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1.  An analysis of Liberia's 2007 national health policy: lessons for health systems strengthening and chronic disease care in poor, post-conflict countries 
Globally, chronic diseases are responsible for an enormous burden of deaths, disability, and economic loss, yet little is known about the optimal health sector response to chronic diseases in poor, post-conflict countries. Liberia's experience in strengthening health systems and health financing overall, and addressing HIV/AIDS and mental health in particular, provides a relevant case study for international stakeholders and policymakers in other poor, post-conflict countries seeking to understand and prioritize the global response to chronic diseases.
We conducted a historical review of Liberia's post-conflict policies and their impact on general economic and health indicators, as well as on health systems strengthening and chronic disease care and treatment. Key sources included primary documents from Liberia's Ministry of Health and Social Welfare, published and gray literature, and personal communications from key stakeholders engaged in Liberia's Health Sector Reform. In this case study, we examine the early reconstruction of Liberia's health care system from the end of conflict in 2003 to the present time, highlight challenges and lessons learned from this initial experience, and describe future directions for health systems strengthening and chronic disease care and treatment in Liberia.
Six key lessons emerge from this analysis: (i) the 2007 National Health Policy's 'one size fits all' approach met aggregate planning targets but resulted in significant gaps and inefficiencies throughout the system; (ii) the innovative Health Sector Pool Fund proved to be an effective financing mechanism to recruit and align health actors with the 2007 National Health Policy; (iii) a substantial rural health delivery gap remains, but it could be bridged with a robust cadre of community health workers integrated into the primary health care system; (iv) effective strategies for HIV/AIDS care in other settings should be validated in Liberia and adapted for use in other chronic diseases; (v) mental health disorders are extremely prevalent in Liberia and should remain a top chronic disease priority; and (vi) better information systems and data management are needed at all levels of the health system.
The way forward for chronic diseases in Liberia will require an increased emphasis on quality over quantity, better data management to inform rational health sector planning, corrective mechanisms to more efficiently align health infrastructure and personnel with existing needs, and innovative methods to improve long-term retention in care and bridge the rural health delivery gap.
PMCID: PMC3201890  PMID: 21985150
2.  A Guide for Health Professionals Working with Aboriginal Peoples: Executive Summary 
to provide Canadian health professionals with a network of information and recommendations regarding Aboriginal health.
health professionals working with Aboriginal individuals and communities in the area of women’s health care.
improved health status of Aboriginal peoples in Canada.
Appropriateness and accessibility of women’s health services for Aboriginal peoples.
Improved communication and clinical skills of health professionals in the area of Aboriginal health.
Improved quality of relationship between health professionals and Aboriginal individuals and communities.
Improved quality of relationship between health care professionals and Aboriginal individuals and communities.
recommendations are based on expert opinion and a review of the literature. Published references were identified by a Medline search of all review articles, randomized clinical control trials, meta-analyses, and practice guidelines from 1966 to February 1999, using the MeSH headings “Indians, North American or Eskimos” and “Health.”* Subsequently published articles were brought to the attention of the authors in the process of writing and reviewing the document. Ancillary and unpublished references were recommended by members of the SOGC Aboriginal Health Issues Committee and the panel of expert reviewers.
information collected was reviewed by the principal author. The social, cultural, political, and historic context of Aboriginal peoples in Canada, systemic barriers regarding the publication of information by Aboriginal authors, the diversity of Aboriginal peoples in Canada, and the need for a culturally appropriate and balanced presentation were carefully considered in addition to more traditional scientific evaluation. The majority of information collected consisted of descriptive health and social information and such evaluation tools as the evidence guidelines of the Canadian Task Force on the Periodic Health exam were not appropriate.
Benefits, costs, and harms
utilization of the information and recommendations by Canadian health professionals will enhance understanding, communication, and clinical skills in the area of Aboriginal health. The resulting enhancement of collaborative relationships between Aboriginal peoples and their women’s health providers may contribute to health services that are more appropriate, effective, efficient, and accessible for Aboriginal peoples in Canada. The educational process may require an initial investment of time from the health professional.
Recommendations were grouped according to four themes: sociocultural context, health concerns, cross-cultural understanding, and Aboriginal health resources. Health professionals are encouraged to learn the appropriate names, demographics, and traditional geographic territories and language groups of the various Aboriginal groups in Canada. In addition, sensitivity to the impact of colonization and current socioeconomic challenges to the health status of Aboriginal peoples is warranted. Health services for Aboriginal peoples should take place as close to home as possible. Governmental obligations and policies regarding determination are recognized. With respect to health concerns, holistic definitions of health, based on Aboriginal perspectives, are put forward. Aboriginal peoples continue to experience a disproportionate burden of health problems. Health professionals are encouraged to become familiar with several key areas of morbidity and mortality. Relationships between Aboriginal peoples and their care providers need to be based on a foundation of mutual respect. Gaps and barriers in the current health care system for Aboriginal peoples are identified. Health professionals are encouraged to work with Aboriginal individuals and communities to address these gaps and barriers. Aboriginal peoples require culturally appropriate health care, including treatment in their own languages when possible. This may require interpreters or Aboriginal health advocates. Health professionals are encouraged to recognize the importance of family and community roles, and to respect traditional medicines and healers. Health professionals can develop their sensitivities towards Aboriginal peoples by participating in workshops, making use of educational resources, and by spending time with Aboriginal peoples in their communities. Aboriginal communities and health professionals are encouraged to support community-based, community-directed health services and health research for Aboriginal peoples. In addition, the education of more Aboriginal health professionals is essential. The need for a preventative approach to health programming in Aboriginal communities is stressed.
recommendations were reviewed and revised by the SOGC Aboriginal Health Issues Committee, a panel of expert reviewers, and the SOGC Council. In addition, this document was also reviewed and supported by the Assembly of First Nations, Canadian Institute of Child Health, Canadian Paediatric Society, College of Family Physicians of Canada, Congress of Aboriginal Peoples, Federation of Medical Women of Canada, Inuit Tapirisat of Canada, Metis National Council, National Indian and Inuit Community Health Representatives Organization, and Pauktuutit Inuit Women’s Association.
Society of Obstetricians and Gynaecologists of Canada.
PMCID: PMC3653835  PMID: 23682204 CAMSID: cams2752
3.  Clinical Effectiveness Research in Managed-care Systems: Lessons from the Pediatric Asthma Care PORT 
Health Services Research  2002;37(3):775-789.
To highlight the unique challenges of evaluative research on practice behavior change in the “real world” settings of contemporary managed-care organizations, using the experience of the Pediatric Asthma Care PORT (Patient Outcomes Research Team).
