanga) and in Accra, Ghana. South Africa and Ghana were selected because postpartum hemorrhage contributes greatly to their maternal mortality numbers and there is potential in both countries to lower those rates through greater use of the UBT. A total of 25 participants were interviewed through purposive sampling, snowball sampling and participant referrals, and included various categories of stakeholders integral to the integration process of a medical device. Individual in-depth interviews were used for data collection, with interview questions being tailored to each stakeholder category. The focus of the interviews was on the protocol used to counter postpartum hemorrhage, the frequency with which the UBT is used as part of the protocol, and the process of integrating it into the South Africa and Ghana’s health systems. The data collected were coded using NVivo and analyzed using content analysis.

Results

The barriers to integration of the uterine balloon tamponade to address postpartum hemorrhage in South Africa and Ghana were evident on the political, economic and health delivery levels. The results indicated that the barriers to integration in South Africa included the low recognition of postpartum hemorrhage as a problem, the lack of clarity surrounding the role of the Medicines Control Council as a regulatory body for medical devices, and low awareness of the UBT as an intervention to control postpartum hemorrhage. The barriers in Ghana were the cash constraints experienced by the Ghana Health Services to fund medical devices, a heavy reliance on donors for funding, and the lack of consistent knowledge on processes involving clinical trials for new medical devices in Ghana.

Conclusion

Existing literature on methods to counter postpartum hemorrhage to reduce maternal mortality has focused on and emphasized the efficacy of the UBT. Despite overwhelming evidence supporting the use of the UBT, many health systems across the world, particularly low-income countries, do not have access to the device owing to numerous barriers in integrating the device into obstetric care. This study illustrates the need to focus on incorporating the UBT into health systems for greater availability to health workers and its use as standard of care. Ultimately, this study can be used as a stepping-stone for more research on this subject, providing evidence to influence policymakers to integrate the UBT into their protocols for postpartum hemorrhage response.

Sex offender risk assessment and management in Ireland

This research examined sex offender risk assessment and management in Ireland. It focused on the statutory agencies with primary responsibility (Garda Síochána and the Probation Service). The goal was to document the historical, contextual and current systems, in addition to identifying areas of concern/improvements. The research was a mixed-methods approach. Eight studies were conducted. This incorporated documentary reviews of four Commission to Inquire Reports, qualitative interviews/focus groups with Garda staff, Probation Service staff, statutory agencies, community stakeholders, various Non-Governmental Organisations (NGOs) and sex offenders. Quantitative questionnaires were also administered to Garda staff. In all over 70 interviews were conducted and questionnaires were forwarded to 270 Garda members. The overall findings are: •Sex offender management in Ireland has become formal only since 2001. Knowledge, skills and expertise is in its infancy and is still evolving. •Mixed reviews and questions regarding fitness for purpose of currently used risk assessments tools were noted. •The Sex Offender Act 2001 requires additional elements to ensure safe sex offender monitoring and public protection. A judicial review of the Sex Offender Act 2001 was recommended by many respondents. •Interagency working under SORAM was hugely welcomed. The sharing of information has been welcomed by managing agencies as the key benefit to improving sex offender management. •Respondents reported that in practice, sex offender management in Ireland is fragmented and unevenly implemented. The research concluded that an independent National Sex Offender Authority should be established as an oversight and regulatory body for policy, strategy and direction in sex offender management. Further areas of research were also highlighted: ongoing evaluation and audits of the joint agency process and systems in place; recidivism studies tracking the risk assessment ratings and subsequent offending; and an evaluation of the current status of sex offender housing in Ireland.

Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS)

