Health promotion roles shaped by professional identity: an ethnographic study in the Netherlands.

How frontline care professionals interpret and fulfill their health promotion roles is of great importance for the health of the vulnerable clients they work with. While the literature on health promotion is limited to describing the roles of healthcare professionals, this study examines the health promotion roles held by various frontline professionals when working with clients with combined psychosocial problems and how this is associated with professional identity. Based on ethnographic data from Dutch frontline professionals in social welfare, general healthcare and mental healthcare, this article shows how various frontline professionals promote health by reframing and customizing health problems and that this is associated with how they identify as pragmatic or holistic professionals.

Empirical Bioethics and the Health 'Brain-Drain': a qualitative study of the experiential and ethical landscape of compulsory community service for a group of South African doctors.

The health 'brain drain' (HBD) is an issue of significant global bioethical concern, resulting in severe maldistribution of healthcare workers (HCWs) and gross inequities in health service provision. The ethics of the HBD and its possible mitigation strategies are, however, complex and areas of active ongoing bioethical debate. South Africa faces a dire and worsening HBD crisis, and use a mitigation strategy of compulsory community service, or 'comserve', for most HCWs. While there is some literature on HCWs' comserve experiences and the various 'push and pull' factors affecting their migratory decisions, there is a notable gap regarding their personal values, beliefs and ethics regarding the HBD and comserve, which, as this research supports, play a prominent role in migratory decisions. This empirical bioethics research aims to explore this among a group of South African doctors who recently completed comserve, as well as how their experiences affected their situation on the individualist-collectivist continuum. This was done qualitatively using semistructured interviews with 11 participants and analysed using reflexive thematic analysis under a methodology of critical realism. Themes identified were 'Special Duties'; 'Freedom and Autonomy'; 'Justice and Accountability'; and 'The Individualist-Collectivist Continuum'. Participants use a variety of ethical theories to discuss the HBD and oppose or support comserve, which play a significant role in their migratory decisions. Most find the policy to be theoretically ethically justifiable but note that procedures undermine this. There are also several factors that appear to affect participants' position on the individualist-collectivist continuum, with some paradoxical effects on the HBD.

Supplemental Security Income enrollment and health care and social assistance employment and wages.

We examine the relationship between disabled working-age Supplemental Security Income (SSI) enrollment and health care and social assistance employment and wages. County-level data are gathered from government and other publicly available sources for 3144 US counties (2012 to 2015). Population-weighted linear regression analyses examine associations between each health care and social assistance employment and wage measure and SSI enrollment, controlling for factors associated with health care and social assistance employment and wages. Results show positive associations between county-level percent of the population enrolled in the SSI program and health care and social assistance employment and wages with strong associations identified for social assistance employment. A one standard deviation increase in SSI enrollment is associated with a 5.6% increase in the health care and social assistance sector employment percent compared with the mean and 9.7% and 7.3% increases in health care and social assistance sector employment and wage shares, respectively, when compared with the means. We find working-age adult SSI enrollment is positively associated with employment outcomes, primarily in the social assistance organization subsector and in lower wage paying jobs. Evolving federal disability policy may influence existing and future SSI enrollment, which has implications for health care workforce employment and composition.

Will the Need-Based Planning of Health Human Resources Currently Undertaken in Several Countries Lead to Excess Supply and Inefficiency? A Comment on Basu and Pak.

Basu and Pak (2014) argue that need-based workforce planning models would not maximize social welfare, and use of need-based models would result in inefficiency. They propose that planning be based on service utilization to incorporate preferences or other socioeconomic factors. We show that the analysis is based on inappropriate considerations of the nature of healthcare demand, a misrepresentation of need-based approaches and misunderstanding publicly funded healthcare system objectives. We explain how current levels of utilization emerge from workload and income interests of providers that underlie utilization-based models and are incompatible with public goals of maximizing health gains. Copyright © 2016 John Wiley & Sons, Ltd.

The growing disconnect between food prices and wages in Europe: cross-national analysis of food deprivation and welfare regimes in twenty-one EU countries, 2004-2012.

