Safety considerations for dietary supplement manufacturers in the United States.

Due to significant dietary supplement use in the US, product manufacturers must understand the importance of implementing a robust approach to establishing safety for all ingredients, including dietary ingredients, components, and finished dietary supplement products. Different regulatory pathways exist by which the safety of dietary ingredients can be established, and thus allowed to be marketed in a dietary supplement. For individual dietary ingredients, safety information may come from a variety of sources including history of safe use, presence of the ingredient in foods, and/or non-clinical and clinical data. On occasion safety data gaps are identified for a specific ingredient, particularly those of botanical origin. Modern toxicological methods and models can prove helpful in satisfying data gaps and are presented in this review. For finished dietary supplement products, issues potentially impacting safety to consider include claims, product labeling, overages, contaminants, residual solvents, heavy metals, packaging, and product stability. In addition, a safety assessment does not end once a product is marketed. It is important that manufacturers actively monitor and record the occurrence of adverse events reported in association with the use of their products, in accordance with the law. Herein, we provide a comprehensive overview of considerations for assessing dietary supplement safety.

A positive yet complicated case of gender-based violence coordination: a qualitative study of Lebanon's protracted humanitarian emergency, 2012-22.

Gender-based violence (GBV), a global health and human rights concern, often intensifies during emergencies. This paper explores the evolution of GBV coordination in Lebanon's protracted Syrian refugee crisis from 2012-22. Utilising 38 in-depth interviews and a document review, the findings were analysed using the framework for effective GBV coordination. Lebanon provides a positive yet complicated example of GBV coordination. Initially established to address the refugee crisis, it matured into a collaborative national coordination mechanism, fostering trust and advancing localisation amidst sectarian complexities. However, the volatile, restrictive policy context hindered government co-leadership and engagement with refugee-led organisations. While essential GBV response services were expanded nationwide, lack of an interagency strategy on GBV risk mitigation and prevention compromised lasting change. The paper emphasises the importance of dedicated GBV coordinators, multi-year funding, and increased attention to GBV prevention. The findings underscore the transformative potential of humanitarian responses and advocate for enhanced engagement with national stakeholders to promote sustainability in protracted crises.

From humanitarian crisis to employment crisis: The lives and livelihoods of South Sudanese refugee health workers in Uganda.

Despite the many benefits of refugee health workers for health systems, they commonly face challenges integrating into host country workforces. The Global Code of Practice on International Recruitment of Health Personnel, which should monitor and protect migrant health workers, offers little guidance for refugees and research is needed to inform strategy. Based on interviews with 34 refugee health workers and 10 leaders across two settlements supporting populations fleeing the humanitarian crisis in South Sudan since 2013, we describe the governance and social dynamics affecting South Sudanese refugee health worker employment in Uganda. Refugees in Uganda legally have the right to work but face an employment crisis. Refugee health workers report that systemic discrimination, competition from underemployed domestic workers, unclear work permit rules and expensive credentialling processes exclude them from meaningful work in public health facilities and good jobs in the humanitarian response. This pushes them into unchallenging roles in private clinics, poorly remunerated positions on village health teams or out of the health sector altogether. Health system strengthening initiatives in Uganda to integrate humanitarian and government services and to deter the domestic workforce from emigration have overlooked the potential contributions of refugee health workers and the employment crisis they face. More effort is needed to increase fairness in public sector recruitment practices for refugee health workers, support credentialling, training opportunities for professional and non-professional cadres, job placements, and to draw attention to the public benefits of refugee health worker employment alongside higher spending on human resources for health.

Rural Veterans' Experiences with Social Risk Factors: Impacts, Challenges, and Care System Recommendations.

BACKGROUND: Social risk factors, such as food insecurity and financial needs, are associated with increased risk of cardiovascular diseases, health conditions that are highly prevalent in rural populations. A better understanding of rural Veterans' experiences with social risk factors can inform expansion of Veterans Health Administration (VHA) efforts to address social needs. OBJECTIVE: To examine social risk and need from rural Veterans' lived experiences and develop recommendations for VHA to address social needs. DESIGN: We conducted semi-structured interviews with participants purposively sampled for racial diversity. The interview guide was informed by Andersen's Behavioral Model of Health Services Use and the Outcomes from Addressing Social Determinants of Health in Systems framework. PARTICIPANTS: Rural Veterans with or at risk of cardiovascular disease who participated in a parent survey and agreed to be recontacted. APPROACH: Interviews were recorded and transcribed. We analyzed transcripts using directed qualitative content analysis to identify themes. KEY RESULTS: Interviews (n = 29) took place from March to June 2022. We identified four themes: (1) Social needs can impact access to healthcare, (2) Structural factors can make it difficult to get help for social needs, (3) Some Veterans are reluctant to seek help, and (4) Veterans recommended enhancing resource dissemination and navigation support. CONCLUSIONS: VHA interventions should include active dissemination of information on social needs resources and navigation support to help Veterans access resources. Community-based organizations (e.g., Veteran Service Organizations) could be key partners in the design and implementation of future social need interventions.

