Public health perspectives on the family: an ecological approach to promoting health in the family and community

The family, as a setting of practice, is increasingly recognized as critical to health promotion. A better understanding of the nature and process through which families take an active part in their own health can serve as the basis for designing and linking health interventions with public health programs. The integrating function of the family, viewed through an ecological context, makes it an effective entry point and central focus in health promotion.     

Coalitions and conflict in the national health service: some implications for general management

Abstract This paper suggests that conflict is an inescapable feature of National Health Service organisational life, and that it is legitimate area of study. It describes a number of powerful coalitions whose interactions can produce conflict as they attempt to influence the distribution of scarce resources. In particular, it focusses on the beliefs and power of a ‘practitioner interests’ coalition and an ‘administrative ethic’ coalition. To survive in this world of coalitions, NHS general managers need to assert their own positions. Are they to be agents of the existing coalitions or can they construct their own and achieve its dominance? The paper concludes by discussing how a distinctive general management coalition might emerge.     

The Effects of Self-Care Instruction on Locus of Control in Children

This study investigated the effects of self-care instruction on locus of control in fifth grade children. Forty-two fifth graders attending an upper middle-class Southwestern school were randomly assigned to either a control group or an experimental group. Children in the experimental group participated in a program adapted from the Health PACT program developed by Igoe and designed to show children how to become managers in their own health care. Children in the control group attended a health discussion. The results of this study suggest that participation in self-care instruction can increase the extent to which children view health event outcomes as being due to their actions. This research provides direct implications that schools should adopt classes encouraging children to become managers in their own health care.     

Nutrient analysis methodology: a review of the DINE developmental literature

In 1986, a collaborative effort among professional associations resulted in the publication of Worksite Nutrition: A Decision Maker's Guide (The American Diabetic Association, 1986). The booklet describes nutrient analysis methodology as a good "promotional gimmick". The development of DINE was an effort to move nutrient analysis from the gimmick level to a viable educational component level. A few examples of the innovative effects of this methodology are (1) individuals' using their own data can learn energy balance by monitoring their food intake and physical activity, (2) individuals can learn the Dietary Goals for the United States (U. S. Senate Select Subcommittee on Nutrition and Human Needs, 1977) and are able graphically to compare how their diet approximates or is different from these goals, and (3) individuals can also learn, from verifications of their own food records, which of their food selections were high in calories, total fat, saturated fat, and cholesterol, and low in complex carbohydrates and dietary fiber. Alternative healthful food choices are identified and the effects of reducing or increasing portion sizes is described. The DINE development team has been working for the past eight years to decrease nutrient analysis variability so that the procedure can be used as an effective independent measure to improve nutritional behavior. Research has been conducted related to database validity and reliability. Formative and process evaluations have been conducted to improve interactive aspects of the software and related manuals and books. DINE procedures have been modified for ease of use, in general, and specifically for elementary students and university students.     

Reforming the health care system: implications for health care marketers

Health care reform has become the dominant domestic policy issue in the United States. President Clinton, and the Democratic leaders in the House and Senate have all proposed legislation to reform the system. Regardless of the plan which is ultimately enacted, health care delivery will be radically changed. Health care marketers, given their perspective, have a unique opportunity to ensure their own institutions' success. Organizational, managerial, and marketing strategies can be employed to deal with the changes which will occur. Marketers can utilize personal strategies to remain proactive and successful during an era of health care reform. As outlined in this article, responding to the health care reform changes requires strategic urgency and action. However, the strategies proposed are practical regardless of the version of health care reform legislation which is ultimately enacted.     

Self-planned experimentation (SPEX) practical classes in physiology

A new form of undergraduate physiology practical experience is described. Students make their acquaintance with the physiological apparatus in the usual manner. At the end of the afternoon each group of four students is allocated an item of equipment with which to perform a true investigative experiment of their own choice, in their own time, the results of which are to be presented 2 weeks later by a randomly chosen member of the group. Students may investigate any question that can be answered using the resources available to them without endangering themselves or their subjects. Marks are awarded for the planning of the experiment (i.e. choice of controls, etc.), the correctness of graphical presentation of the results, the appropriateness of the statistical analysis, and for the discussion. There are no penalties for negative or unexpected results.     

