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1.  Shaped by asymmetrical interdependence: a qualitative case study of the external influences on international non-governmental organizations’ implementation of equity principles in HIV/AIDS work 
Addressing inequities is a key role for international non-governmental organizations (INGOs) working in health and development. Yet, putting equity principles into practice can prove challenging. In-depth empirical research examining what influences INGOs’ implementation of equity principles is limited. This study examined the influences on one INGO’s implementation of equity principles in its HIV/AIDS programs.
This research employed a case study with nested components (an INGO operating in Kenya, with offices in North America). We used multiple data collection methods, including document reviews, interviews (with staff, partners and clients of the INGO in Kenya), and participant observation (with Kenyan INGO staff). Participant observation was conducted with 10 people over three months. Forty-one interviews were completed, and 127 documents analyzed. Data analysis followed Auerbach and Silverstein’s analytic process (2003), with qualitative coding conducted in multiple stages, using descriptive matrices, visual displays and networks (Miles and Huberman, 1994).
There was a gap between the INGO’s intent to implement equity principles and actual practice due to multiple influences from various players, including donors and country governments. The INGO was reliant on donor funding and needed permission from the Kenyan government to work in-country. Major influences included donor agendas and funding, donor country policies, and Southern country government priorities and legislation. The INGO privileged particular vulnerable populations (based on its reputation, its history, and the priorities of the Kenyan government and the donors). To balance its equity commitment with the influences from other players, the INGO aligned with the system as well as pushed back incrementally on the donors and the Kenyan government to influence these organizations’ equity agendas. By moving its equity agenda forward incrementally and using its reputational advantage, the INGO avoided potential negative repercussions that might result from pushing too fast or working outside the system.
The INGO aligned the implementation of equity principles in its HIV/AIDS initiatives by working within a system characterized by asymmetrical interdependence. Influences from the donors and Kenyan government contributed to an implementation gap between what the INGO intended to accomplish in implementing equity principles in HIV/AIDS work and actual practice.
PMCID: PMC4201719  PMID: 25294125
Equity; HIV/AIDS; Non-governmental organizations; Vulnerable populations; Case study
2.  Kenyan Nurses Involvement in National Policy Development Processes 
Nursing Research and Practice  2014;2014:236573.
The aim of this study was to critically examine how nurses have been involved in national policy processes in the Kenyan health sector. The paper reports qualitative results from a larger mixed method study. National nonnursing decision-makers and nurse leaders, and provincial managers as well as frontline nurse managers from two Kenyan districts were purposefully selected for interviews. Interviews dealt with nurses' involvement in national policy processes, factors hindering nurses' engagement in policy processes, and ways to enhance nurses' involvement in policy processes. Critical theory and feminist perspectives guided the study process. Content analysis of data was conducted. Findings revealed that nurses' involvement in policy processes in Kenya was limited. Only a few nurse leaders were involved in national policy committees as a result of their positions in the sector. Critical analysis of the findings revealed that hierarchies and structural factors as well as nursing professional issues were the primary barriers constraining nurses' involvement in policy processes. Thus, there is need to address these factors both by nurses themselves and by nonnursing decision makers, in order to enhance nurses engagement in policy making and further the contribution to quality of services to the communities.
PMCID: PMC4202257  PMID: 25349731
3.  Perioperative critical care management for patients with aneurysmal subarachnoid hemorrhage 
Despite significant regional and risk factor-related variations, the overall mortality rate in patients suffering from aneurysmal subarachnoid hemorrhage (SAH) remains high. Compared to ischemic stroke, which is typically irreversible, hemorrhagic stroke tends to carry a higher mortality, but patients who do survive have less disability. Technologies to monitor and treat complications of SAH have advanced considerably in recent years, but good long-term functional outcome still depends on prompt diagnosis, early aggressive management, and avoidance of premature withdrawal of support. Endovascular procedures and open craniotomy to secure a ruptured aneurysm represent some of the numerous critical steps required to achieve the best possible result. In this review, we have attempted to provide a contemporary, evidence-based outline of the perioperative critical care management of patients with SAH. This is a challenging and potentially fatal disease with a wide spectrum of severity and complications and an often protracted course. The dynamic nature of this illness, especially in its most severe forms, requires considerable flexibility in clinician management, especially given the panoply of available treatment modalities. Judicious hemodynamic monitoring and adaptive therapy are essential to respond to the fluctuating nature of cerebral vasospasm and the varying oxygen demands of the injured brain that may readily induce acute or delayed cerebral ischemia.
PMCID: PMC4166392  PMID: 25237442
Intensive care unit; Multimodality monitoring; Perioperative; Subarachnoid hemorrhage
4.  Perceptions of health stakeholders on task shifting and motivation of community health workers in different socio demographic contexts in Kenya (nomadic, peri-urban and rural agrarian) 
BMC Health Services Research  2014;14(Suppl 1):S4.