How registered nurses are measuring respiratory rates in adult acute care health settings: An integrative review.

AIMS AND OBJECTIVES: This integrative review aimed to draw conclusions from evidence on how registered nurses are measuring respiratory rates for acute care patients. BACKGROUND: Despite the growing research supporting respiratory rate as an early indicator for clinical deterioration, respiratory rate has consistently been the least frequently measured and accurately documented vital sign. DESIGN: An integrative review. METHODS: A systematic literature search was conducted in June 2022 in four databases: CINAHL, PubMed, Medline and Scopus. Quality appraisal was undertaken using the Joanna Briggs Institute's Checklist. PRISMA guidelines were followed to ensure explicit reporting and reported in the PRISMA checklist. RESULTS: Overall, 9915 records were identified, and 19 met the inclusion criteria. Of these 19 articles, seven themes emerged: estimation and digit preference, lack of understanding and knowledge, not valuing the clinical significance of respiratory rate, oxygen saturation substitute, interobserver agreement, subjective concern and count duration. A high prevalence of bias, estimation and incorrect technique was evident. A total of 15 articles reported specifically on how registered nurses are measuring respiratory rates on general medical and surgical wards. CONCLUSIONS: Despite its importance, this integrative review has determined that respiratory rates are not being assessed correctly by nursing staff in the acute care environment. Evidence of using estimation, value bias or quick count and multiply techniques are emerging themes which urgently require further research. No patient or public contribution.

Production of Mare Chorionic Girdle Organoids That Secrete Equine Chorionic Gonadotropin.

The equine chorionic girdle is comprised of specialized invasive trophoblast cells that begin formation approximately 25 days after ovulation (day 0) and invade the endometrium to become endometrial cups. These specialized trophoblast cells transition from uninucleate to differentiated binucleate trophoblast cells that secrete the glycoprotein hormone equine chorionic gonadotropin (eCG; formerly known as pregnant mare serum gonadotropin or PMSG). This eCG has LH-like activity in the horse but variable LH- and FSH-like activity in other species and has been utilized for these properties both in vivo and in vitro. To produce eCG commercially, large volumes of whole blood must be collected from pregnant mares, which negatively impacts equine welfare due to repeated blood collections and the birth of an unwanted foal. Attempts to produce eCG in vitro using long-term culture of chorionic girdle explants have not been successful beyond 180 days, with peak eCG production at 30 days of culture. Organoids are three-dimensional cell clusters that self-organize and can remain genetically and phenotypically stable throughout long-term culture (i.e., months). Human trophoblast organoids have been reported to successfully produce human chorionic gonadotropin (hCG) and proliferate long-term (>1 year). The objective of this study was to evaluate whether organoids derived from equine chorionic girdle maintain physiological functionality. Here we show generation of chorionic girdle organoids for the first time and demonstrate in vitro production of eCG for up to 6 weeks in culture. Therefore, equine chorionic girdle organoids provide a physiologically representative 3D in vitro model for chorionic girdle development of early equine pregnancy.

Barriers and motivators to national board certification as a certified anticoagulation care provider.

