The impact of new public management on the roles of elected councillors, management and the community sector in Irish local government: a case study of Cork County Council

The fundamental aim of this thesis is to examine the effect of New Public Management (NPM) on the traditional roles of elected representatives, management and community activists in Irish local government. This will be achieved through a case study analysis of one local authority, Cork County Council. NPM promises greater democracy in decision-making. Therefore, one can hypothesise that the roles of the three key groupings identified will become more influenced by principles of participatory decision-making. Thus, a number of related questions will be addressed by this work, such as, have the local elected representatives been empowered by NPM? Has a managerial revolution taken place? Has local democracy been enhanced by more effective community participation? It will be seen in chapter 2 that these questions have not been adequately addressed to date in NPM literature. The three groups identified can be regarded as stakeholders although the researcher is cautious in using this term because of its value-laden nature. Essentially, in terms of Cork County Council, stakeholders can be defined as decision-makers and people within the organization and its environment who are interested in or could be affected directly or indirectly by organizational performance. This is an all-embracing definition and includes all citizens, residents, community groups and client organizations. It is in this context that the term 'stakeholder' should be understood when it is occasionally used in this thesis. In this case, the perceptions of elected councilors, management and community representatives with regard to their changing roles are as significant as the changes themselves. The chapter begins with a brief account of the background to this research. This is followed by an explanation of the methodology which is used and then concludes with short statements about the remaining chapters in the thesis.

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.

The brand-orientated play-community: toxic play in the marketplace

This ethnographic study makes a number of original contributions to the consumer identity projects and the marketplace cultures dimensions of consumer culture theory research. This study introduces the notion of the brand-orientated play-community, a novel consumption community form, which displays, as locus, a desire to play. This contributes to our understanding of the fluid relationship between subcultures of consumption, consumer tribes, and brand community. It was found that the brand-orientated play-community’s prime celebration, conceptualised as the ‘branded carnival’, displays characteristics of the archetypal carnival. The community access carnivalistic life and a world-upside-down ethos via the use and misuse of marketplace resources. The branded carnival is further supported by the community’s enactment of ‘toxic play’, which entails abnormal alcohol consumption, black market illegal resources, edgework activities, hegemonic masculinity and upsetting the public. This play-community is discussed in terms of a hyper-masculine playpen, as the play enacted has a direct relationship with the enactment of strong masculine roles. It was found that male play-ground members enact the extremes of contrasting masculine roles as a means to subvert the calculated and sedate ‘man-of-action-hero’ synthesis. Carnivals are unisex, and hence, women have begun entering the play-ground. Female members have successfully renegotiated their role within the community, from playthings to players – they have achieved player equality, which within the liminoid zone is more powerful than gender equality. However, while toxic play is essential to the maintenance of collective identity within the culture so too is the more serious form of play: the toxic sport of professional beer pong. The author conceptualises beer pong as a ‘toxic sport’, as it displays the contradictory play foundations of agon and corrupt ilinx: this is understood as a milestone step in the emergence of the postmodern sport era, in which spontaneity and the carnivalesque will dominate.

Community workers' understandings and practices of resistance

This research is focused on Community Workers located in Southern Ireland, and their understandings and practices of resistance. It is an attempt to explore the ways in which community workers’ understandings and practices of resistance are formed and, in turn, inform their sense of identity and their responses to the wider context of community development work in Ireland today. This study is specifically located but also has wider application and relevance because of the extended international reach of neo-liberal and managerial rationalities, and their implications for politics, policy and practice. The study considers resistance in a number of inter-related ways: as a collective oppositional position (with negative and positive dimensions); a personal and/or professional value (associated with the ‘expansion of contention’); a strategy for negotiating unequal power relations (in a range of levels and spaces of power); an identity (in relation to the sustaining of ‘reflexive subjectivities’); a set of practices, (which take into account the interplay between economic, political and cultural influences); and an educational process through which practitioners assess and enact personal and professional agency. Critical theorisations of community development and of the Irish state over time, trace the ways in which neo-liberalism and managerialism has inflected community development practice and the positions of community workers and communities in that process. The study draws on James C. Scott, Gramsci, Barnes and Prior, among others, which enabled the interrogation of resistance in relation to everyday practices through engaging with ‘hidden transcripts’ and spaces. The method chosen was focus group discussions with three groups of community workers located in different counties in Southern Ireland. This method facilitated a deep discourse analysis of practitioners’ encounters with resistance in the field of community work. Key findings relate to the various interpretations of the role of resistance, practices of resistance (including current restrictions), the value of resistance work and the conditions that may be conducive to practising resistance.