The shortage of health professionals in low income countries is recognized as a crisis. Community health workers are part of a “task-shift” strategy to address this crisis. Task shifting in this paper refers to the delegation of tasks from health professionals to lay, trained volunteers. In Kenya, there is a debate as to whether these volunteers should be compensated, and what motivation strategies would be effective in different socio-demographic contexts, based type of tasks shifted. The purpose of this study was to find out, from stakeholders’ perspectives, the type of tasks to be shifted to community health workers and the appropriate strategies to motivate and retain them.
This was an analytical comparative study employing qualitative methods: key informant interviews with health policy makers, managers, and service providers, and focus group discussions with community health workers and service consumers, to explore their perspectives on tasks to be shifted and appropriate motivation strategies.
The study found that there were tasks to be shifted and motivation strategies that were common to all three contexts. Common tasks were promotive, preventive, and simple curative services. Common motivation strategies were supportive supervision, means of identification, equitable allocation of resources, training, compensation, recognition, and evidence based community dialogue.
Further, in the nomadic and peri-urban sites, community health workers had assumed curative services beyond the range provided for in the Kenyan task shifting policy. This was explained to be influenced by lack of access to care due to distance to health facilities, population movement, and scarcity of health providers in the nomadic setting and the harsh economic realities in peri-urban set up. Therefore, their motivation strategies included training on curative skills, technical support, and resources for curative care. Data collection was viewed as an important task in the rural site, but was not recognized as priority in nomadic and peri-urban sites, where they sought monetary compensation for data collection.
The study concluded that inclusion of curative tasks for community health workers, particularly in nomadic contexts, is inevitable but raises the need for accreditation of their training and regulation of their tasks.
PMCID: PMC4108867  PMID: 25079588
Task shifting; motivation; peri-urban; nomadic; rural; Community Health; Community Health Workers; délégation de tâches; motivation; périurbain; nomade; rural; santé communautaire; travailleurs en santé communautaire
5.  Advances in the Critical Care Management of Ischemic Stroke 
Stroke Research and Treatment  2013;2013:510481.
Given recent advances in diagnostic modalities and revascularization capabilities, clinicians are not only able to rapidly and accurately identify acute ischemic stroke, but may also be able to aggressively intervene to minimize the extent of infarction. In those cases where revascularization cannot occur and/or the extent of infarction is large, there are multiple strategies to prevent secondary decompensation as the stroke evolves, for instance, if malignant cerebral edema should develop. In this paper, we will review the indications for specialized ICU care for an ischemic stroke patient, the treatment principles, and strategies employed by neurointensivists to minimize secondary neuronal injury, the literature in support of such strategies (and the questions to be addressed by future studies), all with the ultimate goal of increasing the likelihood of favorable neurologic outcomes in our ischemic stroke population.
PMCID: PMC3671542  PMID: 23766928
6.  Community SES, Perceived Environment, and Physical Activity During Home-Based Cardiac Rehabilitation: Is There a Need to Consider the Urban vs. Rural Distinction? 
Physical activity (MVPA) levels during home-based cardiac rehabilitation (CR) remain problematic. Consequently, the present study examined the association between MVPA and urban vs. rural residential status and the perceived environment in patients attending home-based CR. A total of 280 patients completed a questionnaire assessing demographic, clinical, MVPA, and perceived environmental variables measured at baseline and 3 months later. Patient addresses were geocoded and linked to the 2006 Canadian census to establish the urban/rural distinction. Results showed that urban and rural patients had similar baseline MVPA and improvements in MVPA by 3 months. Several perceived environmental variables were significantly related to MVPA throughout home-based CR that were common and urban/rural-specific. Therefore, although there does not appear to be an urban vs. rural advantage in MVPA levels during home-based CR, there does appear to be environmental/MVPA-specific relationships specific to urban and rural patients that may warrant attention.
PMCID: PMC3324610  PMID: 22402918
Physical activity; Home-Based cardiac rehabilitation; Urban; Rural; Community SES; Perceived Environment
7.  Asthma and allergies in Jamaican children aged 2–17 years: a cross-sectional prevalence survey 
BMJ Open  2012;2(4):e001132.
To determine the prevalence and severity of asthma and allergies as well as risk factors for asthma among Jamaican children aged 2–17 years.
A cross-sectional, community-based prevalence survey using the International Study of Asthma and Allergies in Childhood questionnaire. The authors selected a representative sample of 2017 children using stratified, multistage cluster sampling design using enumeration districts as primary sampling units.
Jamaica, a Caribbean island with a total population of approximately 2.6 million, geographically divided into 14 parishes.
Children aged 2–17 years, who were resident in private households. Institutionalised children such as those in boarding schools and hospitals were excluded from the survey.
