Caring: the neglected health outcome? or input?

In most forms of evaluation of health care--and it is certainly true of economic evaluation--and is considering the outcomes of such care, caring tends to be omitted, or simply forgotten. It is often the case that little more than lip service is paid to the inclusion of caring as an input. This paper takes a closer look at caring, the neglected outcome of health care. The perspective starts from that of economics but other disciplines are examined briefly along the way to determine whether they deal better with caring than does the dismal science of economics. It is concluded that there is a need for greater consideration of caring as both an outcome and an input in evaluation of health care and that in the specific context of economic evaluation, when considering caring, economists might usefully look to other disciplines to broaden and deepen their conceptualisation of both benefits and costs in their economic evaluation studies.     

Nursing and its reliance on self-care: emancipatory investments or practices of submission?

The paper aimed at reflecting on the prevalence of self-care as a possible and desirable result of nursing education enterprises which focus on individual autonomy for one's own care. It can be argued that, in such a context, the teaching toward self-care has been directed according to technical orientations and biased definitions of "being healthy", of what it means to "be autonomous" and the meanings of "taking care of oneself". In this sense, taking into account the premises of health promotion, one questions the potential for self-care teaching to be liberating and to promote autonomy. One asks whether this could be more of a case of yet another investment on the submission of subjects than an action that promotes emancipation. The conclusion proposes "listening" as an alternative for minimizing the dilemmas produced in this context.     

Racing toward the integration of complementary and alternative medicine: a marathon or a sprint?

Health care opinion leaders concur that integration of complementary and alternative medicine (CAM) into the U.S. health care system must be based on strong supporting evidence of safety and efficacy. As others have pointed out, integration is under way, despite the lack of reliable, rigorous science supporting the use of most CAM treatments. We contend that optimal integration of CAM is a long-term endeavor--a marathon rather than a sprint. The evidence base does not now support its wholesale assimilation; market forces, although compelling, should not be the primary consideration in integration.     

Job strain, effort--reward imbalance, and stress at work: competing or complementary models?

BACKGROUND: The Demand Control Model (DCM) and the Effort Reward Imbalance Model (ERI) offer putative explanations of the relationship between stressful working conditions, job strain, and psychological and physical ill health. AIMS: The aims of this study are to: (a) compare the predictive powers of the two models for explaining perceived job stress and mental distress amongst workers as a whole, (b) identify whether a model which combines dimensions of the DCM and ERI might have more predictive power than either of them separately, and (c) ascertain whether the models make distinct contributions to explaining stress at work in specific occupational settings. METHODS: Statistical analysis was carried out on data collected from a cross-sectional postal survey of a random sample (n = 7,069), of the adult population in an urban area in Southern England. The analysis focused on the 4,135 respondents who were in paid employment. RESULTS: There was little support for combining the models as the combined model was dominated by the predictive power of dimensions from the ERI. However, the results also showed that the models or dimensions of the models made distinct contributions to explaining perceived work stress in different types of occupation. CONCLUSIONS: There is little evidence to support a combined model of work characteristics. The ERI appears to be the stronger of the two models although the DCM has explanatory value for specific occupations.     

(n-3) fatty acids and cardiovascular health: are effects of EPA and DHA shared or complementary?

Considerable research supports cardiovascular benefits of consuming omega-3 PUFA, also known as (n-3) PUFA, from fish or fish oil. Whether individual long-chain (n-3) PUFA have shared or complementary effects is not well established. We reviewed evidence for dietary and endogenous sources and cardiovascular effects on biologic pathways, physiologic risk factors, and clinical endpoints of EPA [20:5(n-3)], docosapentaenoic acid [DPA, 22:5(n-3)], and DHA [22:6(n-3)]. DHA requires direct dietary consumption, with little synthesis from or retroconversion to DPA or EPA. Whereas EPA is also largely derived from direct consumption, EPA can also be synthesized in small amounts from plant (n-3) precursors, especially stearidonic acid. In contrast, DPA appears principally derived from endogenous elongation from EPA, and DPA can also undergo retroconversion back to EPA. In experimental and animal models, both EPA and DHA modulate several relevant biologic pathways, with evidence for some differential benefits. In humans, both fatty acids lower TG levels and, based on more limited studies, favorably affect cardiac diastolic filling, arterial compliance, and some metrics of inflammation and oxidative stress. All three (n-3) PUFA reduce ex vivo platelet aggregation and DHA also modestly increases LDL and HDL particle size; the clinical relevance of such findings is uncertain. Combined EPA+DHA or DPA+DHA levels are associated with lower risk of fatal cardiac events and DHA with lower risk of atrial fibrillation, suggesting direct or indirect benefits of DHA for cardiac arrhythmias (although not excluding similar benefits of EPA or DPA). Conversely, EPA and DPA, but not DHA, are associated with lower risk of nonfatal cardiovascular endpoints in some studies, and purified EPA reduced risk of nonfatal coronary syndromes in one large clinical trial. Overall, for many cardiovascular pathways and outcomes, identified studies of individual (n-3) PUFA were relatively limited, especially for DPA. Nonetheless, the present evidence suggests that EPA and DHA have both shared and complementary benefits. Based on current evidence, increasing consumption of either would be advantageous compared to little or no consumption. Focusing on their combined consumption remains most prudent given the potential for complementary effects and the existing more robust literature on cardiovascular benefits of their combined consumption as fish or fish oil for cardiovascular benefits.     

Caring relationships: an investment in health?

Although the US has created the most expensive, technologically advanced medical system in the world, health outcomes are not commensurate with investment. The author argues that providers and policy makers have neglected the effect of human relationships on health, citing research showing that better relationships lead to better health. The author concludes with recommendations for improving public health by supporting society's investments in social capital.     

Children’s museums: purposes,practices and play?

Children’s museums have been increasing rapidly since their beginnings in the nineteenth century, and especially so in the past 30 years. This article is based on my observations of 30 children’s museums in Europe, North America, South America and the Middle East and the article briefly discusses the history and development of children’s museums, their definitions, missions/goals and models of children’s museums. Then, trends related to types of exhibits, programming and outreach activities are presented. Finally, some frequent challenges and issues around the establishment and continuation of children’s museums such as funding, sponsorship, attendance, exhibit design and technology are discussed. A summary of research on children’s museums is included.     

Independence for group practices: is it possible and desirable?

Technological advances, patient demands, pressures from payors, and change driven by hospitals or competing group practices combine to create a very dynamic practice management environment. For practice executives, these changes are focusing more attention on strategic and long-term planning, raising the question of continuing as independent private practices or considering other alternatives. There are several macro trends that impact the future of group practice. Understanding these general trends can serve as a starting point for practices to develop their specific roadmap to the future.