Professionals voice confusion between the distinctions of board certification and educational certificate courses, and note barriers and motivators in obtaining national anticoagulation board certification. To identify barriers vs. motivators in obtaining board certification and detail the differences in board certification and educational certificate courses, an IRB-approved electronic survey was sent to professionals completing the University of Southern Indiana (USI) Anticoagulation Therapy educational certificate course (n = 491) and existing Certified Anticoagulation Care Providers (CACP, n = 622). A total of 1049 surveys were delivered successfully, with a 26% response rate (USI = 62, CACP = 211.) Respondents identified as a nurse (n = 52, 19%), advanced practice nurse (n = 14, 5.1%), pharmacist (n = 206, 75.5%) or physician (n = 5, 1.8%). Overall, respondents indicated board certification via CACP has significant impact on patient/organizational outcomes (n = 118, 43.2%). Top motivators for board certification include personal accomplishment (n = 147, 53%) and professional growth (n = 139, 50.9%). Top barriers include lack of time to prepare (n = 102, 37.3%,) board certification exam cost (n = 95, 34.8%), and for CACP recertification, and requirement to recertify by examination (n = 74, 35.1%). Of board-certified respondents, 45.4% indicated they were not employed at an Anticoagulation Center of Excellence (ACE), 34.8% employed at an ACE and 16.8% were unsure of ACE status. Narrative comments were obtained and evaluated. Significant personal and professional barriers exist in completing, and subsequently maintaining, board certification in anticoagulation. This offers great insight for NCBAP to invoke changes to support clinicians and healthcare organizations in seeking and maintaining CACP credentialing, a component of ACE attainment.

Public health emergency and psychological distress among healthcare workers: a scoping review.

BACKGROUND: Pandemics and natural disasters are immensely stressful events for frontline healthcare workers, as they provide patient care to a population undergoing the impacts of the disaster while experiencing such impacts to their personal lives themselves. With increased stressors to an already demanding job, frontline healthcare workers are at a higher risk of adverse effects to their mental health. The current COVID-19 pandemic has already shown to have had significant impact on the mental health of healthcare workers with increased rates of burnout, anxiety and depression. There is already literature showing the utility of individual programs at improving mental health, however, interventions at the organizational level are not well explored. This scoping review aims to provide an overview and determine the utility of a systematic review of the current body of literature assessing the effectiveness of mental health interventions at the organizational level for healthcare workers during or after a public health emergency. METHODS: Electronic databases such as Medline on OVID, CENTRAL, PsycINFO on OVID and Embase on OVID were searched. A targeted search of the grey literature was conducted to identify any non-indexed studies. The population, concept and context approach was used to develop the eligibility criteria. Articles were included if (1) they assessed the impact of interventions to improve wellbeing or reduce the distress on healthcare personnel, first responders or military actively providing medical care; (2) provided quantitative or qualitative data with clearly defined outcomes that focused on established mental health indicators or qualitative descriptions on distress and wellbeing, validated scales and workplace indicators; (3) focused on organizational level interventions that occurred in a public health crisis. RESULTS: The literature search resulted in 4007 citations and 115 potentially relevant full-text papers. All except 5 were excluded. There were four review articles and one experimental study. There were no other unpublished reports that warranted inclusion. CONCLUSIONS: There is a distinct lack of research examining organizational interventions addressing mental resilience and well-being in healthcare workers in disaster settings. A systematic review in this area would be low yield. There is a clear need for further research in this area.

Individual-, family- and school-based interventions to prevent multiple risk behaviours relating to alcohol, tobacco and drug use in young people aged 8-25 years: a systematic review and meta-analysis.

BACKGROUND: Engagement in multiple substance use risk behaviours such as tobacco smoking, alcohol and drug use during adolescence can result in adverse health and social outcomes. The impact of interventions that address multiple substance use risk behaviours, and the differential impact of universal versus targeted approaches, is unclear given findings from systematic reviews have been mixed. Our objective was to assess effects of interventions targeting multiple substance use behaviours in adolescents. METHODS: Eight databases were searched to October 2019. Individual and cluster randomised controlled trials were included if they addressed two or more substance use behaviours in individuals aged 8-25 years. Data were pooled in random-effects meta-analyses, reported by intervention and setting. Quality of evidence was assessed using GRADE. Heterogeneity was assessed using between-study variance, τ2 and Ι2, and the p-value of between-study heterogeneity statistic Q. Sensitivity analyses were undertaken using the highest and lowest intra-cluster correlation coefficient (ICC). RESULTS: Of 66 included studies, most were universal (n=52) and school-based (n=41). We found moderate quality evidence that universal school-based interventions are likely to have little or no short-term benefit (up to 12 months) in relation to alcohol use (OR 0.94, 95% CI: 0.84, 1.04), tobacco use (OR 0.98, 95% CI: 0.83, 1.15), cannabis use (OR 1.06, 95% CI: 0.86, 1.31) and other illicit drug use (OR 1.09, 95% CI: 0.85, 1.39). For targeted school-level interventions, there was low quality evidence of no or a small short-term benefit: alcohol use (OR 0.90, 95% CI: 0.74-1.09), tobacco use (OR 0.86, 95% CI: 0.66, 1.11), cannabis use (OR 0.84, 95% CI: 0.66-1.07) and other illicit drug use (OR 0.79, 95% CI 0.62-1.02). There were too few family-level (n=4), individual-level (n=2) and combination level (n=5) studies to draw confident conclusions. Sensitivity analyses of ICC did not change results. CONCLUSIONS: There is low to moderate quality evidence that universal and targeted school-level interventions have no or a small beneficial effect for preventing substance use multiple risk behaviours in adolescents. Higher quality trials and study reporting would allow better evidence syntheses, which is needed given small benefit of universal interventions can have high public health benefit. TRIAL REGISTRATION: Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD011374. DOI: 10.1002/14651858.CD011374.