Primary and secondary outcome measures
The prevalence and severity of asthma and allergy symptoms, doctor-diagnosed asthma and risk factors for asthma.
Almost a fifth (19.6%) of Jamaican children aged 2–17 years had current wheeze, while 16.7% had self-reported doctor-diagnosed asthma. Both were more common among males than among females. The prevalence of rhinitis, hay fever and eczema among children was 24.5%, 25% and 17.3%, respectively. Current wheeze was more common among children with rhinitis in the last 12 months (44.3% vs 12.6%, p<0.001), hay fever (36.8% vs 13.8%, p<0.001) and eczema (34.1% vs 16.4%, p<0.001). Independent risk factors for current wheeze (ORs, 95% CI) were chest infections in the first year of life 4.83 (3.00 to 7.77), parental asthma 4.19 (2.8 to 6.08), rhinitis in the last 12 months 6.92 (5.16 to 9.29), hay fever 4.82 (3.62 to 6.41), moulds in the home 2.25 (1.16 to 4.45), cat in the home 2.44 (1.66 to 3.58) and dog in the home 1.81 (1.18 to 2.78).
The prevalence of asthma and allergies in Jamaican children is high. Significant risk factors for asthma include chest infections in the first year of life, a history of asthma in the family, allergies, moulds and pets in the home.
Article summary
Article focus
The prevalence of asthma and allergies in both developed and developing countries is continuing to rise.
In some Caribbean countries, asthma is a public health problem associated with high economic costs.
This study determined the prevalence of asthma, allergy symptoms and associated risk factors.
Key messages
We demonstrated that the prevalence of asthma and allergy symptoms among Jamaican children aged 2–17 years is high.
Both the prevalence and severity of asthma symptoms are comparable to that reported among children in high-income countries.
Current wheeze and doctor-diagnosed asthma were more common in males and in children with allergies.
A history of asthma in the family, chest infections in the first year of life, allergies, exposure to moulds and pets in the home were associated with significant risk for asthma.
Identifying children at high risk for asthma and controlling modifiable risk factors is important in reducing the prevalence and morbidity related to asthma.
Strengths and limitations of this study
This is the first national study on asthma and allergies in Jamaica using a nationally representative sample of children with a response rate of 80%.
We used a modified ISAAC protocol in which sampling was done by household rather than by school. Using a population-based sampling strategy; we sampled one child and one adult per household. This approach enabled us to obtain national prevalence estimates for both adults and children in one survey at a reduced cost.
Limitations of this study include the fact that the prevalence of asthma and allergies was based solely on self-reports, no objective measures were done. Also in younger children, caregivers responded to questionnaires.
PMCID: PMC3400072  PMID: 22798254
8.  The use of tacit and explicit knowledge in public health: a qualitative study 
Planning a public health initiative is both a science and an art. Public health practitioners work in a complex, often time-constrained environment, where formal research literature can be unavailable or uncertain. Consequently, public health practitioners often draw upon other forms of knowledge.
Through use of one-on-one interviews and focus groups, we aimed to gain a better understanding of how tacit knowledge is used to inform program initiatives in public health. This study was designed as a narrative inquiry, which is based on the assumption that we make sense of the world by telling stories. Four public health units were purposively selected for maximum variation, based on geography and academic affiliation.
Analysis revealed different ways in which tacit knowledge was used to plan the public health program or initiative, including discovering the opportunity, bringing a team together, and working out program details (such as partnering, funding).
The findings of this study demonstrate that tacit knowledge is drawn upon, and embedded within, various stages of the process of program planning in public health. The results will be useful in guiding the development of future knowledge translation strategies for public health organizations and decision makers.
PMCID: PMC3325865  PMID: 22433980
Knowledge translation; Tacit knowledge; Narrative inquiry; Public health; Program planning
9.  Uncovering Tacit Knowledge: A Pilot Study to Broaden the Concept of Knowledge in Knowledge Translation 
All sectors in health care are being asked to focus on the knowledge-to-practice gap, or knowledge translation, to increase service effectiveness. A social interaction approach to knowledge translation assumes that research evidence becomes integrated with previously held knowledge, and practitioners build on and co-create knowledge through mutual interactions. Knowledge translation strategies for public health have not provided anticipated positive changes in evidence-based practice, possibly due in part to a narrow conceptualization of knowledge. More work is needed to understand the role of tacit knowledge in decision-making and practice. This pilot study examined how health practitioners applied tacit knowledge in public health program planning and implementation.
This study used a narrative approach, where teams from two public health units in Ontario, Canada were conveniently selected. Respondents participated in individual interviews and focus groups at each site. Questions were designed to understand the role of tacit knowledge as it related to the program planning process. Data were analyzed through a combination of content analysis and thematic comparison.