Transitions: From novice participation to expertise, pre-school 'matters' in an Irish pre-school community

This in depth, qualitative, participant observer study tracks children's transition experiences from novice to experienced membership of their pre-school community. It also considers adult roles in mediating this process in the context of the recent introduction of a universal free-pre-school year for children growing up in Ireland. Participation and the space to negotiate a participatory identity is understood in this study as a key element of positive experiences of early years transitions, within pre-school and beyond. The underlying theoretical framework is socio-cultural. This approach shifts from a scientific positivist view of thinking and learning as an individual inside the head process and asserts the historical, social, cultural as well as the situated context of learning and meaning making All participants, including myself as researcher, are recognised, explored and valued as embedded in the cultural context studied. In a sense, this approach tilts the worlds being observed through participation in them and reflects them in new light. The aim is to interpret and reflect the multiple realities constructed in this context rather than seek a truth out there waiting to be found. Special efforts are made to be invited in to and acknowledge children's expertise in the cultural worlds they negotiate with peers and adults in pre-school. The aim is to better understand what children may find motivating, interesting or problematic as they interpret reproduce and transform meaning within their play and learning worlds. My aim is for an honest rendering of the voices of stakeholders in pre-school communities from teachers, parents, and policy makers to children themselves. It makes visible constraints; potentials and possibilities within everyday Irish pre-school practices in the situated context studied as well as the broader societal, legislative and macro policy influences it reflects. Casting light on the taken for granted opens the possibility of adaptation or transformation. Transition itself can act as a tool to meet the changing needs of children on their developmental pathways across the life cycle

Vulnerability and adaptation to climate change in Guam – a case-study of the perceptions, attitudes, behaviors, and knowledge of a small rural community towards their watershed

This thesis argues that examining the attitudes, perceptions, behaviors, and knowledge of a community towards their specific watershed can reveal their social vulnerability to climate change. Understanding and incorporating these elements of the human dimension in coastal zone management will lead to efficient and effective strategies that safeguard the natural resources for the benefit of the community. By having healthy natural resources, ecological and community resilience to climate change will increase, thus decreasing vulnerability. In the Pacific Ocean, climate and SLR are strongly modulated by the El Niño Southern Oscillation. SLR is three times the global average in the Western Pacific Ocean (Merrifield and Maltrud 2011; Merrifield 2011). Changes in annual rainfall in the Western North Pacific sub‐region from 1950-2010 show that islands in the east are getting much less than in the past, while the islands in the west are getting slightly more rainfall (Keener et al. 2013). For Guam, a small island owned by the United States and located in the Western Pacific Ocean, these factors mean that SLR is higher than any other place in the world and will most likely see increased precipitation. Knowing this, the social vulnerability may be examined. Thus, a case-study of the community residing in the Manell and Geus watersheds was conducted on the island of Guam. Measuring their perceptions, attitudes, knowledge, and behaviors should bring to light their vulnerability to climate change. In order to accomplish this, a household survey was administered from July through August 2010. Approximately 350 surveys were analysed using SPSS. To supplement this quantitative data, informal interviews were conducted with the elders of the community to glean traditional ecological knowledge about perceived climate change. A GIS analysis was conducted to understand the physical geography of the Manell and Geus watersheds. This information about the human dimension is valuable to CZM managers. It may be incorporated into strategic watershed plans, to better administer the natural resources within the coastal zone. The research conducted in this thesis is the basis of a recent watershed management plan for the Guam Coastal Management Program (see King 2014).

Evaluation of a WHO-Validated Serotype-Specific Serological Assay for the Diagnosis of Pneumococcal Etiology in Children with Community-Acquired Pneumonia.