Study Setting
The Pediatric Asthma Care PORT is a five-year initiative funded by the Agency for Healthcare Research and Quality to study strategies for asthma care improvement in three managed-care plans in Chicago, Seattle, and Boston. At its core is a randomized trial of two care improvement strategies compared with usual care: (1) a targeted physician education program using practice based Peer Leaders (PL) as change agents, (2) adding to the PL intervention a “Planned Asthma Care Intervention” incorporating joint “asthma check-ups” by nurse-physician teams. During the trial, each of the participating organizations viewed asthma care improvement as an immediate priority and had their own corporate improvement programs underway.
Data Collection
Investigators at each health plan described the organizational and implementation challenges in conducting the PAC PORT randomized trial. These experiences were reviewed for common themes and “lessons” that might be useful to investigators planning interventional research in similar care-delivery settings.
Randomized trials in “real world” settings represent the most robust design available to test care improvement strategies. In complex, rapidly changing managed-care organizations, blinding is not feasible, corporate initiatives may complicate implementation, and the assumption that a “usual care” arm will be static is highly likely to be mistaken. Investigators must be prepared to use innovative strategies to maintain the integrity of the study design, including: continuous improvement within the intervention arms, comanagement by researchers and health plan managers of condition-related quality improvement initiatives, procedures for avoiding respondent burden in health plan enrollees, and anticipation and minimization of risks from experimental arm contamination and major organizational change. With attention to these delivery system issues, as well as the usual design features of randomized trials, we believe managed-care organizations can serve as important laboratories to test care improvement strategies.
PMCID: PMC1434661  PMID: 12132605
Guideline implementation; managed-care research; childhood asthma; physician behavior change; randomized trials
4.  Boundaries and e-health implementation in health and social care 
The major problem facing health and social care systems globally today is the growing challenge of an elderly population with complex health and social care needs. A longstanding challenge to the provision of high quality, effectively coordinated care for those with complex needs has been the historical separation of health and social care. Access to timely and accurate data about patients and their treatments has the potential to deliver better care at less cost.
To explore the way in which structural, professional and geographical boundaries have affected e-health implementation in health and social care, through an empirical study of the implementation of an electronic version of Single Shared Assessment (SSA) in Scotland, using three retrospective, qualitative case studies in three different health board locations.
Progress in effectively sharing electronic data had been slow and uneven. One cause was the presence of established structural boundaries, which lead to competing priorities, incompatible IT systems and infrastructure, and poor cooperation. A second cause was the presence of established professional boundaries, which affect staffs’ understanding and acceptance of data sharing and their information requirements. Geographical boundaries featured but less prominently and contrasting perspectives were found with regard to issues such as co-location of health and social care professionals.
To provide holistic care to those with complex health and social care needs, it is essential that we develop integrated approaches to care delivery. Successful integration needs practices such as good project management and governance, ensuring system interoperability, leadership, good training and support, together with clear efforts to improve working relations across professional boundaries and communication of a clear project vision. This study shows that while technological developments make integration possible, long-standing boundaries constitute substantial risks to IT implementations across the health and social care interface which those initiating major changes would do well to consider before committing to the investment.
PMCID: PMC3465217  PMID: 22958223
5.  Clinical trials in a remote Aboriginal setting: lessons from the BOABS smoking cessation study 
BMC Public Health  2014;14:579.
There is limited evidence regarding the best approaches to helping Indigenous Australians to stop smoking. The composite analysis of the only two smoking cessation randomised controlled trials (RCTs) investigating this suggests that one-on-one extra support delivered by and provided to Indigenous Australians in a primary health care setting appears to be more effective than usual care in encouraging smoking cessation. This paper describes the lessons learnt from one of these studies, the Be Our Ally Beat Smoking (BOABS) Study, and how to develop and implement an integrated smoking cessation program.
Qualitative study using data collected from multiple documentary sources related to the BOABS Study. As the project neared completion the research team participated in four workshops to review and conduct thematic analyses of these documents.
Challenges we encountered during the relatively complex BOABS Study included recruiting sufficient number of participants; managing the project in two distant locations and ensuring high quality work across both sites; providing appropriate training and support to Aboriginal researchers; significant staff absences, staff shortages and high workforce turnover; determining where and how the project fitted in the clinics and consequent siloing of the Aboriginal researchers relating to the requirements of RCTs; resistance to change, and maintaining organisational commitment and priority for the project. The results of this study also demonstrated the importance of local Aboriginal ownership, commitment, participation and control. This included knowledge of local communities, the flexibility to adapt interventions to local settings and circumstances, and taking sufficient time to allow this to occur.
The keys to the success of the BOABS Study were local development, ownership and participation, worker professional development and support, and operating within a framework of cultural safety. There were difficulties associated with the BOABS Study being an RCT, and many of these are shared with stand-alone programs. Interventions targeted at particular health problems are best integrated with usual primary health care. Research to investigate complex interventions in Indigenous health should not be limited to randomised clinical trials and funding needs to reflect the additional, but necessary, cost of providing for local control of planning and implementation.
PMCID: PMC4064520  PMID: 24912949
Indigenous; Aboriginal; Torres Strait Islander; Smoking cessation; Be Our Ally Beat Smoking (BOABS) study; Qualitative; Randomised controlled trial
6.  Sustained Hospital-based Wellness Program 
Global Advances in Health and Medicine  2014;3(Suppl 1):BPA05.
Beginning as a grassroots initiative, a community hospital employing 2800 celebrates the stress-transforming benefits of HeartMath for its employees and community. Initially introduced to address the deleterious effects of personal stress experienced by the high healthcare claimants of the organization, HeartMath was eventually introduced to every stratification of the organization's population health management. The ensuing depth and breadth of HeartMath's presence in the organization is a consequence of a deliberate effort to integrate the program at every possible and sensible touch point of the organization and, ultimately, patient care. Today, 5 years later, the success of HeartMath at Indiana University (IU) Health Bloomington continues to be a tribute to the grassroots movement of an established worksite wellness program.
HeartMath was initiated as an intervention for transforming the stress of a workforce's highest healthcare claimants: those with the complexities of co-morbidities as well as challenging psychosocial and economic realities. This segment of a workforce is invariably the greatest strain to any organization's health plan. As importantly, on an individual level and subsequent to their health status, the respective employees can experience tremendous personal strain in several dimensions of their lives. Further compounding their marginal and worsening physical health, the inherent challenges of the current medical system to integrate and advocate for their care requires that stress be addressed and skills developed for a positive, long-term, and sustainable outcome.
From this small but powerful vantage point, IU Health Bloomington's platinum worksite wellness program (a distinction of the Wellness Council of America) extended HeartMath to every population health management stratification within the organization. This specific program migration happened initially by way of departments and units that expressed, in an employee opinion survey, high levels of stress. In some instances, these highly-stressed departments were also departments with higher staff turnover, attributed most consistently to the acuity of patient care. The critical mass of acquired HeartMath mastery by more than one thousand employees allowed the organization to introduce HeartMath's neutral technique as a nonpharmacological option for patients experiencing pain, anxiety, or sleeplessness.