The findings highlighted two major aspects of knowledge that arose: the use of tacit knowledge and the integration of tacit and explicit knowledge. Tacit knowledge included: past experiences, organization-specific knowledge, community contextual knowledge, and the recognition of the tacit knowledge of others. Explicit knowledge included: research literature, the Internet, popular magazines, formal assessments (surveys and interviews), legislation and regulations. Participants sometimes deliberately combined tacit and explicit knowledge sources in planning.
This pilot demonstrated that front-line public health workers draw upon both tacit knowledge and explicit knowledge in their everyday lived reality. Further, tacit knowledge plays an important role in practitioners' interpretation and implementation of explicit research findings. This indicates a need to broaden the scope of knowledge translation to include other forms of knowledge beyond explicit knowledge acquired through research. Strategies that recognize and support the use of tacit knowledge, such as communities of practice or networks, may be important components of a comprehensive approach to knowledge translation. This study provides support for further investigation of the role of tacit knowledge in the planning and delivery of effective public health services.
PMCID: PMC3173304  PMID: 21851617
10.  A review of equity issues in quantitative studies on health inequalities: the case of asthma in adults 
The term 'inequities' refers to avoidable differences rooted in injustice. This review examined whether or not, and how, quantitative studies identifying inequalities in risk factors and health service utilization for asthma explicitly addressed underlying inequities. Asthma was chosen because recent decades have seen strong increases in asthma prevalence in many international settings, and inequalities in risk factors and related outcomes.
A review was conducted of studies that identified social inequalities in asthma-related outcomes or health service use in adult populations. Data were extracted on use of equity terms (objective evidence), and discussion of equity issues without using the exact terms (subjective evidence).
Of the 219 unique articles retrieved, 21 were eligible for inclusion. None used the terms equity/inequity. While all but one article traced at least partial pathways to inequity, only 52% proposed any intervention and 55% of these interventions focused exclusively on the more proximal, clinical level.
Without more in-depth and systematic examination of inequities underlying asthma prevalence, quantitative studies may fail to provide the evidence required to inform equity-oriented interventions to address underlying circumstances restricting opportunities for health.
PMCID: PMC3149599  PMID: 21749720
11.  Inequitable walking conditions among older people: examining the interrelationship of neighbourhood socio-economic status and urban form using a comparative case study 
BMC Public Health  2010;10:677.
Supportive neighbourhood walking conditions are particularly important for older people as they age and who, as a group, prefer walking as a form of physical activity. Urban form and socio-economic status (SES) can influence neighbourhood walking behaviour. The objectives of this study were: a) to examine how urban form and neighbourhood SES inter-relate to affect the experiences of older people who walk in their neighbourhoods; b) to examine differences among neighbourhood stakeholder key informant perspectives on socio-political processes that shape the walkability of neighbourhood environments.
An embedded comparative case study examined differences among four Ottawa neighbourhoods that were purposefully selected to provide contrasts on urban form (inner-urban versus suburban) and SES (higher versus lower). Qualitative data collected from 75 older walkers and 19 neighbourhood key informants, as well as quantitative indicators were compared on the two axes of urban form and SES among the four neighbourhoods.
Results and discussion
Examining the inter-relationship of neighbourhood SES and urban form characteristics on older people's walking experiences indicated that urban form differences were accentuated positively in higher SES neighbourhoods and negatively in lower SES neighbourhoods. Older people in lower SES neighbourhoods were more affected by traffic hazards and more reliant on public transit compared to their higher SES counterparts. In higher SES neighbourhoods the disadvantages of traffic in the inner-urban neighbourhood and lack of commercial destinations in the suburban neighbourhood were partially offset by other factors including neighbourhood aesthetics. Key informant descriptions of the socio-political process highlighted how lower SES neighbourhoods may face greater challenges in creating walkable places. These differences pertained to the size of neighbourhood associations, relationships with political representatives, accessing information and salient neighbourhood association issues. Findings provide evidence of inequitable walking environments.
Future research on walking must consider urban form-SES inter-relationships and further examine the equitable distribution of walking conditions as well as the socio-political processes driving these conditions. There is a need for municipal governments to monitor differences in walking conditions among higher and lower SES neighbourhoods, to be receptive to the needs of lower SES neighbourhood and to ensure that policy decisions are taken to address inequitable walking conditions.