OBJECTIVE: Food insecurity has been rising across Europe following the Great Recession, but to varying degrees across countries and over time. The reasons for this increase are not well understood, nor are what factors might protect people's access to food. Here we test the hypothesis that an emerging gap between food prices and wages can explain increases in reported inability to afford protein-rich foods and whether welfare regimes can mitigate its impact. DESIGN: We collected data in twenty-one countries from 2004 to 2012 using two databases: (i) on food prices and deprivation related to food (denoted by reported inability to afford to eat meat, chicken, fish or a vegetarian equivalent every second day) from EuroStat 2015 edition; and (ii) on wages from the Organisation for Economic Co-operation and Development 2015 edition. RESULTS: After adjusting for macroeconomic factors, we found that each 1 % rise in the price of food over and above wages was associated with greater self-reported food deprivation (ß=0·060, 95 % CI 0·030, 0·090), particularly among impoverished groups. However, this association also varied across welfare regimes. In Eastern European welfare regimes, a 1 % rise in the price of food over wages was associated with a 0·076 percentage point rise in food deprivation (95 % CI 0·047, 0·105) while in Social Democratic welfare regimes we found no clear association (P=0·864). CONCLUSIONS: Rising prices of food coupled with stagnating wages are a major factor driving food deprivation, especially in deprived groups; however, our evidence indicates that more generous welfare systems can mitigate this impact.

[The Hospital, patients, health and territories Act and the recentralisation of the social and long term care sector]. / Les acteurs de la loi HPST confrontés à la recentralisation du secteur médicosocial.

Hypothesis: The 2009 Hospital, Patients, Health and Territories Act crystallises a central government attempt to regain control over the social and long term care sector, which involves the utilisation of policy instruments borrowed from the hospital sector: capped budgets, agreements on targets and resources, competitive tendering or quasi-market mechanisms involving hospitals and services, etc. This paper is therefore based on the hypothesis of a recentralisation and healthicization of the social and long term care sector, with a key role for the regional health authorities. Method and data: 27 semi-structured interviews were conducted with actors operating within and outside the regional health agencies and thereafter analysed using Alceste. The aim was to describe and to analyse the positioning of the RHAs in relation to key actors of the social and long-term care sector in 2 regions in 2011. Results: Key issues for public organisations include the style of planning and knowhow transfer, while the professionals were chiefly concerned with the intensity of the ambulatory turn and needs analysis methodology. The compromises forged were related to types of democratic legitimacy, namely representative or participatory democracy. Conclusion: There is little evidence to support the initial hypothesis, namely the existence of a link between the creation of RHAs and a recentralisation of health policy between 2009 and 2013. One may rather suggest that a reconfiguration of the activities and resources of the actors operating at the centre (RHAs and conseils départementaux) and at the periphery (territorial units of the RHAs and third sector umbrella organisations) has occurred.

Will the Needs-Based Planning of Health Human Resources Currently Undertaken in Several Countries Lead to Excess Supply and Inefficiency?

Recently, the emphasis on health human resources (HHR) planning has shifted away from a utilization-based approach toward a needs-based one in which planning is based on the projected health needs of the population. However, needs-based models that are currently in use rely on a definition of 'needs' that include only the medical circumstances of individuals and not personal preferences or other socio-economic factors. We examine whether planning based on such a narrow definition will maximize social welfare. We show that, in a publicly funded healthcare system, if the planner seeks to meet the aggregate need without taking utilization into consideration, then oversupply of HHR is likely because 'needs' do not necessarily translate into 'usage.' Our result suggests that HHR planning should track the healthcare system as access gradually improves because, even if health care is fully accessible, individuals may not fully utilize it to the degree prescribed by their medical circumstances.

A changing landscape: mapping provider organisations for community nursing services in England.

AIM(S): To scope the provision of community nursing services in England after implementation of the Transforming Community Services Programme. BACKGROUND: Over the past decade, significant UK policy initiatives have shaped the structure, organisation and responsibilities of community nursing services. Understanding these organisational changes is important in the context of organisations seeking to deliver 'care closer to home'. METHOD(S): A systematic mapping exercise to scope and categorise community nursing service organisation provider models. RESULTS: There are 102 provider organisations representing a range of organisational models. Two-thirds of these organisations have structurally integrated with another NHS Trust. Smaller numbers reorganised to form community trusts or community interest companies. Only a few services have been tendered to an accredited willing provider while a small number have yet to establish their new service model. Local discretion appears to have dominated the choice of organisational form. CONCLUSION(S): National policies have driven the reorganisation of community nursing services and we have been able to describe, for the first time, these 'transformed' structures and organisations. IMPLICATIONS FOR NURSING MANAGEMENT: Providing detail of these 'new' models of service provision, and where these have been introduced, is new information for nurse managers, policy makers and organisational leaders, as well as researchers.

Nursing Under the Old Poor Law in Midland and Eastern England 1780-1834.