Wrapping “heart” around self-care (through the worksite wellness program), patient care (at the bedside, laboring mothers, hospice patients and families), and subsequently a culture of care, HeartMath is credited, in part, with the increase in the organization's aggregate “culture of care” index.
Transforming stress from a worksite wellness program to a culture of care required a thoughtful internal audit of training and patient touch points that were sensible and appropriate to teach, reinforce, and practice HeartMath. From the mandated training for Giving and Receiving Feedback to patient registration, onboarding to inpatient Behavioral Health group and individual sessions, and Nurse Residency retention programs to the VA Clinic outreach, HeartMath is the stress-transformation technique for employees and patients with the ultimate goal of creating a healthier and more resilient community.
HeartMath has become the stress-transforming practice for IU Health Bloomington. Because of the numerous touch points of integration and the delivery platform of an established employee wellness program, HeartMath is a dimension of employee experience without boundaries—boundaries that are otherwise and previously accepted: departmental, human resource development and performance, as well as clinician and patient. Statistically, from 2009 to 2012 the response to the question regarding employees' perception of the organization's interest in creating a healthy workplace increased overall by 6% in the categories of excellent, high interest, and good interest.
Contrary to the more common launching point of HeartMath by way of senior leader stewardship, the potential for grassroots introduction can lead to rich integration of existing programs, organizational practice, and policy making with an outcome of enhanced culture of care and employee satisfaction.
PMCID: PMC3923282
Hospital wellness program; stress reduction; HeartMath; biofeedback
7.  The RAFT Telemedicine Network: Lessons Learnt and Perspectives from a Decade of Educational and Clinical Services in Low- and Middle-Incomes Countries 
Background: The objectives of this paper are to (i) provide an overview of the educational and clinical experiences of the Réseau en Afrique Francophone pour la Télémédecine (RAFT) network, (ii) analyze key challenges and lessons learnt throughout a decade of activity, and (iii) draw a vision and perspectives of its sustainability.
Methods: The study was carried out following three main stages: (i) a literature review, (ii) the analysis of key documents, and (iii) discussions with key collaborators of the RAFT.
Results: Réseau en Afrique Francophone pour la Télémédecine has been offering an important quantity of educational, clinical, and public health activities during the last decade. The educational activities include the weekly delivery of video-lectures for continuing and post-graduate medical education, the use of virtual patients for training in clinical decision making, research training activities using ICTs and other e-learning activities. The clinical and public health activities include tele-expertise to support health professionals in the management of difficult clinical cases, the implementation of clinical information systems in African hospitals, the deployment of mHealth projects, etc. Since 2010, the RAFT has been extended to the Altiplano in Bolivia and Nepal (in progress).
Lessons Learnt and Perspectives: Important lessons have been learnt from the accumulated experiences throughout these years. These lessons concern: social and organization, human resources, technologies and data security, policy and legislation, and economy and financing. Also, given the increase of the activities and the integration of eHealth and telemedicine in the health system of most of the countries, the RAFT network faces many other challenges and perspectives such as learning throughout life, recognition, and valorization of teaching or learning activities, the impact evaluation of interventions, and the scaling up and transferability out of Africa of RAFT activities. Based on the RAFT experience, effective integration and optimum use of eHealth and telemedicine in low- and middle-income countries (LMICs) health systems should take into account the context (resources, infrastructure, and funding), the needs of key stakeholders, and the results derived from theoretical and practical experience. The relevant items highlighted to illustrate the sustainability of the RAFT network and the analyses performed in this study, should serve as discussion basis for the development of eHealth and telemedicine in LMICs.
PMCID: PMC4187539  PMID: 25340048
telemedicine; eHealth; low and middle income countries; Africa; telemedicine network
8.  Contact tracing of in-flight measles exposures: lessons from an outbreak investigation and case series, Australia, 2010 
To describe a 2010 outbreak of nine cases of measles in Australia possibly linked to an index case who travelled on an international flight from South Africa while infectious.
Three Australian state health departments, Victoria, Queensland and New South Wales, were responsible for the investigation and management of this outbreak, following Australian public health guidelines.
An outbreak of measles occurred in Australia after an infectious case arrived on a 12-hour flight from South Africa. Only one of four cases in the first generation exposed to the index case en route was sitting within the two rows recommended for contact tracing in Australian and other guidelines. The remaining four cases in subsequent generations, including two health care workers, were acquired in health care settings. Seven cases were young adults. Delays in diagnosis and notification hampered disease control and contact tracing efforts.
Review of current contact tracing guidelines following in-flight exposure to an infectious measles case is required. Alternative strategies could include expanding routine contact tracing beyond the two rows on either side of the case’s row or expansion on a case-by-case basis depending on cabin layout and case and contact movements in flight. Releasing information about the incident by press release or providing generic information to everyone on the flight using e-mail or text messaging information obtained from the relevant airline, may also be worthy of consideration. Disease importation, inadequately vaccinated young adults and health care-related transmission remain challenges for measles control in an elimination era.
PMCID: PMC3729056  PMID: 23908891
9.  Human resources for health: lessons from the cholera outbreak in Papua New Guinea 
Papua New Guinea is striving to achieve the minimum core requirements under the International Health Regulations in surveillance and outbreak response, and has experienced challenges in the availability and distribution of health professionals.
Since mid-2009, a large cholera outbreak spread across lowland regions of the country and has been associated with more than 15 500 notifications at a case fatality ratio of 3.2%. The outbreak placed significant pressure on clinical and public health services.
We describe some of the challenges to cholera preparedness and response in this human resource-limited setting, the strategies used to ensure effective cholera management and lessons learnt.
Cholera task forces were useful to establish a clear system of leadership and accountability for cholera outbreak response and ensure efficiencies in each technical area. Cholera outbreak preparedness and response was strongest when human resource and health systems functioned well before the outbreak. Communication relied on coordination of existing networks and methods for empowering local leaders and villagers to modify behaviours of the population.
In line with the national health emergencies plan, the successes of human resource strategies during the cholera outbreak should be built upon through emergency exercises, especially in non-affected provinces. Population needs for all public health professionals involved in health emergency preparedness and response should be mapped, and planning should be implemented to increase the numbers in relevant areas. Human resource planning should be integrated with health emergency planning. It is essential to maintain and strengthen the human resource capacities and experiences gained during the cholera outbreak to ensure a more effective response to the next health emergency.
PMCID: PMC3854099  PMID: 24319607
10.  From scaling up to sustainability in HIV: potential lessons for moving forward 
In 30 years of experience in responding to the HIV epidemic, critical decisions and program characteristics for successful scale-up have been studied. Now leaders face a new challenge: sustaining large-scale HIV prevention programs. Implementers, funders, and the communities served need to assess what strategies and practices of scaling up are also relevant for sustaining delivery at scale.
We reviewed white and gray literature to identify domains central to scaling-up programs and reviewed HIV case studies to identify how these domains might relate to sustaining delivery at scale.