The use of portfolios for assessment of the competence and performance of doctors in practice

BACKGROUND: The use of portfolios can potentially provide flexibility in the summative assessment of doctors in practice. An assessment system should reflect and reinforce the active and planned professional development goals of individual doctors. This paper discusses some of the issues involved in developing such a system. RESULTS: To provide a complete picture of an individual doctor's practice, we suggest that a portfolio should encompass: (1) evidence covering all three domains of patient care, personal development and context management; (2) evidence that the person continuously undertakes critical assessment of their own performance, identifies and prioritises areas requiring enhanced performance and takes action to improve them as appropriate; (3) evidence that has been generated by assessments that are acceptably reliable, and (4) evidence which, taken in its entirety, is sufficient, valid, current and authentic. We include a suggested outline of the components of such a portfolio and suggest some criteria to determine the effectiveness of learning cycles. Portfolio reliability and validity requires sufficient evidence on which to base a judgement combined with reliable processes. CONCLUSION: Carefully specified portfolios can contribute to a system that ensures all doctors take an active part in identifying and meeting their own learning needs. Such a system, if properly implemented, would have a greatly beneficial impact on continuous quality improvement for the profession in general.     

Health care perceptions of the standardized patient

As the use of standardized patients (SPs) for education and assessment continues to grow, there becomes an ever-increasing cohort of patients in our clinical practices who have participated as SPs. The present study is part of a five-year longitudinal study to examine the impact of participation as a standardized patient on the perceptions of the standardized patient's own health care. SPs participating in the 1993, 1994 and 1995 Objective Structured Clinical Examinations (OSCE) for medical students at the end of their third year were requested to respond to mailed questionnaires before, immediately after and one year after their participation in the OSCE(s). Results indicated that, while overall the SP's perceptions of their interactions with their doctors were positive both before and after participation in the OSCE, as a group, their perceptions of their own health care was significantly worse at one year post-OSCE. Additionally, when divided according to SP experience, that is novice versus experienced SP, most of the items on which there were changes were mutually exclusive between the groups. If these significant negative changes are due to the SPs becoming more educated consumers of medical care, this can be seen as a positive outcome. However, if the changes are due to variables particular to the third-year medical student OSCEs themselves, debriefing of the SPs following their participation in the OSCE may be warranted.     

浅谈实习生临床思维能力的培养

目的：重视实习生临床思维能力的培养,是各级带教老师不容忽视的一个重要问题。分析临床思维能力欠缺的原因。从提高查房质量、组织病例讨论、开展以“问题为中心”的专题讲座、重视自然辩证法的学习、加强带教医师自身建设、专家现身说法6个方面论述实习生临床思维能力的培养。     

The patient as a source to improve the medical record

BACKGROUND: The problem list is an important tool in general practice for care as well as research purposes. As the central part of the problem-oriented medical record, it lists the main medical problems which the GP wants to have knowledge of during any patient encounter. The assessment of its quality is usually made by comparing with other sources of information on the patient's problems. OBJECTIVE: This study addresses the question of to what extent the problem list can be improved by asking the patient about their own medical problems. METHODS: During 7 weeks, all patients who visited three GPs in a health care centre in an Amsterdam suburb were interviewed. During the interview, they were confronted with the problem list made by their own GP and stimulated to make suggestions for addition or removal of problems. RESULTS: All in all, patients were in agreement with 88% of all listed problems. The completeness of the problem list could be increased by 28%, while 4% ultimately were removed: a net gain of 24%. CONCLUSION: The patient can be used as a sourcetool for improvement of the quality of the problem list when its prime function is patient care. It becomes more complicated when the problem list also serves a research purpose. Clear inclusion rules will then have to be formulated.     

Education in psychogeriatrics: the leap of the imagination

In an attempt to bridge the gap between healthy young people in their early 20s and mentally ill old people in their 80s six consecutive classes of final-year medical students of psychogeriatrics were asked to imagine and to record how they thought they might feel in certain fictitious situations which lay nearer to their own experience. They then explored links between the given situations and the feelings which might be experienced by mentally ill elderly people and their carers. The exercise has proved to be a popular and creative learning experience.     

大学对附属医院经营效果影响的研究

大学附属医院区别于普通公立医院的职能和体制会对其经营效果产生一些影响.文章以规模、实力和市场环境类似的大学附属医院和普通公立医院作为对比组,收集了它们相同年度的经营成果资料,采用定量对比分析方法研究大学是否对其附属医院经营效果产生影响.然后用德尔菲法定性研究出大学哪些行为及功能时其附属医院经营会产生影响.并把这些能产生影响的行为扣功能归纳为附属医院经营影响因子,形成大学对其附属医院经营效果影响三角模型和函数关系.     

Understanding the conditions for improvement: research to discover which context influences affect improvement success

Context can be defined as all factors that are not part of a quality improvement intervention itself. More research indicates which aspects are 'conditions for improvement', which influence improvement success. However, little is known about which conditions are most important, whether these are different for different quality interventions or whether some become less or more important at different times in carrying out an improvement. Knowing more about these conditions could help speed up and spread improvements and develop the science. This paper proposes ways to build knowledge about the conditions needed for different changes, and to create conditional-attribution explanations to provide qualified generalisations. It describes theory-based, non-experimental research designs. It also suggests that 'practical improvers' can make their changes more effective by reflecting on and revising their own 'assumption-theories' about the conditions which will help and hinder the improvements they aim to implement.     