BACKGROUND: The etiologic diagnosis of community-acquired pneumonia (CAP) remains challenging in children because blood cultures have low sensitivity. Novel approaches are needed to confirm the role of Streptococcus pneumoniae. METHODS: In this study, pneumococcal aetiology was determined by serology using a subset of blood samples collected during a prospective multicentre observational study of children <15 years of age hospitalised in Belgium with X-ray-confirmed CAP. Blood samples were collected at admission and 3-4 weeks later. Pneumococcal (P)-CAP was defined in the presence of a positive blood or pleural fluid culture. Serotyping of Streptococcus pneumoniae isolates was done with the Quellung reaction. Serological diagnosis was assessed for nine serotypes using World Health Organization validated IgG and IgA serotype-specific enzyme-linked immunosorbent assays (ELISAs). RESULTS: Paired admission/convalescent sera from 163 children were evaluated by ELISA (35 with proven P-CAP and 128 with non proven P-CAP). ELISA detected pneumococci in 82.8% of patients with proven P-CAP. The serotypes identified were the same as with the Quellung reaction in 82% and 59% of cases by IgG ELISA and IgA ELISA, respectively. Overall, ELISA identified a pneumococcal aetiology in 55% of patients with non-proven P-CAP. Serotypes 1 (51.6%), 7F (19%), and 5 (15.7%) were the most frequent according to IgG ELISA. CONCLUSIONS: In conclusion, the serological assay allows recognition of pneumococcal origin in 55% of CAP patients with negative culture. This assay should improve the diagnosis of P-CAP in children and could be a useful tool for future epidemiological studies on childhood CAP etiology.

Establishing a regional, multisite database for quality improvement and service planning in community-based palliative care and hospice.

BACKGROUND: Outpatient palliative care, an evolving delivery model, seeks to improve continuity of care across settings and to increase access to services in hospice and palliative medicine (HPM). It can provide a critical bridge between inpatient palliative care and hospice, filling the gap in community-based supportive care for patients with advanced life-limiting illness. Low capacities for data collection and quantitative research in HPM have impeded assessment of the impact of outpatient palliative care. APPROACH: In North Carolina, a regional database for community-based palliative care has been created through a unique partnership between a HPM organization and academic medical center. This database flexibly uses information technology to collect patient data, entered at the point of care (e.g., home, inpatient hospice, assisted living facility, nursing home). HPM physicians and nurse practitioners collect data; data are transferred to an academic site that assists with analyses and data management. Reports to community-based sites, based on data they provide, create a better understanding of local care quality. CURRENT STATUS: The data system was developed and implemented over a 2-year period, starting with one community-based HPM site and expanding to four. Data collection methods were collaboratively created and refined. The database continues to grow. Analyses presented herein examine data from one site and encompass 2572 visits from 970 new patients, characterizing the population, symptom profiles, and change in symptoms after intervention. CONCLUSION: A collaborative regional approach to HPM data can support evaluation and improvement of palliative care quality at the local, aggregated, and statewide levels.

Prevalence and predictors of HIV-related stigma among institutional- and community-based caregivers of orphans and vulnerable children living in five less-wealthy countries.