We found 10 domains identified as important for successfully scaling up programs that have potential relevance for sustaining delivery at scale: fiscal support; political support; community involvement, integration, buy-in, and depth; partnerships; balancing flexibility/adaptability and standardization; supportive policy, regulatory, and legal environment; building and sustaining strong organizational capacity; transferring ownership; decentralization; and ongoing focus on sustainability. We identified one additional potential domain important for programs sustaining delivery at scale: emphasizing equity.
Today, the public and private sector are examining their ability to generate value for populations. All stakeholders are aiming to stem the tide of the HIV epidemic. Implementers need a framework to guide the evolution of their strategies and management practices. Greater research is needed to refine the domains for policy and program implementers working to sustain HIV program delivery at scale.
PMCID: PMC3826849  PMID: 24199749
Scale-up; Sustainability; Large-scale; HIV; Literature review; Framework; Public health; Care delivery
11.  e-Health, m-Health and healthier social media reform: the big scale view 
In the upcoming decade, digital platforms will be the backbone of a strategic revolution in the way medical services are provided, affecting both healthcare providers and patients. Digital-based patient-centered healthcare services allow patients to actively participate in managing their own care, in times of health as well as illness, using personally tailored interactive tools. Such empowerment is expected to increase patients’ willingness to adopt actions and lifestyles that promote health as well as improve follow-up and compliance with treatment in cases of chronic illness. Clalit Health Services (CHS) is the largest HMO in Israel and second largest world-wide. Through its 14 hospitals, 1300 primary and specialized clinics, and 650 pharmacies, CHS provides comprehensive medical care to the majority of Israel’s population (above 4 million members). CHS e-Health wing focuses on deepening patient involvement in managing health, through personalized digital interactive tools. Currently, CHS e-Health wing provides e-health services for 1.56 million unique patients monthly with 2.4 million interactions every month (August 2011). Successful implementation of e-Health solutions is not a sum of technology, innovation and health; rather it’s the expertise of tailoring knowledge and leadership capabilities in multidisciplinary areas: clinical, ethical, psychological, legal, comprehension of patient and medical team engagement etc. The Google Health case excellently demonstrates this point. On the other hand, our success with CHS is a demonstration that e-Health can be enrolled effectively and fast with huge benefits for both patients and medical teams, and with a robust business model.
CHS e-Health core components
They include:
1. The personal health record layer (what the patient can see) presents patients with their own medical history as well as the medical history of their preadult children, including diagnoses, allergies, vaccinations, laboratory results with interpretations in layman’s terms, medications with clear, straightforward explanations regarding dosing instructions, important side effects, contraindications, such as lactation etc., and other important medical information. All personal e-Health services require identification and authorization.
2. The personal knowledge layer (what the patient should know) presents patients with personally tailored recommendations for preventative medicine and health promotion. For example, diabetic patients are push notified regarding their yearly eye exam. The various health recommendations include: occult blood testing, mammography, lipid profile etc. Each recommendation contains textual, visual and interactive content components in order to promote engagement and motivate the patient to actually change his health behaviour.
3. The personal health services layer (what the patient can do) enables patients to schedule clinic visits, order chronic prescriptions, e-consult their physician via secured e-mail, set SMS medication reminders, e-consult a pharmacist regarding personal medications. Consultants’ answers are sent securely to the patients’ personal mobile device.
On December 2009 CHS launched secured, web based, synchronous medical consultation via video conference. Currently 11,780 e-visits are performed monthly (May 2011). The medical encounter includes e-prescription and referral capabilities which are biometrically signed by the physician. On December 2010 CHS launched a unique mobile health platform, which is one of the most comprehensive personal m-Health applications world-wide. An essential advantage of mobile devices is their potential to bridge the digital divide. Currently, CHS m-Health platform is used by more than 45,000 unique users, with 75,000 laboratory results views/month, 1100 m-consultations/month and 9000 physician visit scheduling/month.
4. The Bio-Sensing layer (what physiological data the patient can populate) includes diagnostic means that allow remote physical examination, bio-sensors that broadcast various physiological measurements, and smart homecare devices, such as e-Pill boxes that gives seniors, patients and their caregivers the ability to stay at home and live life to its fullest. Monitored data is automatically transmitted to the patient’s Personal Health Record and to relevant medical personnel.
The monitoring layer is embedded in the chronic disease management platform, and in the interactive health promotion and wellness platform. It includes tailoring of consumer-oriented medical devices and service provided by various professional personnel—physicians, nurses, pharmacists, dieticians and more.
5. The Social layer (what the patient can share). Social media networks triggered an essential change at the humanity ‘genome’ level, yet to be further defined in the upcoming years. Social media has huge potential in promoting health as it combines fun, simple yet extraordinary user experience, and bio-social-feedback. There are two major challenges in leveraging health care through social networks:
a. Our personal health information is the cornerstone for personalizing healthier lifestyle, disease management and preventative medicine. We naturally see our personal health data as a super-private territory. So, how do we bring the power of our private health information, currently locked within our Personal Health Record, into social media networks without offending basic privacy issues?
b. Disease management and preventive medicine are currently neither considered ‘cool’ nor ‘fun’ or ‘potentially highly viral’ activities; yet, health is a major issue of everybody’s life. It seems like we are missing a crucial element with a huge potential in health behavioural change—the Fun Theory. Social media platforms comprehends user experience tools that potentially could break current misconception, and engage people in the daily task of taking better care of themselves.
CHS e-Health innovation team characterized several break-through applications in this unexplored territory within social media networks, fusing personal health and social media platforms without offending privacy. One of the most crucial issues regarding adoption of e-health and m-health platforms is change management. Being a ‘hot’ innovative ‘gadget’ is far from sufficient for changing health behaviours at the individual and population levels.
CHS health behaviour change management methodology includes 4 core elements:
1. Engaging two completely different populations: patients, and medical teams. e-Health applications must present true added value for both medical teams and patients, engaging them through understanding and assimilating “what’s really in it for me”. Medical teams are further subdivided into physicians, nurses, pharmacists and administrative personnel—each with their own driving incentive. Resistance to change is an obstacle in many fields but it is particularly true in the conservative health industry. To successfully manage a large scale persuasive process, we treat intra-organizational human resources as “Change Agents”. Harnessing the persuasive power of ~40,000 employees requires engaging them as the primary target group. Successful recruitment has the potential of converting each patient-medical team interaction into an exposure opportunity to the new era of participatory medicine via e-health and m-health channels.
2. Implementation waves: every group of digital health products that are released at the same time are seen as one project. Each implementation wave leverages the focus of the organization and target populations to a defined time span. There are three major and three minor implementation waves a year.
3. Change-Support Arrow: a structured infrastructure for every implementation wave. The sub-stages in this strategy include:
Cross organizational mapping and identification of early adopters and stakeholders relevant to the implementation wave
Mapping positive or negative perceptions and designing specific marketing approaches for the distinct target groups
Intra and extra organizational marketing
Conducting intensive training and presentation sessions for groups of implementers
Running conflict-prevention activities, such as advanced tackling of potential union resistance
Training change-agents with resistance-management behavioural techniques, focused intervention for specific incidents and for key opinion leaders
Extensive presence in the clinics during the launch period, etc.