PMCID: PMC2992515  PMID: 21054879
12.  Aboriginal Children and Their Caregivers Living with Low Income: Outcomes from a Two-Generation Preschool Program 
The development of preschool children of Aboriginal heritage is jeopardized by the inter-generational transmission of risk that has created, and continues to create, social disadvantage. Early intervention programs are intended to mitigate the impact of social disadvantage. Yet, evidence of the effectiveness of these programs for children of Aboriginal heritage is limited. The purpose of this study was to examine the effects of a two-generation, multi-cultural preschool program on 45 children of Aboriginal heritage and their caregivers. We used a single-group, pretest (program intake)/posttest (program exit) design with follow-up when the children were 7 years old. We used an observational measure of child receptive language (Peabody Picture Vocabulary Test–III) and caregiver-reported measures of child development (Nipissing District Developmental Screen), risk for child maltreatment (Adult-Adolescent Parenting Inventory; AAPI), parenting stress (Parenting Stress Index; PSI), self-esteem (Rosenberg Self-Esteem scale; RSE), and life skills (Community Life Skills scale; CLS). Using paired t-tests we found statistically significant increases in child receptive language scores between intake and exit, and repeated-measures ANOVA showed that these improvements were maintained up to age 7 years. For caregivers, Pearson’s correlations demonstrated that risk for child maltreatment, parenting stress, self-esteem, and life skills were stable over time. Results of this study suggest that children of Aboriginal heritage can benefit from participation in a two-generation, multi-cultural preschool program. Their caregivers may have received greater benefit if issues of intergenerational transmission of the negative influences of residential schools were addressed as part of programming.
PMCID: PMC3087084  PMID: 21654915
Aboriginal; Preschool children; Parents; Intervention studies; Poverty
13.  Unpacking vertical and horizontal integration: childhood overweight/obesity programs and planning, a Canadian perspective 
Increasingly, multiple intervention programming is being understood and implemented as a key approach to developing public health initiatives and strategies. Using socio-ecological and population health perspectives, multiple intervention programming approaches are aimed at providing coordinated and strategic comprehensive programs operating over system levels and across sectors, allowing practitioners and decision makers to take advantage of synergistic effects. These approaches also require vertical and horizontal (v/h) integration of policy and practice in order to be maximally effective.
This paper examines v/h integration of interventions for childhood overweight/obesity prevention and reduction from a Canadian perspective. It describes the implications of v/h integration for childhood overweight and obesity prevention, with examples of interventions where v/h integration has been implemented. An application of a conceptual framework for structuring v/h integration of an overweight/obesity prevention initiative is presented. The paper concludes with a discussion of the implications of vertical/horizontal integration for policy, research, and practice related to childhood overweight and obesity prevention multiple intervention programs.
Both v/h integration across sectors and over system levels are needed to fully support multiple intervention programs of the complexity and scope required by obesity issues. V/h integration requires attention to system structures and processes. A conceptual framework is needed to support policy alignment, multi-level evaluation, and ongoing coordination of people at the front lines of practice. Using such tools to achieve integration may enhance sustainability, increase effectiveness of prevention and reduction efforts, decrease stigmatization, and lead to new ways to relate the environment to people and people to the environment for better health for children.
PMCID: PMC2883960  PMID: 20478054
14.  Time-Lapse Mapping of Cortical Changes in Schizophrenia with Different Treatments 
Cerebral Cortex (New York, NY)  2008;19(5):1107-1123.
Using time-lapse maps, we visualized the dynamics of schizophrenia progression, revealing spreading cortical changes that depend on the type of antipsychotic treatment. Dynamic, 4-dimensional models of disease progression were created from 4 repeated high-resolution brain magnetic resonance imaging scans of 36 first-episode schizophrenia patients (30 men/6 women; mean age: 24.2 ± 5.1 SD years) randomized to haloperidol (HAL) (n = 15) or olanzapine (OLZ) treatment (n = 21), imaged at baseline, 3, 6, and 12 months (144 scans). Based on surface-based cortical models and point-by-point measures of gray matter volume, we generated time-lapse maps for each treatment. Disease trajectories differed for atypical versus typical neuroleptic drugs. A rapidly advancing parietal-to-frontal deficit trajectory, in HAL-treated patients, mirrored normal cortical maturation but greatly intensified. The disease trajectory advanced even after symptom normalization, involving the frontal cortex within 12 months with typical drug treatment. Areas with fastest tissue loss shifted anteriorly in the first year of psychosis. This trajectory was not seen with OLZ. Whether this association reflects either reduced neurotoxicity or neuroprotection cannot be addressed with neuroimaging; changes may relate to glial rather than neural components. These maps revise current models of schizophrenia progression; due to power limitations, the findings require confirmation in a sample large enough to model group × time interactions.
PMCID: PMC2665155  PMID: 18842668
cortex; development; imaging; neurotoxicity; schizophrenia
15.  The Jamaica asthma and allergies national prevalence survey: rationale and methods 
Asthma is a significant public health problem in the Caribbean. Prevalence surveys using standardized measures of asthma provide valid prevalence estimates to facilitate regional and international comparisons and monitoring of trends. This paper describes methods used in the Jamaica Asthma and Allergies National Prevalence Survey, challenges associated with this survey and strategies used to overcome these challenges.