This article uses data drawn from the overseers' accounts and supporting documentation in thirty-six parishes spread over four English counties, to answer three basic questions. First, what was the character, extent, structure, range of activities, and remuneration of the nursing labor force under the Old Poor Law between the late eighteenth century and the implementation of the New Poor Law in the 1830s? Second, were there regional and intra-regional differences in the scale and nature of spending on nursing care for the sick poor? Third, how might one explain such differences? The article suggests that nursing became an increasingly important category of spending for the poor law from the later eighteenth century, but that there were significant variations within and (particularly) between English counties in parochial attitudes toward the provision of nursing for the sick poor. These variations can be explained by applying a matrix of explanatory variables ranging from the minor (differences in how parishes defined "nursing") through to the major (long-standing cultural attitudes toward the responsibility of parishioners to their sick compatriots and the ingrained expectations of the sick poor). The article also throws new light on the hidden aspects of female labor force participation, pointing to the development of professional nursing networks long before the later nineteenth century.

Rethinking industrial citizenship: the role and meaning of work in an age of austerity.

T. H. Marshall in his famous tract Citizenship and Social Class wrote briefly about what he called 'industrial citizenship', a type of belonging rooted in the workplace. Here Marshall's ideas are developed alongside a consideration of Durkheim's Professional Ethics and Civic Morals together with research material from the Guinness Company. It shows the way the Company actively sought to create 'Guinness citizenship' within its London brewery. The article draws out the ways in which the significance and potential of work based citizenship for ameliorating the ills of industrial society are clearly articulated in mid-twentieth century Britain and echo earlier neglected Durkheimian sociological ideas on work. These ideas have real potential to inform contemporary academic and policy debates about the nature of capitalism and the form and content of work now and in the future.

Placement, support, and retention of health professionals: national, cross-sectional findings from medical and dental community service officers in South Africa.

BACKGROUND: In South Africa, community service following medical training serves as a mechanism for equitable distribution of health professionals and their professional development. Community service officers are required to contribute a year towards serving in a public health facility while receiving supervision and remuneration. Although the South African community service programme has been in effect since 1998, little is known about how placement and practical support occur, or how community service may impact future retention of health professionals. METHODS: National, cross-sectional data were collected from community service officers who served during 2009 using a structured self-report questionnaire. A Supervision Satisfaction Scale (SSS) was created by summing scores of five questions rated on a three-point Likert scale (orientation, clinical advising, ongoing mentorship, accessibility of clinic leadership, and handling of community service officers' concerns). Research endpoints were guided by community service programmatic goals and analysed as dichotomous outcomes. Bivariate and multivariate logistical regressions were conducted using Stata 12. RESULTS: The sample population comprised 685 doctors and dentists (response rate 44%). Rural placement was more likely among unmarried, male, and black practitioners. Rates of self-reported professional development were high (470 out of 539 responses; 87%). Participants with higher scores on the SSS were more likely to report professional development. Although few participants planned to continue work in rural, underserved communities (n = 171 out of 657 responses, 25%), those serving in a rural facility during the community service year had higher intentions of continuing rural work. Those reporting professional development during the community service year were twice as likely to report intentions to remain in rural, underserved communities. CONCLUSIONS: Despite challenges in equitable distribution of practitioners, participant satisfaction with the compulsory community service programme appears to be high among those who responded to a 2009 questionnaire. These data offer a starting point for designing programmes and policies that better meet the health needs of the South African population through more appropriate human resource management. An emphasis on professional development and supervision is crucial if South Africa is to build practitioner skills, equitably distribute health professionals, and retain the medical workforce in rural, underserved areas.

Surgical training and capacity development in the South African internship programme.

Medical practitioners in South Africa manage a quadruple burden of disease. Junior doctors, who contribute significantly to the health workforce, must complete 2 years of internship training and 1 year of community service work in state health facilities after graduation to register as an independent medical practitioner. The aim of this article is to give a critical appraisal of the current national internship programme and why it was implemented, and outline suggestions for future changes. There is a compelling need to train competent, confident doctors while ensuring that the requirements and demands of our health system remain a central concern.

Using Multi-Arm Designs to Test Operating Welfare-to-Work Programs.

BACKGROUND: In the early 1970s, most researchers thought that randomized controlled trials (RCTs) could not be used to measure the effectiveness of large-scale operating welfare reform and employment programs. By the mid-1970s, the Supported Work Demonstration showed that, under certain conditions, this was both feasible and valuable. However, the experimental design was simple; a multi-arm test had been rejected as unrealistic. Within 10 years, a three-arm design was implemented in San Diego to assess both a welfare-to-work program's overall impact and the contribution of a specific component. Less than 10 years later, the Job Opportunities and Basic Skills Training (JOBS)/National Evaluation of Welfare-to-Work Strategies (NEWWS) study used a more complex design to determine the relative effectiveness of two strategies operated in the same locations: one emphasizing getting a job quickly and the other requiring basic education. In San Diego and JOBS/NEWWS, the tested reforms emerged from political processes and were funded through regular program budgets. In both cases, researchers inserted multi-arm RCTs into operating welfare offices, trading control over the treatment for scale (thousands of people) and real-world conditions. Both RCTs were successfully implemented. OBJECTIVES AND RESULTS: This article examines why multi-arm designs were attempted, how they were structured, why public administrators cooperated, what various actors sought to learn, and how the researchers determined what strategies the different experimental arms ended up to truly represent. The article concludes that these designs provide convincing evidence and can be inserted into operating programs if the studies address questions that are of keen and immediate interest to state or local program administrators and researchers.