The entire process is monitored and managed continuously by a review team.
4. Closing Phase: each wave is analyzed and a “lessons-learned” session concludes the changes required in the modus operandi of the e-health project team.
PMCID: PMC3571141
e-Health; mobile health; personal health record; online visit; patient empowerment; knowledge prescription
12.  “If Only Someone Had Told Me…”: Lessons From Rural Providers 
Health care providers face challenges in rural service delivery due to the unique circumstances of rural living. The intersection of rural living and health care challenges can create barriers to care that providers may not be trained to navigate, resulting in burnout and high turnover. Through the exploration of experienced rural providers’ knowledge and lessons learned, this study sought to inform future practitioners, educators, and policy makers in avenues through which to enhance training, recruiting, and maintaining a rural workforce across multiple health care domains.
Using a qualitative study design, 18 focus groups were conducted, with a total of 127 health care providers from Alaska and New Mexico. Transcribed responses from the question, “What are the 3 things you wish someone would have told you about delivering health care in rural areas?” were thematically coded.
Emergent themes coalesced into 3 overarching themes addressing practice-related factors surrounding the challenges, adaptations, and rewards of being a rural practitioner.
Based on the themes, a series of recommendations are offered to future rural practitioners related to community engagement, service delivery, and burnout prevention. The recommendations offered may help practitioners enter communities more respectfully and competently. They can also be used by training programs and communities to develop supportive programs for new practitioners, enabling them to retain their services and help practitioners integrate into the community. Moving toward an integrative paradigm of health care delivery wherein practitioners and communities collaborate in service delivery will be the key to enhancing rural health care and reducing disparities.
PMCID: PMC3057882  PMID: 21204979
access to care; allied health; health disparities; qualitative research; rural health care providers
13.  An Overview of the CERC ARTEMIS Project 
The basic premise of this effort is that health care can be made more effective and affordable by applying modern computer technology to improve collaboration among diverse and distributed health care providers.
Information sharing, communication, and coordination are basic elements of any collaborative endeavor. In the health care domain, collaboration is characterized by cooperative activities by health care providers to deliver total and real-time care for their patients. Communication between providers and managed access to distributed patient records should enable health care providers to make informed decisions about their patients in a timely manner. With an effective medical information infrastructure in place, a patient will be able to visit any health care provider with access to the network, and the provider will be able to use relevant information from even the last episode of care in the patient record. Such a patient-centered perspective is in keeping with the real mission of health care providers.
Today, an easy-to-use, integrated health care network is not in place in any community, even though current technology makes such a network possible. Large health care systems have deployed partial and disparate systems that address different elements of collaboration. But these islands of automation have not been integrated to facilitate cooperation among health care providers in large communities or nationally.
CERC and its team members at Valley Health Systems, Inc., St. Marys Hospital and Cabell Huntington Hospital form a consortium committed to improving collaboration among the diverse and distributed providers in the health care arena. As the first contract recipient of the multi-agency High Performance Computing and Communications (HPCC) Initiative, this team of computer system developers, practicing rural physicians, community care groups, health care researchers, and tertiary care providers are using research prototypes and commercial off-the-shelf technologies to develop an open collaboration environment for the health care domain. This environment is called ARTEMIS — Advanced Research TEstbed for Medical InformaticS.
PMCID: PMC2579046  PMID: 8563249
14.  Addressing the Neglected Tropical Disease Podoconiosis in Northern Ethiopia: Lessons Learned from a New Community Podoconiosis Program 
Despite its great public health importance, few control initiatives addressing podoconiosis (non-filarial elephantiasis, a geochemical neglected tropical disease) exist. In June 2010, the first podoconiosis program in Northern Ethiopia, consisting of prevention, awareness, and care and support activities, began in Debre Markos, Northern Ethiopia. This study aims to document and disseminate the lessons learned from a new community podoconiosis program in Debre Markos.
Methods/Principal Findings
We used a content analysis approach to examine and evaluate data from a series of sources. These sources include conducted interview transcripts, a focus group discussion transcript and secondary sources including monitoring and evaluation field reports, observation notes, and research obtained from a literature review. Themes were identified and grouped into matrix tables. Overall, sixteen program steps were identified and grouped into 6 domains: Initial preparation, training and sensitization, foundation building, treatment activity implementation, awareness, and follow-up. Emphasis is placed on the need for baseline data, effective training, local leadership, experience-sharing, mass-awareness, cross-cutting sector issues (i.e., water and waste management), and integration with government health systems. Related successes and challenges are also described, as are stakeholder roles and misconceptions and socio-cultural challenges affecting the program start-up. Many of the identified successes and challenges are relevant to the aim of the podoconiosis program to be sustainable and community-led.
Much of this information has already been used to improve the Debre Markos program. We also anticipate that the domains and steps identified will be useful in guiding new programs in other settings where podoconiosis is highly prevalent. We hope to encourage partnerships and collaboration among podoconiosis stakeholders in future growth and disease control expansion.
Author Summary
Podoconiosis is a chronic non-infectious disease that causes leg swelling among those living and walking bare-footed in red clay soil areas. It can be prevented and treated primarily by the use of shoes and foot hygiene. In Ethiopia, it is estimated that nearly 11 million people are at risk but few control programs exist. We aimed to assess and document the lessons learned from the first community podoconiosis program started in Northern Ethiopia in June 2010. We conducted interviews and a focus group discussion in addition to examining monitoring and evaluation field reports, observation notes, and other research articles. Overall, sixteen program steps were identified and grouped into 6 domains: Initial preparation, training and sensitization, foundation building, treatment activity implementation, awareness, and follow-up. Related successes and challenges, stakeholder roles, misconceptions and socio-cultural challenges affecting the program start-up were also identified. We hope that the results will be useful in guiding new programs in other settings where podoconiosis is highly prevalent.
PMCID: PMC3302806  PMID: 22428078
15.  Health and Wellness Technology Use by Historically Underserved Health Consumers: Systematic Review 
The implementation of health technology is a national priority in the United States and widely discussed in the literature. However, literature about the use of this technology by historically underserved populations is limited. Information on culturally informed health and wellness technology and the use of these technologies to reduce health disparities facing historically underserved populations in the United States is sparse in the literature.
To examine ways in which technology is being used by historically underserved populations to decrease health disparities through facilitating or improving health care access and health and wellness outcomes.
We conducted a systematic review in four library databases (PubMed, PsycINFO, Web of Science, and Engineering Village) to investigate the use of technology by historically underserved populations. Search strings consisted of three topics (eg, technology, historically underserved populations, and health).