BACKGROUND: In the face of the HIV/AIDS epidemic that has contributed to the dramatic increase in orphans and abandoned children (OAC) worldwide, caregiver attitudes about HIV, and HIV-related stigma, are two attributes that may affect caregiving. Little research has considered the relationship between caregiver attributes and caregiver-reported HIV-related stigma. In light of the paucity of this literature, this paper will describe HIV-related stigma among caregivers of OAC in five less wealthy nations. METHODS: Baseline data were collected between May 2006 through February 2008. The sample included 1,480 community-based and 192 institution-based caregivers. Characteristics of the community-based and institution-based caregivers are described using means and standard deviations for continuous variables or counts and percentages for categorical variables. We fit logistic regression models, both for the full sample and separately for community-based and institution-based caregivers, to explore predictors of acceptance of HIV. RESULTS: Approximately 80% of both community-based and institution-based caregivers were female; and 84% of institution-based caregivers, compared to 66% of community-based caregivers, said that they would be willing to care for a relative with HIV. Similar proportions were reported when caregivers were asked if they were willing to let their child play with an HIV-infected child. In a multivariable model predicting willingness to care for an HIV-infected relative, adjusted for site fixed effects, being an institution-based caregiver was associated with greater willingness (less stigma) than community-based caregivers. Decreased willingness was reported by older respondents, while willingness increased with greater formal education. In the adjusted models predicting willingness to allow one's child to play with an HIV-infected child, female gender and older age was associated with less willingness. However, willingness was positively associated with years of formal education. CONCLUSIONS: The caregiver-child relationship is central to a child's development. OAC already face stigma as a result of their orphaned or abandoned status; the addition of HIV-related stigma represents a double burden for these children. Further research on the prevalence of HIV-related acceptance and stigma among caregivers and implications of such stigma for child development will be critical as the policy community responds to the global HIV/AIDS orphan crisis.

Risk factors for and estimated incidence of community-associated Clostridium difficile infection, North Carolina, USA.

We determined estimated incidence of and risk factors for community-associated Clostridium difficile infection (CA-CDI) among patients treated at 6 North Carolina hospitals. CA-CDI case-patients were defined as adults (>18 years of age) with a positive stool test result for C. difficile toxin and no hospitalization within the prior 8 weeks. CA-CDI incidence was 21 and 46 per 100,000 person-years in Veterans Affairs (VA) outpatients and Durham County populations, respectively. VA case-patients were more likely than controls to have received antimicrobial drugs (adjusted odds ratio [aOR] 17.8, 95% confidence interval [CI] 6.6-48] and to have had a recent outpatient visit (aOR 5.1, 95% CI 1.5-17.9). County case-patients were more likely than controls to have received antimicrobial drugs (aOR 9.1, 95% CI 2.9-28.9), to have gastroesophageal reflux disease (aOR 11.2, 95% CI 1.9-64.2), and to have cardiac failure (aOR 3.8, 95% CI 1.1-13.7). Risk factors for CA-CDI overlap with those for healthcare-associated infection.

How Locally Designed Access and Use Controls Can Prevent the Tragedy of the Commons in a Mexican Small-Scale Fishing Community

The Seri people, a self-governed community of small-scale fishermen in the Gulf of California, Mexico, have ownership rights to fishing grounds where they harvest highly valuable commercial species of bivalves. Outsiders are eager to gain access, and the community has devised a set of rules to allow them in. Because Seri government officials keep all the economic benefits generated from granting this access for themselves, community members create alternative entry mechanisms to divert those benefits to themselves. Under Hardin’s model of the tragedy of the commons, this situation would eventually lead to the overexploitation of the fishery. The Seri people, however, are able to simultaneously maintain access and use controls for the continuing sustainability of their fishing grounds. Using insights from common- pool resources theory, I discuss how Seri community characteristics help mediate the conflict between collective action dilemmas and access and use controls.

Lack of cross-scale linkages reduces robustness of community-based fisheries management.

Community-based management and the establishment of marine reserves have been advocated worldwide as means to overcome overexploitation of fisheries. Yet, researchers and managers are divided regarding the effectiveness of these measures. The "tragedy of the commons" model is often accepted as a universal paradigm, which assumes that unless managed by the State or privatized, common-pool resources are inevitably overexploited due to conflicts between the self-interest of individuals and the goals of a group as a whole. Under this paradigm, the emergence and maintenance of effective community-based efforts that include cooperative risky decisions as the establishment of marine reserves could not occur. In this paper, we question these assumptions and show that outcomes of commons dilemmas can be complex and scale-dependent. We studied the evolution and effectiveness of a community-based management effort to establish, monitor, and enforce a marine reserve network in the Gulf of California, Mexico. Our findings build on social and ecological research before (1997-2001), during (2002) and after (2003-2004) the establishment of marine reserves, which included participant observation in >100 fishing trips and meetings, interviews, as well as fishery dependent and independent monitoring. We found that locally crafted and enforced harvesting rules led to a rapid increase in resource abundance. Nevertheless, news about this increase spread quickly at a regional scale, resulting in poaching from outsiders and a subsequent rapid cascading effect on fishing resources and locally-designed rule compliance. We show that cooperation for management of common-pool fisheries, in which marine reserves form a core component of the system, can emerge, evolve rapidly, and be effective at a local scale even in recently organized fisheries. Stakeholder participation in monitoring, where there is a rapid feedback of the systems response, can play a key role in reinforcing cooperation. However, without cross-scale linkages with higher levels of governance, increase of local fishery stocks may attract outsiders who, if not restricted, will overharvest and threaten local governance. Fishers and fishing communities require incentives to maintain their management efforts. Rewarding local effective management with formal cross-scale governance recognition and support can generate these incentives.