An island wide, cross-sectional, community-based survey of asthma, asthma symptoms and allergies was done among adults and children using the European Community Respiratory Health Survey Questionnaire for adults and the International Study of Asthma and Allergies in Children. Stratified multi-stage cluster sampling was used to select 2, 163 adults aged 18 years and older and 2, 017 children aged 2-17 years for the survey. The Kish selection table was used to select one adult and one child per household. Data analysis accounted for sampling design and prevalence estimates were weighted to produce national estimates.
The Jamaica Asthma and Allergies National Prevalence Survey is the first population- based survey in the Caribbean to determine the prevalence of asthma and allergies both in adults and children using standardized methods. With response rates exceeding 80% in both groups, this approach facilitated cost-effective gathering of high quality asthma prevalence data that will facilitate international and regional comparison and monitoring of asthma prevalence trends. Another unique feature of this study was the partnership with the Ministry of Health in Jamaica, which ensured the collection of data relevant for decision-making to facilitate the uptake of research evidence. The findings of this study will provide important data on the burden of asthma and allergies in Jamaica and contribute to evidence-informed planning of comprehensive asthma management and education programs.
PMCID: PMC2861068  PMID: 20361871
16.  Is research working for you? validating a tool to examine the capacity of health organizations to use research 
'Is research working for you? A self-assessment tool and discussion guide for health services management and policy organizations', developed by the Canadian Health Services Research Foundation, is a tool that can help organizations understand their capacity to acquire, assess, adapt, and apply research. Objectives were to: determine whether the tool demonstrated response variability; describe how the tool differentiated between organizations that were known to be lower-end or higher-end research users; and describe the potential usability of the tool.
Thirty-two focus groups were conducted among four sectors of Canadian health organizations. In the first hour of the focus group, participants individually completed the tool and then derived a group consensus ranking on items. In the second hour, the facilitator asked about overall impressions of the tool, to identify insights that emerged during the review of items on the tool and to elicit comments on research utilization. Discussion data were analyzed qualitatively, and individual and consensus item scores were analyzed using descriptive and non-parametric statistics.
The tool demonstrated good usability and strong response variability. Differences between higher-end and lower-end research use organizations on scores suggested that this tool has adequate discriminant validity. The group discussion based on the tool was the more useful aspect of the exercise, rather than the actual score assigned.
The tool can serve as a catalyst for an important discussion about research use at the organizational level; such a discussion, in and of itself, demonstrates potential as an intervention to encourage processes and supports for research translation.
PMCID: PMC2727486  PMID: 19627601
Intravenous enzyme replacement therapy (ERT) with purified glucocerebrosidase (GLA) leads to significant improvement of the clinical manifestations in patients with Type 1 Gaucher disease. However, the high doses required, slow response and inability to recover most of the infused enzyme in the target tissues may be attributed to losses occurring during transit en route to the lysosome. Pre-incubation of GLA with isofagomine (IFG), a slow-binding inhibitor, significantly increased stability of the enzyme to heat, neutral pH and denaturing agents in vitro. Preincubation of GLA with isofagomine prior to uptake by cultured cells results in increased intracellular enzyme activity accompanied by an increase in enzyme protein suggesting that reduced denaturation of GLA in the presence of isofagomine leads to a decrease in the degradation of the enzyme after internalization. Pre-incubation of GLA with slow-binding inhibitors before infusion may improve the effectiveness of ERT for Gaucher disease.
PMCID: PMC2374924  PMID: 18328804
pharmacological chaperone; Gaucher disease; lysosomal storage disorders; glucocerebrosidase; molecular chaperone; molecular mechanisms of pharmacological action; enzyme replacement therapy
18.  Provincial prenatal record revision: a multiple case study of evidence-based decision-making at the population-policy level 
There is a significant gap in the knowledge translation literature related to how research evidence actually contributes to health care decision-making. Decisions around what care to provide at the population (rather than individual) level are particularly complex, involving considerations such as feasibility, cost, and population needs in addition to scientific evidence. One example of decision-making at this "population-policy" level involves what screening questions and intervention guides to include on standardized provincial prenatal records. As mandatory medical reporting forms, prenatal records are potentially powerful vehicles for promoting population-wide evidence-based care. However, the extent to which Canadian prenatal records reflect best-practice recommendations for the assessment of well-known risk factors such as maternal smoking and alcohol consumption varies markedly across Canadian provinces and territories. The goal of this study is to better understand the interaction of contextual factors and research evidence on decision-making at the population-policy level, by examining the processes by which provincial prenatal records are reviewed and revised.
Guided by Dobrow et al.'s (2004) conceptual model for context-based evidence-based decision-making, this study will use a multiple case study design with embedded units of analysis to examine contextual factors influencing the prenatal record revision process in different Canadian provinces and territories. Data will be collected using multiple methods to construct detailed case descriptions for each province/territory. Using qualitative data analysis techniques, decision-making processes involving prenatal record content specifically related to maternal smoking and alcohol use will be compared both within and across each case, to identify key contextual factors influencing the uptake and application of research evidence by prenatal record review committees. All study participants will be required to give written informed consent prior to participating in data collection.