A total of 424 search phrases applied in the four databases returned 16,108 papers. After review, 125 papers met the selection criteria. Within the selected papers, 30 types of technology, 19 historically underserved groups, and 23 health issues were discussed. Further, almost half of the papers (62 papers) examined the use of technology to create effective and culturally informed interventions or educational tools. Finally, 12 evaluation techniques were used to assess the technology.
While the reviewed studies show how technology can be used to positively affect the health of historically underserved populations, the technology must be tailored toward the intended population, as personally relevant and contextually situated health technology is more likely than broader technology to create behavior changes. Social media, cell phones, and videotapes are types of technology that should be used more often in the future. Further, culturally informed health information technology should be used more for chronic diseases and disease management, as it is an innovative way to provide holistic care and reminders to otherwise underserved populations. Additionally, design processes should be stated regularly so that best practices can be created. Finally, the evaluation process should be standardized to create a benchmark for culturally informed health information technology.
PMCID: PMC3799608  PMID: 22652979
health care disparities; biomedical technology; health education; health knowledge, attitudes, and practice; health care quality, access, and evaluation; educational technology; cultural diversity
16.  German translation of the Alberta context tool and two measures of research use: methods, challenges and lessons learned 
Understanding the relationship between organizational context and research utilization is key to reducing the research-practice gap in health care. This is particularly true in the residential long term care (LTC) setting where relatively little work has examined the influence of context on research implementation. Reliable, valid measures and tools are a prerequisite for studying organizational context and research utilization. Few such tools exist in German. We thus translated three such tools (the Alberta Context Tool and two measures of research use) into German for use in German residential LTC. We point out challenges and strategies for their solution unique to German residential LTC, and demonstrate how resolving specific challenges in the translation of the health care aide instrument version streamlined the translation process of versions for registered nurses, allied health providers, practice specialists, and managers.
Our translation methods were based on best practices and included two independent forward translations, reconciliation of the forward translations, expert panel discussions, two independent back translations, reconciliation of the back translations, back translation review, and cognitive debriefing.
We categorized the challenges in this translation process into seven categories: (1) differing professional education of Canadian and German care providers, (2) risk that German translations would become grammatically complex, (3) wordings at risk of being misunderstood, (4) phrases/idioms non-existent in German, (5) lack of corresponding German words, (6) limited comprehensibility of corresponding German words, and (7) target persons’ unfamiliarity with activities detailed in survey items. Examples of each challenge are described with strategies that we used to manage the challenge.
Translating an existing instrument is complex and time-consuming, but a rigorous approach is necessary to obtain instrument equivalence. Essential components were (1) involvement of and co-operation with the instrument developers and (2) expert panel discussions, including both target group and content experts. Equivalent translated instruments help researchers from different cultures to find a common language and undertake comparative research. As acceptable psychometric properties are a prerequisite for that, we are currently carrying out a study with that focus.
PMCID: PMC3893410  PMID: 24238613
Translation; Cultural adaptation; Alberta Context Tool; Estabrooks’ Kind of Research Utilization; Conceptual Research Use scale; Organizational context; Research utilization; Residential long term care
17.  What are the ‘success factors’ for effective integration? Lessons from international case studies 
To describe key success factors, derived from literature review and international case studies that enable effective integration between clinicians, teams and organizations.
Effective integration is dependent on consideration of diverse factors operating at macro, meso and micro levels of health care.
Data sources
Literature review and four international case studies.
A maximum variation sample of four ICOs was selected from organizations and services nominated by international experts as ‘high performing’; ensuring a range of national policy contexts, organizational arrangements, and integrative approaches. Case studies in the USA, Holland and Scotland, drew on data from 10 to 15 semi-structured interviews with managers and clinicians and on document review. Interviews explored understanding of and objectives for ‘integration’, external influences and impact of internal characteristics (e.g. leadership, governance, IT) in facilitating/hindering integration. Clinical interviewees also described hypothetical patient journeys. Analysis focused on potential barriers and facilitators to integration.
Preliminary conclusions
Findings suggest integration requires four tiers of ‘success factors’: 1) a supportive ‘operating environment’ with appropriate policy, regulation, law, and payment systems; 2) organisational culture, infrastructure and processes (which may cross organizational boundaries) to support integration and enable; 3) effective inter-professional teams operating within or between organizations with linked infrastructure; shared assessments; common standards; care co-ordination and shared care plans and 4) activated patients to participate in care planning.
Those wishing to develop effective ICOs will need to ensure that each of these four tiers is addressed simultaneously across all levels (i.e. macro, meso and micro) of health care.
PMCID: PMC2807100
integrated care; success factors; international case studies; literature review
18.  The Emergence of Ebola as a Global Health Security Threat: From ‘Lessons Learned’ to Coordinated Multilateral Containment Efforts 
First reported in remote villages of Africa in the 1970s, the Ebolavirus was originally believed to be transmitted to people from wild animals. Ebolavirus (EBOV) causes a severe, frequently fatal hemorrhagic syndrome in humans. Each outbreak of the Ebolavirus over the last three decades has perpetuated fear and economic turmoil among the local and regional populations in Africa. Until now it has been considered a tragic malady confined largely to the isolated regions of the African continent, but it is no longer so. The frequency of outbreaks has increased since the 1970s. The 2014 Ebola outbreak in Western Africa has been the most severe in history and was declared a public health emergency by the World Health Organization. Given the widespread use of modern transportation and global travel, the EBOV is now a risk to the entire Global Village, with intercontinental transmission only an airplane flight away. Clinically, symptoms typically appear after an incubation period of approximately 11 days. A flu-like syndrome can progress to full hemorrhagic fever with multiorgan failure, and frequently, death. Diagnosis is confirmed by detection of viral antigens or Ribonucleic acid (RNA) in the blood or other body fluids. Although historically the mortality of this infection exceeded 80%, modern medicine and public health measures have been able to lower this figure and reduce the impact of EBOV on individuals and communities. The treatment involves early, aggressive supportive care with rehydration. Core interventions, including contact tracing, preventive initiatives, active surveillance, effective isolation and quarantine procedures, and timely response to patients, are essential for a successful outbreak control. These measures, combined with public health education, point-of-care diagnostics, promising new vaccine and pharmaceutical efforts, and coordinated efforts of the international community, give new hope to the Global effort to eliminate Ebola as a public health threat. Here we present a review of EBOV infection in an effort to further educate medical and political communities on what the Ebolavirus disease entails, and what efforts are recommended to treat, isolate, and eventually eliminate it.