© 2014, Canadian Anesthesiologists' Society.Optimal perioperative fluid management is an important component of Enhanced Recovery After Surgery (ERAS) pathways. Fluid management within ERAS should be viewed as a continuum through the preoperative, intraoperative, and postoperative phases. Each phase is important for improving patient outcomes, and suboptimal care in one phase can undermine best practice within the rest of the ERAS pathway. The goal of preoperative fluid management is for the patient to arrive in the operating room in a hydrated and euvolemic state. To achieve this, prolonged fasting is not recommended, and routine mechanical bowel preparation should be avoided. Patients should be encouraged to ingest a clear carbohydrate drink two to three hours before surgery. The goals of intraoperative fluid management are to maintain central euvolemia and to avoid excess salt and water. To achieve this, patients undergoing surgery within an enhanced recovery protocol should have an individualized fluid management plan. As part of this plan, excess crystalloid should be avoided in all patients. For low-risk patients undergoing low-risk surgery, a “zero-balance” approach might be sufficient. In addition, for most patients undergoing major surgery, individualized goal-directed fluid therapy (GDFT) is recommended. Ultimately, however, the additional benefit of GDFT should be determined based on surgical and patient risk factors. Postoperatively, once fluid intake is established, intravenous fluid administration can be discontinued and restarted only if clinically indicated. In the absence of other concerns, detrimental postoperative fluid overload is not justified and “permissive oliguria” could be tolerated.

Habitat Use of the Key Largo Woodrat (Neotoma floridana smalli)

Key Largo woodrats are an endangered subspecies with an extremely limited habitat. This study sought to understand woodrat habitat preferences in order to guide management. Woodrats build stick nests from natural and artificial materials, so nest distribution and nest occupancy were used as indicators of preference. Distribution was determined by nest surveys, and remote cameras were used to assess occupancy. Forest structure, human disturbance, nest, and animal presence metrics were also collected. More nests were found along abandoned roads than along forest transects and more artificial nests were occupied than natural nests. These findings indicate that woodrats prefer areas with human disturbance, rather than forest age and structure as previously believed. This may have consequences on woodrat management, as it suggests that man-made materials are currently needed by woodrats even in a protected natural area.

An Epistemic Event-based Correlation Scheme for Pervasive Network Management

Computer networks produce tremendous amounts of event-based data that can be collected and managed to support an increasing number of new classes of pervasive applications. Examples of such applications are network monitoring and crisis management. Although the problem of distributed event-based management has been addressed in the non-pervasive settings such as the Internet, the domain of pervasive networks has its own characteristics that make these results non-applicable. Many of these applications are based on time-series data that possess the form of time-ordered series of events. Such applications also embody the need to handle large volumes of unexpected events, often modified on-the-fly, containing conflicting information, and dealing with rapidly changing contexts while producing results with low-latency. Correlating events across contextual dimensions holds the key to expanding the capabilities and improving the performance of these applications. This dissertation addresses this critical challenge. It establishes an effective scheme for complex-event semantic correlation. The scheme examines epistemic uncertainty in computer networks by fusing event synchronization concepts with belief theory. Because of the distributed nature of the event detection, time-delays are considered. Events are no longer instantaneous, but duration is associated with them. Existing algorithms for synchronizing time are split into two classes, one of which is asserted to provide a faster means for converging time and hence better suited for pervasive network management. Besides the temporal dimension, the scheme considers imprecision and uncertainty when an event is detected. A belief value is therefore associated with the semantics and the detection of composite events. This belief value is generated by a consensus among participating entities in a computer network. The scheme taps into in-network processing capabilities of pervasive computer networks and can withstand missing or conflicting information gathered from multiple participating entities. Thus, this dissertation advances knowledge in the field of network management by facilitating the full utilization of characteristics offered by pervasive, distributed and wireless technologies in contemporary and future computer networks.

An Institutional, Socio-economic, and Legal Analysis of Fisheries Co-management and Regulation in the Gulf of Nicoya, Costa Rica

Marine Areas for Responsible Artisanal Fishing (AMPR) have emerged as a new model for co-managing small-scale fisheries in Costa Rica, one that involves collaboration between fishers, government agencies and NGOs. This thesis aims to examine the context for collective action and co-management by small-scale fishers; evaluate the design, implementation, and enforcement of AMPRs; and conduct a linguistic analysis of fisheries legislation. The present work relies on the analysis of several types of qualitative data, including interviews with 23 key informants, rapid rural assessments, and legal documents. Findings demonstrate the strong influence of economic factors for sustaining collective action, as well as the importance of certain types of external organizations for community development and co-management. Additionally, significant enforcement gaps and institutional deficiencies were identified in the work of regulating agencies. Legal analysis suggests that mechanisms for government accountability are unavailable and that legal discourse reflects some of the most salient problems in management.