Low Exposure to Home- and Community-Based Services Among U.S. Adults: Cause for Concern?

Home- and community-based services (HCBS) facilitate community living for older adults and persons with disabilities, but limited awareness of HCBS is a significant barrier to access. Social exposure is one potential conduit for HCBS knowledge. To understand the general population's social exposure to HCBS-that is, knowing someone who has used HCBS (including one's self)-we fielded a survey item with a nationally representative panel of U.S. adults. An estimated 53% of U.S. adults reported not knowing anyone who had used HCBS. Exposure rates were low across specific HCBS types (6%-28%). Women had greater exposure than men for eight of the 11 HCBS. We also found differences by age, racial/ethnic identity, rurality, education, and income. Increasing the general public's awareness of HCBS may facilitate access when services are needed, enhance readiness for aging in place, and increase the visibility and inclusion of older adults, persons with disabilities, and caregivers.

Materialities of care for older people: caring together/apart in the political economy of caring apparatus.

By applying a posthuman perspective to the analysis of care for older people (COP), we analyse the agential cuts (together/apart) enacted by humans (mainly caregivers and older people) and more-than-humans (a camera intra-acting with other objects) whose agential entanglement configures and reconfigures the political economy of the caring apparatus. Our study identifies 'targeting', 'monitoring', and 'aligning' as interrelated caring practices, thus contributing to advance a posthuman understanding of welfare technology, and advancing a critical use of the possibilities enacted by technologies.

Endogenous longevity and optimal tax progressivity.

We study the impact of endogenous longevity on optimal tax progressivity and inequality in an overlapping generations model with skill heterogeneity. Higher tax progressivity decreases both the longevity gap and net income inequality, but at the expense of lower average lifetime and income. We find that the welfare-maximizing income tax is less progressive in our model with endogenous longevity than in our model with exogenous longevity. In a highly stylized calibration of the US economy, we show that optimal tax progressivity is less than what prevails under the current US tax system. Our results are robust to the range of empirical labor supply elasticity and the assumptions of missing annuity markets and stochastic health. Our conclusion for the optimal progressivity of the US tax system can be altered by the adoption of a more egalitarian welfare function or by increases in prevailing levels of wage inequality.

Achieving Meaningful Access to Medicaid.

Federal and state budgetary constraints continually challenge Medicaid. The effects of benefit cuts are common: long waiting lists for community-based services, skeletonized drug formularies with unstable access to long-term prescriptions, no psychiatric therapy for people immobilized by depression, and no more than fourteen days of acute hospitalization. Reimbursements may be so low that providers cannot hire qualified staff and must reduce services, close facilities, or refuse to take Medicaid altogether. Misguided efficiency policies may afflict some groups of patients as well. Decisions to narrow access rights to publicly funded health care promote the perception that more broadly inclusive programs would be unwisely and unfairly generous. They also risk characterizing disability rights as "special," confined to a narrow class of people who charitably ought not to be expected to provide for themselves. In contrast, on a philosophical view we have been exploring-one that addresses problems of justice under circumstances of injustice by pursuing rather than reducing inclusion-efforts like these are unjust.

An evolving community-based dental course on professionalism and community service.

In 2007, the Faculty of Dentistry at the University of British Columbia formally introduced the course Professionalism and Community Service (PACS) in year one of its dental curriculum. PACS features community-based dental education as an experiential learning pedagogy, as well as additional themes that support the community experience. PACS will be incorporated into all four years of the curriculum, with health promotion activities in community sites as the focus in years one and two and the provision of patient care in community clinics in years three and four. Students are encouraged to provide feedback on this newly implemented course. The objective of this article is to provide an overview of the themes and modules of PACS, in the context of its being an evolving course for implementing community-based health promotion activities as experiential education for dental students. The current PACS modules are designed to expose students to a variety of experiences-from assessing community needs and developing, applying, and evaluating an educational health promotion activity to demonstrating a systematic approach to ethical reasoning and critical thinking. In their feedback, students have expressed their appreciation for the community experience and suggested modifications to the course in terms of guidelines and assignments.