PMCID: PMC4265832  PMID: 25538455
Containment; Ebolavirus; Epidemic; Outbreak; Global response; Government response system; Global Health Security Agenda; Virus transmission
19.  A new model of care collaboration for community-dwelling elders: findings and lessons learned from the NORC-health care linkage evaluation 
Providing care for older individuals with chronic illnesses in the community requires a model of service delivery that takes into account both physical health and social health needs. However, packaging care in this way does not fit into existing service or reimbursement structures in the US, and there are few financial incentives that encourage service coordination. Lack of coordinated care can negatively affect access to high quality, appropriate care, putting seniors' physical and mental health and quality of life at risk, as well as their ability to stay in the community. Supportive Social Programs (SSPs), operating in Naturally Occurring Retirement Communities (NORCs), attempt to increase access to care and enhance care quality for aging residents through outreach and service facilitation. Since their inception in 1986, NORC-SSPs have partnered with local health care providers to address both individual and community-wide health issues; however, each sector continues to operate along functional lines, and on a reactive basis. This article presents findings from an evaluation conducted from 2002 to 2006 looking at the feasibility, quality and outcomes of linking health and social services through innovative NORC-SSP and health organization partnerships.
Four NORC-SSPs participated in the study by finding a health care provider to collaborate on addressing health conditions that could benefit from a biopsychosocial approach. Each site focused on a specific population, a specific condition or problem, and created different linkages to address the target problem. Using a case study approach, incorporating both qualitative and quantitative methods, this evaluation sought to answer the following two primary questions: 1) have the participating sites created viable linkages between the participating organizations that did not exist prior to the study; and, 2) to what extent have the linkages resulted in improvements in clinical and other health and social outcomes?
Findings suggest that immediate outcomes were widely achieved across sites: knowledge of other sector providers' capabilities and services increased; communication across providers increased; identification of target population increased; and, awareness of risks, symptoms and healthy behaviors among clients/patients increased. Furthermore, intermediate outcomes were also widely achieved: shared care planning increased across providers; continuity of care was enhanced; disease management improved; and self care among clients improved. Finally, several linkage partnerships were also able to demonstrate improvements in distal outcomes: falls risk decreased; clinical indicators for diabetes management improved; and inappropriate hospitalizations decreased.
Using simple, familiar and relatively low-tech approaches to sharing critical patient information among collaborating organizations, inter-sector linkages were successfully established at all four sites. Seven critical success factors emerged that increase the likelihood that linkages will be implemented, effective and sustained: 1) careful goal selection; 2) meaningful collaboration; 3) appropriate role for clients; 4) realistic interventions; 5) realistic expectations for implementation environment; 6) continuous focus on outcomes; and, 7) stable leadership. A considerable amount of literature speaks to the importance of organizational partnerships to improve community health; however, findings from this evaluation suggest that less complex, more focused, micro-level collaborations can also make a difference, extending the feasibility that organizations will enter into such endeavors.
PMCID: PMC2807089
older people; integrated care models; linkage
20.  Lessons learned from scaling up a community-based health program in the Upper East Region of northern Ghana 
The original CHPS model deployed nurses to the community and engaged local leaders, reducing child mortality and fertility substantially. Key scaling-up lessons: (1) place nurses in home districts but not home villages, (2) adapt uniquely to each district, (3) mobilize local resources, (4) develop a shared project vision, and (5) conduct “exchanges” so that staff who are initiating operations can observe the model working in another setting, pilot the approach locally, and expand based on lessons learned.
The original CHPS model deployed nurses to the community and engaged local leaders, reducing child mortality and fertility substantially. Key scaling-up lessons: (1) place nurses in home districts but not home villages, (2) adapt uniquely to each district, (3) mobilize local resources, (4) develop a shared project vision, and (5) conduct “exchanges” so that staff who are initiating operations can observe the model working in another setting, pilot the approach locally, and expand based on lessons learned.
Ghana's Community-Based Health Planning and Service (CHPS) initiative is envisioned to be a national program to relocate primary health care services from subdistrict health centers to convenient community locations. The initiative was launched in 4 phases. First, it was piloted in 3 villages to develop appropriate strategies. Second, the approach was tested in a factorial trial, which showed that community-based care could reduce childhood mortality by half in only 3 years. Then, a replication experiment was launched to clarify appropriate activities for implementing the fourth and final phase—national scale up. This paper discusses CHPS progress in the Upper East Region (UER) of Ghana, where the pace of scale up has been much more rapid than in the other 9 regions of the country despite exceedingly challenging economic, ecological, and social circumstances. The UER employed 5 strategies that facilitated scale up: (1) nurse recruitment from their home districts to improve worker morale and cultural grounding, balanced with some social distance from the village community to ensure client confidentiality, particularly regarding family planning use; (2) prioritization of CHPS planning and continuous review in management meetings to make necessary modifications to the initiative's approach; (3) community engagement and advocacy to local politicians to mobilize resources for financing start-up costs; (4) a shared and consistent vision about CHPS among health administration leaders to ensure appropriate resources and commitment to the initiative; and (5) knowledge exchange visits between new and advanced CHPS implementers to facilitate learning and scale up within and between districts.
PMCID: PMC4168550  PMID: 25276522
21.  A Holistic Framework to Improve the Uptake and Impact of eHealth Technologies 
Many eHealth technologies are not successful in realizing sustainable innovations in health care practices. One of the reasons for this is that the current development of eHealth technology often disregards the interdependencies between technology, human characteristics, and the socioeconomic environment, resulting in technology that has a low impact in health care practices. To overcome the hurdles with eHealth design and implementation, a new, holistic approach to the development of eHealth technologies is needed, one that takes into account the complexity of health care and the rituals and habits of patients and other stakeholders.
The aim of this viewpoint paper is to improve the uptake and impact of eHealth technologies by advocating a holistic approach toward their development and eventual integration in the health sector.
To identify the potential and limitations of current eHealth frameworks (1999–2009), we carried out a literature search in the following electronic databases: PubMed, ScienceDirect, Web of Knowledge, PiCarta, and Google Scholar. Of the 60 papers that were identified, 44 were selected for full review. We excluded those papers that did not describe hands-on guidelines or quality criteria for the design, implementation, and evaluation of eHealth technologies (28 papers). From the results retrieved, we identified 16 eHealth frameworks that matched the inclusion criteria. The outcomes were used to posit strategies and principles for a holistic approach toward the development of eHealth technologies; these principles underpin our holistic eHealth framework.
A total of 16 frameworks qualified for a final analysis, based on their theoretical backgrounds and visions on eHealth, and the strategies and conditions for the research and development of eHealth technologies. Despite their potential, the relationship between the visions on eHealth, proposed strategies, and research methods is obscure, perhaps due to a rather conceptual approach that focuses on the rationale behind the frameworks rather than on practical guidelines. In addition, the Web 2.0 technologies that call for a more stakeholder-driven approach are beyond the scope of current frameworks. To overcome these limitations, we composed a holistic framework based on a participatory development approach, persuasive design techniques, and business modeling.
To demonstrate the impact of eHealth technologies more effectively, a fresh way of thinking is required about how technology can be used to innovate health care. It also requires new concepts and instruments to develop and implement technologies in practice. The proposed framework serves as an evidence-based roadmap.