An innovative and integrated model for global outbreak response and research - a case study of the UK Public Health Rapid Support Team (UK-PHRST).

BACKGROUND: Despite considerable institutional experimentation at national and international levels in response to calls for global health security reform, there is little research on organisational models that address outbreak preparedness and response. Created in the aftermath of the 2013-16 West African Ebola epidemic, the United Kingdom's Public Health Rapid Support Team (UK-PHRST) was designed to address critical gaps in outbreak response illuminated during the epidemic, while leveraging existing UK institutional strengths. The partnership between the government agency, Public Health England, and an academic consortium, led by the London School of Hygiene and Tropical Medicine, seeks to integrate outbreak response, operational research and capacity building. We explored the design, establishment and early experiences of the UK-PHRST as one of the first bodies of its kind globally, paying particular attention to governance decisions which enabled them to address their complex mission. METHODS: We conducted a qualitative case study using 19 in-depth interviews with individuals knowledgeable about the team's design and implementation, review of organisational documents, and observations of meetings to analyse the UK-PHRST's creation, establishment and initial 2 years of operations. RESULTS: According to key informants, adopting a triple mandate (response, research and capacity building) established the team as novel in the global epidemic response architecture. Key governance decisions recognised as vital to the model included: structuring the team as a government-academic collaboration which leveraged long-term and complementary UK investments in public health and the higher education sector; adopting a more complex, dual reporting and funding structure to maintain an ethos of institutional balance between lead organisations; supporting a multidisciplinary team of experts to respond early in outbreaks for optimal impact; prioritising and funding epidemic research to influence response policy and practice; and ensuring the team's activities reinforced the existing global health architecture. CONCLUSION: The UK-PHRST aims to enhance global outbreak response using an innovative and integrated model that capitalises on institutional strengths of the partnership. Insights suggest that despite adding complexity, integrating operational research through the government-academic collaboration contributed significant advantages. This promising model could be adopted and adapted by countries seeking to build similar outbreak response and research capacities.

Device-related pressure injuries in adult intensive care unit patients: An Australian and New Zealand point prevalence study.

BACKGROUND: Device-related pressure injuries (DRPIs) are an ongoing iatrogenic problem evident in intensive care unit (ICU) settings. Critically ill patients are at high risk of developing pressure injuries caused by devices. OBJECTIVE: The aim of the study was to determine the prevalence of DRPI in critically ill patients in intensive care and the location, stage, and attributable device of DRPI and describe the products and processes of care used to prevent these injuries. METHODS: This was a prospective, multicentre, cross-sectional point prevalence study of patients aged more than 16 years in Australian and New Zealand ICUs. The study was part of the Australian and New Zealand Intensive Care Society Clinical Trials Group Point Prevalence Program coordinated by The George Institute for Global Health. MAIN OUTCOME MEASURE: Identification of DRPI on the study day was the main outcome measure. RESULTS: Of the 624 patients included from 44 participating ICUs, 27 were found to have 35 identified DRPIs, giving a point prevalence DRPI rate of 4.3% (27/624). Study patients had a mean age of 59 years, and 60.3% were men. Patients with DRPI compared with patients without DRPI were significantly heavier (median: 92 kg versus 80 kg, respectively, p = 0.027), were less likely to survive the ICU (63.0% versus 85.9%, respectively, p = 0.015), had higher Acute Physiology and Chronic Health Evaluation II scores at admission to the ICU (median: 20 versus 16, respectively, p = 0.001), received mechanical ventilation more often (88.9% versus 43.5%, respectively, p < 0.001), and were more frequently diagnosed with respiratory conditions (37.0% versus 18.6%, respectively, p = 0.022). Processes of care activities were surveyed in 42 ICUs. Most DRPIs were attributed to endotracheal tubes and other respiratory devices. Forty-two ICUs reported processes of care to prevent DRPI, and just more than half of the participating sites (54.8%, 23/44) reported a dedicated ICU-based protocol for prevention of DRPI. CONCLUSION: DRPIs pose a burden on patients in the ICU. Our study showed a DRPI prevalence comparable with other studies. Prevention strategies targeting DRPI should be included in ICU-specific pressure injury prevention guidelines or protocols.