It works better when problems are shared. Interview by Mark Perlberg.

In an exclusive interview, Jeannette R. Kramer, a specialist in the provision of long-term care, discusses the concept of the therapeutic community that she and her husband have instituted in the skilled nursing care facility that they own and operate. By providing an environment in which patients, their families, and the staff can communicate easily, the nursing facility can pinpoint problems and solve them early.     

Evangelization through institutional sponsorship. Education and experience in the congregation's tradition can move the laity to full partnership in the ministry

Sponsors' efforts to empower lay leaders to carry on the Catholic healthcare ministry can be understood as a process of evangelization, or the proclamation of the Gospel to Christians and non-Christians in order to awaken and nourish faith. By involving the laity in the operation of their institutions, sponsors assume an evangelizing posture. To ensure the continuation of their ministry, sponsors share with the laity their history, charism, and values. They thus set a standard on which institutions can base their own mission and values. Catechetics, or religious instruction, is another aspect of evangelization. For sponsors, catechesis takes place through governance and mission integration activities. The sacraments are also important to evangelization. Through prayer before a board meeting, the use of paraliturgy during the commissioning of new board members, or the eucharistic liturgy, sponsors raise people's awareness of the sacred even in the midst of workplace routine. Sponsors themselves need continual evangelization. As congregations help the laity carry out the Church's healing mission, they are also called to examine how they sponsor.     

Health in Cuba and the millennium development goals]

The first assessments of the Millennium Development Goals of the United Nations have been completed, and deliberations about world health are increasing. Now is an appropriate time to consider the case of Cuba, which has functioned under difficult conditions for many years, and followed its own path. Cuba's health indicators are much better than might be expected considering its level of income; in many cases the indicators compare to those of industrialized countries. These results should be viewed as the product of a well-defined strategy and the use of essential public health principles rather than as the accumulation of better numbers. The Cuban experience demonstrates that a population's health can improve in even the most adverse economic conditions. This is attainable when sound public health practices are implemented under the principle that health is a basic right and therefore a national priority. An understanding of the Cuban public health system can help other low-income countries adapt these practices to their own conditions and meet the Millennium Development Goals. If this were to occur, there would be substantial improvement in the world's health.     

Volunteer human subjects' understandings of their participation in a biomedical research experiment

The paper focuses on how volunteer human subjects in research understand their own participation in experimentation. We ask how they view their own role, the experimental setting, and how they articulate their understanding of the researcher-subject relationship. The empirical basis of the study is participant-observation and qualitative semi-structures interviews with volunteers in an experimental setting far removed from the more commonly studied randomised control trial (RCT), namely, the early stage testing of a prototype instrument for breast imaging. Analysis of this empirical data leads us to conclude that research subjects do not conform solely to one or other of the models of the researcher-subject relationship suggested in the literature. Rather, the interaction needs to be considered as a social situation which volunteer subjects actively negotiate in real time. They move through multiple roles and identities as part of the navigation through unfamiliar social territory, in order to establish a relationship in which they can feel socially comfortable and appropriately valued.     

Organ transplantation and meaning of life: the quest for self fulfilment

Today, the frequency and the rate of success resulting from advances in medicine have made organ transplantations an everyday occurrence. Still, organ transplantations and donations modify the subjective experience of human beings as regards the image they have of themselves, of body, of life and of death. If the concern of the quality of life and the survival of the patients is a completely human phenomenon, the fact remains that the possibility of organ transplantation and its justification depend a great deal on the culture in which we live. The exploration of the philosophical tradition allows for a reconsideration of organ transplantation. If we listen to people who have experienced the decline of one of their organs and their own rebirth through the organ of someone else, we arrive at the conclusion that they went through an extreme experience in which nothing appeared as before. All those experiences intensify philosophical questionings on the meaning of life with respect to self fulfilment. The concept of nature as the experience of others can be an authentic source from which to nourish our thoughts about organ transplantation. However, and this is our hypothesis, we need something more if we are to decide something about our own life. We need a hermeneutical stance in relation to ourselves and to our world. Philosophical counselling, as a long established tradition originating with Pythagoras and later reframed by the German philosopher Achenbach could be useful in inspiring a reflection on the good life, chiefly as it takes the form of a Socratic dialogue.     

Leaving violent relationships and avoiding homelessness - providing a choice for women and their children

The report Staying Home/Leaving Violence describes a research study that explores how women, leaving a relationship where they experience domestic violence, can remain safely in their own homes with their children, with the violent offender being removed. In this qualitative study, 29 women were interviewed about their experiences of leaving a violent relationship. Of these 29 women, nine remained in their own home. This article describes the factors that enabled these nine women to remain in their homes and comments on the policy and practice implications for health workers.