Applying complexity science to air traffic management

Complexity science is the multidisciplinary study of complex systems. Its marked network orientation lends itself well to transport contexts. Key features of complexity science are introduced and defined, with a specific focus on the application to air traffic management. An overview of complex network theory is presented, with examples of its corresponding metrics and multiple scales. Complexity science is starting to make important contributions to performance assessment and system design: selected, applied air traffic management case studies are explored. The important contexts of uncertainty, resilience and emergent behaviour are discussed, with future research priorities summarised.

Graded Exercise Therapy Guided Self-Help Trial for Patients with Chronic Fatigue Syndrome (GETSET): Protocol for a Randomized Controlled Trial and Interview Study

Background: Chronic fatigue syndrome, also known as myalgic encephalomyelitis (CFS/ME), is characterized by chronic disabling fatigue and other symptoms, which are not explained by an alternative diagnosis. Previous trials have suggested that graded exercise therapy (GET) is an effective and safe treatment. GET itself is therapist-intensive with limited availability. Objective: While guided self-help based on cognitive behavior therapy appears helpful to patients, Guided graded Exercise Self-help (GES) is yet to be tested. Methods: This pragmatic randomized controlled trial is set within 2 specialist CFS/ME services in the South of England. Adults attending secondary care clinics with National Institute for Health and Clinical Excellence (NICE)-defined CFS/ME (N=218) will be randomly allocated to specialist medical care (SMC) or SMC plus GES while on a waiting list for therapist-delivered rehabilitation. GES will consist of a structured booklet describing a 6-step graded exercise program, supported by up to 4 face-to-face/telephone/Skype™ consultations with a GES-trained physiotherapist (no more than 90 minutes in total) over 8 weeks. The primary outcomes at 12-weeks after randomization will be physical function (SF-36 physical functioning subscale) and fatigue (Chalder Fatigue Questionnaire). Secondary outcomes will include healthcare costs, adverse outcomes, and self-rated global impression change scores. We will follow up all participants until 1 year after randomization. We will also undertake qualitative interviews of a sample of participants who received GES, looking at perceptions and experiences of those who improved and worsened. Results: The project was funded in 2011 and enrolment was completed in December 2014, with follow-up completed in March 2016. Data analysis is currently underway and the first results are expected to be submitted soon. Conclusions: This study will indicate whether adding GES to SMC will benefit patients who often spend many months waiting for rehabilitative therapy with little or no improvement being made during that time. The study will indicate whether this type of guided self-management is cost-effective and safe. If this trial shows GES to be acceptable, safe, and comparatively effective, the GES booklet could be made available on the Internet as a practitioner and therapist resource for clinics to recommend, with the caveat that patients also be supported with guidance from a trained physiotherapist. The pragmatic approach in this trial means that GES findings will be generalizable to usual National Health Service (NHS) practice.

A Social Networking Strategy for Improving Knowledge Management and Communication in the Travel Industry

In today’s technology-driven marketplace, the adoption and management of corporate and customer-facing Social Networking Sites (SNs) is often viewed as a key success factor for Travel Industry (TI) organisations. Knowledge management and the sharing of expertise and experiences through communication between internal and external stakeholders via social networks is an activity which TI organisations are aiming to exploit in order to improve the open sharing, retrieval, organisation and leveraging of knowledge. Through a study of currently-available literature relating to social networking adoption within the TI and a case study analysis of corporate social networking practices at three multi-national TI organisations (British Airways, Thomas Cook and Marriott Hotels), it may be observed that correlations exist between the development of social networking and the processes TI organisations now use to manage knowledge. We explore how these companies are currently utilizing SNs to improve knowledge management practices inside and outside of their organisational boundaries. From our analysis, lessons may emerge as to how TI companies are gaining competitive advantage through the use of social networking; a proposed strategy is identified to determine how TI organisations may make best use of social networks.

Service Quality in Arts Events: Operations Management Strategies for Effective Delivery

Recent debate on the quality of arts events has concentrated on the requirement to deliver against a complex range of political, social, and cultural criteria with an emphasis on the external partnerships that are forged. Yet those aspects of quality over which event organizers have more direct control have been accorded minor examination. The authors believe that operational effectiveness is key to service quality in the cultural context, and seek to demonstrate that a balanced consideration of both process and product is vital to fully deliver quality arts events. This article identifies areas of emergent research and practice and focuses on issues in the front-of-house environment where the breakdown of service quality is a real concern, using the experience of one UK not-for-profit arts organization as a case study to illustrate potential management responses.