PMCID: PMC3278097  PMID: 22155738
eHealth; design; participation; implementation; evaluation; multidisciplinary approach; Health 2.0; Wiki; e-collaboration
22.  Health Information Exchange Implementation: Lessons Learned and Critical Success Factors From a Case Study 
JMIR Medical Informatics  2014;2(2):e19.
Much attention has been given to the proposition that the exchange of health information as an act, and health information exchange (HIE), as an entity, are critical components of a framework for health care change, yet little has been studied to understand the value proposition of implementing HIE with a statewide HIE. Such an organization facilitates the exchange of health information across disparate systems, thus following patients as they move across different care settings and encounters, whether or not they share an organizational affiliation. A sociotechnical systems approach and an interorganizational systems framework were used to examine implementation of a health system electronic medical record (EMR) system onto a statewide HIE, under a cooperative agreement with the Office of the National Coordinator for Health Information Technology, and its collaborating organizations.
The objective of the study was to focus on the implementation of a health system onto a statewide HIE; provide insight into the technical, organizational, and governance aspects of a large private health system and the Virginia statewide HIE (organizations with the shared goal of exchanging health information); and to understand the organizational motivations and value propositions apparent during HIE implementation.
We used a formative evaluation methodology to investigate the first implementation of a health system onto the statewide HIE. Qualitative methods (direct observation, 36 hours), informal information gathering, semistructured interviews (N=12), and document analysis were used to gather data between August 12, 2012 and June 24, 2013. Derived from sociotechnical concepts, a Blended Value Collaboration Enactment Framework guided the data gathering and analysis to understand organizational stakeholders’ perspectives across technical, organizational, and governance dimensions.
Several challenges, successes, and lessons learned during the implementation of a health system to the statewide HIE were found. The most significant perceived success was accomplishing the implementation, although many interviewees also underscored the value of a project champion with decision-making power. In terms of lessons learned, social reasons were found to be very significant motivators for early implementation, frequently outweighing economic motivations. It was clear that understanding the guides early in the project would have mitigated some of the challenges that emerged, and early communication with the electronic health record vendor so that they have a solid understanding of the undertaking was critical. An HIE implementations evaluation framework was found to be useful for assessing challenges, motivations, value propositions for participating, and success factors to consider for future implementations.
This case study illuminates five critical success factors for implementation of a health system onto a statewide HIE. This study also reveals that organizations have varied motivations and value proposition perceptions for engaging in the exchange of health information, few of which, at the early stages, are economically driven.
PMCID: PMC4288070  PMID: 25599991
health information exchange; blended value collaboration enactment framework; HIE value proposition; interorganizational systems; HIE implementation
23.  Long-term Radiation-Related Health Effects in a Unique Human Population: Lessons Learned from the Atomic Bomb Survivors of Hiroshima and Nagasaki 
For 63 years scientists in the Atomic Bomb Casualty Commission and its successor, the Radiation Effects Research Foundation, have been assessing the long-term health effects in the survivors of the atomic bombings of Hiroshima and Nagasaki and in their children. The identification and follow-up of a large population (approximately a total of 200 000, of whom more than 40% are alive today) that includes a broad range of ages and radiation exposure doses, and healthy representatives of both sexes; establishment of well-defined cohorts whose members have been studied longitudinally, including some with biennial health examinations and a high survivor participation rate; and careful reconstructions of individual radiation doses have resulted in reliable excess relative risk estimates for radiation-related health effects, including cancer and noncancer effects in humans, for the benefit of the survivors and for all humankind. This article reviews those risk estimates and summarizes what has been learned from this historic and unique study.
PMCID: PMC3907953  PMID: 21402804
atomic bomb; ionizing radiation; cancer; genetics; health effects; epidemiology; excess relative risks
24.  Supporting middle-cadre health care workers in Malawi: lessons learned during implementation of the PALM PLUS package 
BMC Health Services Research  2014;14(Suppl 1):S8.
The government of Malawi is committed to the broad rollout of antiretroviral treatment in Malawi in the public health sector; however one of the primary challenges has been the shortage of trained health care workers. The Practical Approach to Lung Health Plus HIV/AIDS in Malawi (PALM PLUS) package is an innovative guideline and training intervention that supports primary care middle-cadre health care workers to provide front-line integrated primary care. The purpose of this paper is to describe the lessons learned in implementing the PALM PLUS package.
A clinical tool, based on algorithm- and symptom-based guidelines was adapted to the Malawian context. An accompanying training program based on educational outreach principles was developed and a cascade training approach was used for implementation of the PALM PLUS package in 30 health centres, targeting clinical officers, medical assistants, and nurses. Lessons learned were identified during program implementation through engagement with collaborating partners and program participants and review of program evaluation findings.
Key lessons learned for successful program implementation of the PALM PLUS package include the importance of building networks for peer-based support, ensuring adequate training capacity, making linkages with continuing professional development accreditation and providing modest in-service training budgets. The main limiting factors to implementation were turnover of staff and desire for financial training allowances.
The PALM PLUS approach is a potential model for supporting mid-level health care workers to provide front-line integrated primary care in low and middle income countries, and may be useful for future task-shifting initiatives.
PMCID: PMC4108880  PMID: 25080192
training; educational outreach; task-shifting; continuing professional development; antiretroviral treatment; integrated primary care; nurses; clinical officers; medical assistants; health surveillance assistants; guideline; train-the-trainer; south-south collaboration; formation; sensibilisation; délégation de tâches; formation continue; soins primaires intégrés; personnel infirmier; personnel clinique; auxiliaires médicaux; adjoints à la surveillance sanitaire; lignes directrices; formation des formateurs; collaboration Sud-Sud
25.  Multilevel Intervention Research: Lessons Learned and Pathways Forward 
This summary reflects on this monograph regarding multilevel intervention (MLI) research to 1) assess its added value; 2) discuss what has been learned to date about its challenges in cancer care delivery; and 3) identify specific ways to improve its scientific soundness, feasibility, policy relevance, and research agenda. The 12 submitted chapters, and discussion of them at the March 2011 multilevel meeting, were reviewed and discussed among the authors to elicit key findings and results addressing the questions raised at the outset of this effort. MLI research is underrepresented as an explicit focus in the cancer literature but may improve implementation of studies of cancer care delivery if they assess contextual, organizational, and environmental factors important to understanding behavioral and/or system-level interventions. The field lacks a single unifying theory, although several psychological or biological theories are useful, and an ecological model helps conceptualize and communicate interventions. MLI research designs are often complex, involving nonlinear and nonhierarchical relationships that may not be optimally studied in randomized designs. Simulation modeling and pilot studies may be necessary to evaluate MLI interventions. Measurement and evaluation of team and organizational interventions are especially needed in cancer care, as are attention to the context of health-care reform, eHealth technology, and genomics-based medicine. Future progress in MLI research requires greater attention to developing and supporting relevant metrics of level effects and interactions and evaluating MLI interventions. MLI research holds an unrealized promise for understanding how to improve cancer care delivery.
PMCID: PMC3482966  PMID: 22623606

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