This study will advance knowledge in the field of evidence-based decision-making by illustrating the complex interaction of contextual factors and evidence on health policy decision-making by provincial-level committees. By increasing the transparency of decision-making within provincial prenatal record committees, this study will help inform more effective strategies for enhancing the integration of best-practice evidence into prenatal records.
PMCID: PMC2642799  PMID: 19099585
19.  Differential Effects of Typical and Atypical Antipsychotics on Brain Myelination in Schizophrenia 
Schizophrenia research  2007;93(1-3):13-22.
Imaging and post-mortem studies provide converging evidence that patients with schizophrenia have a dysregulated developmental trajectory of frontal lobe myelination even in adulthood. Atypical antipsychotics have been shown to have a wide spectrum of efficacy across multiple psychiatric diseases and to be particularly efficacious in treatment resistant cases of disorders such as schizophrenia.
To test the a priori hypothesis that antipsychotic medications may differentially impact frontal lobe myelination in patients with schizophrenia.
Design, setting, and participants
Participants ranged in age from 18–35 years, were all male, and were recruited by a single group of investigators using the same criteria. Two cohorts of subjects with schizophrenia early in their disease who were treated either with oral risperidone (Ris) or fluphenazine decanoate (Fd) were imaged in conjunction with cohorts of healthy controls. Each cohort was imaged using a different MRI instrument using identical imaging sequences.
Main outcome measure
MRI measures of frontal lobe white matter volume.
We estimated differences due to differences in the MRI instruments used in the two studies in the two healthy control groups matched to the patient samples, adjusting for age and other covariates. We then statistically removed those differences (which we assumed were instrument artifacts) from the data in the schizophrenia samples by subtraction. Relative to the differences seen in controls, the two groups of schizophrenic patients differed in their pattern of frontal lobe structure with the Ris-treated group having significantly larger white matter volume than the Fd group.
The results suggest that the choice of antipsychotic treatment may differentially impact brain myelination in adults with schizophrenia. Prospective studies are needed to confirm this finding. MRI can be used to dissect subtle differences in brain tissue characteristics and thus could help clarify the effect of pharmacologic treatments on neurodevelopmental and pathologic processes in vivo.
PMCID: PMC1974878  PMID: 17407804
Schizophrenia; antipsychotic; medication; typical; atypical; frontal lobe; myelin; white matter; gray matter; oligodendrocyte; trajectory; development; lipid; intracortical; age; treatment; prevention; human; primate
20.  Is reporting on interventions a weak link in understanding how and why they work? A preliminary exploration using community heart health exemplars 
The persistent gap between research and practice compromises the impact of multi-level and multi-strategy community health interventions. Part of the problem is a limited understanding of how and why interventions produce change in population health outcomes. Systematic investigation of these intervention processes across studies requires sufficient reporting about interventions. Guided by a set of best processes related to the design, implementation, and evaluation of community health interventions, this article presents preliminary findings of intervention reporting in the published literature using community heart health exemplars as case examples.
The process to assess intervention reporting involved three steps: selection of a sample of community health intervention studies and their publications; development of a data extraction tool; and data extraction from the publications. Publications from three well-resourced community heart health exemplars were included in the study: the North Karelia Project, the Minnesota Heart Health Program, and Heartbeat Wales.
Results are organized according to six themes that reflect best intervention processes: integrating theory, creating synergy, achieving adequate implementation, creating enabling structures and conditions, modifying interventions during implementation, and facilitating sustainability. In the publications for the three heart health programs, reporting on the intervention processes was variable across studies and across processes.
Study findings suggest that limited reporting on intervention processes is a weak link in research on multiple intervention programs in community health. While it would be premature to generalize these results to other programs, important next steps will be to develop a standard tool to guide systematic reporting of multiple intervention programs, and to explore reasons for limited reporting on intervention processes. It is our contention that a shift to more inclusive reporting of intervention processes would help lead to a better understanding of successful or unsuccessful features of multi-strategy and multi-level interventions, and thereby improve the potential for effective practice and outcomes.
PMCID: PMC2413262  PMID: 18492247
21.  Insights about the process and impact of implementing nursing guidelines on delivery of care in hospitals and community settings 
Little is known about the impact of implementing nursing-oriented best practice guidelines on the delivery of patient care in either hospital or community settings.