Institutional and ecological interplay for successful self-governance of community-based fisheries

The goal of this paper is to improve our understanding of the role of institutional arrangements and ecological factors that facilitate the emergence and sustainability of successful collective action in small-scale fishing social-ecological systems. Using a modified logistic growth function, we simulate how ecological factors (i.e. carrying capacity) affect small-scale fishing communities with varying degrees of institutional development (i.e. timeliness to adopt new institutions and the degree to which harvesting effort is reduced), in their ability to avoid overexploitation. Our results show that strong and timely institutions are necessary but not sufficient to maintain sustainable harvests over time. The sooner communities adopt institutions, and the stronger the institutions they adopt, the more likely they are to sustain the resource stock. Exactly how timely the institutions must be adopted, and by what amount harvesting effort must be diminished, depends on the ecological carrying capacity of the species at the particular location. Small differences in the carrying capacity between fishing sites, even under scenarios of similar institutional development, greatly affects the likelihood of effective collective action. © 2009 Elsevier B.V. All rights reserved.

Experimental evidence that phenotypic divergence in predators drives community divergence in prey.

Studies of adaptive divergence have traditionally focused on the ecological causes of trait diversification, while the ecological consequences of phenotypic divergence remain relatively unexplored. Divergence in predator foraging traits, in particular, has the potential to impact the structure and dynamics of ecological communities. To examine the effects of predator trait divergence on prey communities, we exposed zooplankton communities in lake mesocosms to predation from either anadromous or landlocked (freshwater resident) alewives, which have undergone recent and rapid phenotypic differentiation in foraging traits (gape width, gill raker spacing, and prey size-selectivity). Anadromous alewives, which exploit large prey items, significantly reduced the mean body size, total biomass, species richness, and diversity of crustacean zooplankton relative to landlocked alewives, which exploit smaller prey. The zooplankton responses observed in this experiment are consistent with patterns observed in lakes. This study provides direct evidence that phenotypic divergence in predators, even in its early stages, can play a critical role in determining prey community structure.

Eco-evolutionary feedbacks in community and ecosystem ecology: interactions between the ecological theatre and the evolutionary play.

Interactions between natural selection and environmental change are well recognized and sit at the core of ecology and evolutionary biology. Reciprocal interactions between ecology and evolution, eco-evolutionary feedbacks, are less well studied, even though they may be critical for understanding the evolution of biological diversity, the structure of communities and the function of ecosystems. Eco-evolutionary feedbacks require that populations alter their environment (niche construction) and that those changes in the environment feed back to influence the subsequent evolution of the population. There is strong evidence that organisms influence their environment through predation, nutrient excretion and habitat modification, and that populations evolve in response to changes in their environment at time-scales congruent with ecological change (contemporary evolution). Here, we outline how the niche construction and contemporary evolution interact to alter the direction of evolution and the structure and function of communities and ecosystems. We then present five empirical systems that highlight important characteristics of eco-evolutionary feedbacks: rotifer-algae chemostats; alewife-zooplankton interactions in lakes; guppy life-history evolution and nutrient cycling in streams; avian seed predators and plants; and tree leaf chemistry and soil processes. The alewife-zooplankton system provides the most complete evidence for eco-evolutionary feedbacks, but other systems highlight the potential for eco-evolutionary feedbacks in a wide variety of natural systems.