Tourism in Albarracín and Region. Local Public Action and dynamics in recent key sustainable tourism development

Spanish tourist destinations in rural areas have been established over more than two decades of implementation of various public policy instruments (mainly tourism and rural development policies). These convey complementary objectives in theory but provoke distant results in practice. The intervention of these instruments produces in the region of Sierra de Albarracín (Teruel) two types of destination whose sustainability is committed: the historical urban site of Albarracín as a consolidated cultural tourism destination based on heritage and the Sierra as a generic and incipient destination of rural tourism. It is discussed how the deployment of the local public action causes a fragmented territory in two models of management and tourism development. Cooperation is presented as a key element for the necessary rethinking of tourism development in the region.

Genetic analyses reveal high levels of seed and pollen flow in hawthorn (Crataegus monogyna Jacq.), a key component of hedgerows

Hedgerows represent important components of agri-environment landscapes that are increasingly coming under threat from climate change, emergent diseases, invasive species and land use change. Given that population genetic data can be used to inform best-practice management strategies for woodland and hedgerow tree species, we carried out a study on hawthorn (Crataegus monogyna Jacq.), a key component of hedgerows, on a regional basis using a combination of nuclear and chloroplast microsatellite markers. We found that levels of genetic diversity were high and comparable to, or slightly higher than, other tree species from the same region. Levels of population differentiation for both sets of markers, however, were extremely low, suggesting extensive gene flow via both seed and pollen. These findings suggest that a holistic approach to woodland management, one which does not necessarily rely on the concept of “seed zones” previously suggested, but which also takes into account populations with high and/or rare chloroplast (i.e. seed-specific) genetic variation, might be the best approach to restocking and replanting.

“There’s a Catch-22”. The complexities of pain management for people with advanced dementia nearing the end of life: a qualitative exploration of physicians’ perspectives

Background: Pain management is a cornerstone of palliative care. The clinical issues encountered by physicians when managing pain in patients dying with advanced dementia, and how these may impact on prescribing and treatment, are unknown. Aim: To explore physicians’ experiences of pain management for patients nearing the end of life, the impact of these on prescribing and treatment approaches, and the methods employed to overcome these challenges. Design: Qualitative, semi-structured interview study exploring: barriers to and facilitators of pain management, prescribing and treatment decisions, and training needs. Thematic analysis was used to elicit key themes. Settings/Participants: Twenty-three physicians, responsible for treating patients with advanced dementia approaching the end of life, were recruited from primary care (n=9), psychiatry (n=7) and hospice care (n=7). Results: Six themes emerged: diagnosing pain, complex prescribing and treatment approaches, side-effects and adverse events, route of administration, importance of sharing knowledge and training needs. Knowledge exchange was often practised through liaison with physicians from other specialties. Cross-specialty mentoring, and the creation of knowledge networks were believed to improve pain management in this patient population. Conclusions: Pain management in end-stage dementia is complex, requiring cross-population of knowledge between palliative care specialists and non-specialists, in addition to collateral information provided by other health professionals and patients’ families. Regular, cost- and time-effective mentoring and ongoing professional development are perceived to be essential in empowering physicians to meet clinical challenges in this area.

Policy for the Provision and Management of Cleaning Services (PDF 464KB)

This policy sets out the Department’s commitment to maintaining and improving environmental cleanliness in Northern Ireland (NI). It has been developed with the aim that best management practice, staff training and continued monitoring of performance will lead to services being maintained and improved in a challenging financial climate. The detail of the policy is presented in the three sections which follow this executive summary. Section 1 – Introduction and Background. This section sets out the aims, objectives and scope of the policy. It also sets out the key principles which should apply to cleaning services. Section 2 - Developments since the launch of Cleanliness Matters Strategy in October 2005. This outlines events and progress since 2005 and indicates how these are shaping the proposed strategic direction. Section 3 - The Way Forward. This section sets out the areas for attention over the coming years.