A naturalistic study with a prospective, before and after design documented the implementation of six newly developed nursing best practice guidelines (asthma, breastfeeding, delirium-dementia-depression (DDD), foot complications in diabetes, smoking cessation and venous leg ulcers). Eleven health care organisations were selected for a one-year project. At each site, clinical resource nurses (CRNs) worked with managers and a multidisciplinary steering committee to conduct an environmental scan and develop an action plan of activities (i.e. education sessions, policy review). Process and patient outcomes were assessed by chart audit (n = 681 pre-implementation, 592 post-implementation). Outcomes were also assessed for four of six topics by in-hospital/home interviews (n = 261 pre-implementation, 232 post-implementation) and follow-up telephone interviews (n = 152 pre, 121 post). Interviews were conducted with 83/95 (87%) CRN's, nurses and administrators to describe recommendations selected, strategies used and participants' perceived facilitators and barriers to guideline implementation.
While statistically significant improvements in 5% to 83% of indicators were observed in each organization, more than 80% of indicators for breastfeeding, DDD and smoking cessation did not change. Statistically significant improvements were found in > 50% of indicators for asthma (52%), diabetes foot care (83%) and venous leg ulcers (60%). Organizations with > 50% improvements reported two unique implementation strategies which included hands-on skill practice sessions for nurses and the development of new patient education materials. Key facilitators for all organizations included education sessions as well as support from champions and managers while key barriers were lack of time, workload pressure and staff resistance.
Implementation of nursing best practice guidelines can result in improved practice and patient outcomes across diverse settings yet many indicators remained unchanged. Mobilization of the nursing workforce to actively implement guidelines and to monitor the delivery of their care is important so that patients may learn about and receive recommended healthcare.
PMCID: PMC2279128  PMID: 18241349
22.  Regulation and Function of Aquaporin-1 in Glioma Cells1 
Neoplasia (New York, N.Y.)  2007;9(9):777-787.
Glioblastoma multiformes (GBMs) express increased aquaporin (AQP) 1 compared to normal brain. AQPs may contribute to edema, cell motility, and shuttling of H2O and H+ from intracellular to extracellular space. We sought to gain insight into AQP1 function in GBM. In cultured 9L gliosarcoma cells, AQP1 expression was induced by dexamethasone, platelet-derived growth factor, NaCl, hypoxia, d-glucose (but not l-glucose), and fructose. Induction of AQP1 expression correlated with the level of glycolysis, maximized by increasing medium d-glucose or fructose and decreasing O2, and was quantified by measuring lactate dehydrogenase (LDH) activity and medium lactate concentration. Upregulation of the protease cathepsin B was also observed in 9L cells cultured under glycolytic conditions. Immunohistochemical staining of human GBM specimens revealed increased coincident expression of AQP1, LDH, and cathepsin B in glioma cells associated with blood vessels at the tumor periphery. GBMs are known to exhibit aerobic glycolysis. Increased glucose metabolism at the tumor periphery may provide a scenario by which upregulation of AQP1, LDH, and cathepsin B contributes to acidification of the extracellular milieu and to invasive potential of glioma cells in perivascular space. The specific upregulation and metabolic consequences of increased AQP1 in gliomas may provide a therapeutic target, both as a cell surface marker and as a functional intervention.
PMCID: PMC1993862  PMID: 17898873
Aquaporin; cathepsin B; glioma; glycolysis; invasion
23.  Implementing nursing best practice guidelines: Impact on patient referrals 
BMC Nursing  2007;6:4.
Although referring patients to community services is important for optimum continuity of care, referrals between hospital and community sectors are often problematic. Nurses are well positioned to inform patients about referral resources. The objective of this study is to describe the impact of implementing six nursing best practice guidelines (BPGs) on nurses' familiarity with patient referral resources and referral practices.
A prospective before and after design was used. For each BPG topic, referral resources were identified. Information about these resources was presented at education sessions for nurses. Pre- and post-questionnaires were completed by a random sample of 257 nurses at 7 hospitals, 2 home visiting nursing services and 1 public health unit. Average response rates for pre- and post-implementation questionnaires were 71% and 54.2%, respectively. Chart audits were completed for three BPGs (n = 421 pre- and 332 post-implementation). Post-hospital discharge patient interviews were conducted for four BPGs (n = 152 pre- and 124 post-implementation).
There were statistically significant increases in nurses' familiarity with resources for all BPGs, and self-reported referrals to specific services for three guidelines. Higher rates of referrals were observed for services that were part of the organization where the nurses worked. There was almost a complete lack of referrals to Internet sources. No significant differences between pre- and post-implementation referrals rates were observed in the chart documentation or in patients' reports of referrals.
Implementing nursing BPGs, which included recommendations on patient referrals produced mixed results. Nurses' familiarity with referral resources does not necessarily change their referral practices. Nurses can play a vital role in initiating and supporting appropriate patient referrals. BPGs should include specific recommendations on effective referral processes and this information should be tailored to the community setting where implementation is taking place.
PMCID: PMC1947981  PMID: 17598917
24.  Can we develop wait lists for public health issues? 
PMCID: PMC1402367  PMID: 16534086
25.  Perils of systematic reviews 
PMCID: PMC554848  PMID: 15795389

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