Contested legitimacy for anthropologists involved in medical humanitarian action: experiences from the 2014-2016 West Africa Ebola epidemic.

The growing involvement of anthropologists in medical humanitarian response efforts has laid bare the moral and ethical consequences that emerge from humanitarian action. Anthropologists are well placed to examine the social, political, cultural and economic dimensions that influence the spread of diseases, and the ways in which to respond to epidemics. Anthropologists are also, with care, able to turn a critical lens on medical humanitarian response. However, there remains some resistance to involving anthropologists in response activities in the field. Drawing on interviews with anthropologists and humanitarian workers involved in the 2014-2016 West African Ebola epidemic, this paper reveals the complex roles taken on by anthropologists in the field and reveals how anthropologists faced questions of legitimacy vis-à-vis communities and responders in their roles in response activities, which focused on acting as 'firefighters' and 'cultural brokers' as well as legitimacy as academic researchers. Whilst these anthropologists were able to conduct research alongside these activities, or draw on anthropological knowledge to inform response activities, questions also arose about the legitimacy of these roles for anthropological academia. We conclude that the process of gaining legitimacy from all these different constituencies is particular to anthropologists and reveals the role of 'giving voice' to communities alongside critiquing medical humanitarianism. Whilst these anthropologists have strengthened the argument for the involvement of anthropologists in epidemic response this anthropological engagement with medical humanitarianism has revealed theoretical considerations more broadly for the discipline, as highlighted through engagement in other fields, especially in human rights and global health.

Barriers and facilitators to implementing a pragmatic trial to improve advance care planning in the nursing home setting.

BACKGROUND: The PRagmatic trial Of Video Education in Nursing homes (PROVEN) aims to test the effectiveness of an advance care planning (ACP) video intervention. Relatively little is known about the challenges associated with implementing ACP interventions in the nursing home (NH) setting, especially within a pragmatic trial. To address this research gap, this report sought to identify facilitators of and barriers to implementing PROVEN from the perspective of the Champions charged with introducing the ACP video program delivery to patients and families. METHODS: In semi-structured telephone interviews at 4 and 15 months of the 18-month implementation period, ACP Champions at all PROVEN intervention facilities (N = 119) were asked about their perceptions of program implementation. Forty interviews were purposively sampled, transcribed, and analyzed using a hybrid deductive/inductive approach to thematic analysis incorporating the Consolidated Framework for Implementation Research's domains: Intervention Characteristics (IC), Inner Setting (IS), Characteristics of Individuals (CI), Outer Setting (OS), and Process (P). RESULTS: Implementation facilitators identified by Champions included: the intervention's adaptable mode of presentation and minimal time burden (IC) as well as the program's customizable delivery to patients and families and opportunity for group reflection on implementation among ACP Champions (P). Barriers included mandated protocol-driven aspects of the program (OS), limited time to deliver the intervention (IS), and lack of perceived relevance and emotional readiness for ACP amongst stakeholders (CI). CONCLUSIONS: Despite the promise of PROVEN's intervention for improving ACP in nursing homes, unchangeable setting and characteristics of Champions, patients, and family members presented implementation barriers. Researchers need to engage all program participants (i.e., facility staff, patients, and families), in addition to corporate-level stakeholders, in early pragmatic trial design to minimize such obstacles. Further, despite the facilitating nature of PROVEN's implementation processes, the study encountered tension between scientific rigor and real-world demands. Researchers need to optimize the real-world authenticity of pragmatic trial design while avoiding excessive implementation protocol deviations. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02612688. Registered 19 November 2015.

Blended Facilitation as an Effective Implementation Strategy for Quality Improvement and Research in Nursing Homes.

BACKGROUND: Blended facilitation, which leverages the complementary skills and expertise of external and internal facilitators, is a powerful strategy that nursing stakeholders and researchers may use to improve implementation of quality improvement (QI) innovations and research performed in nursing homes. PROBLEM: Nursing homes present myriad challenges (eg, time constraints, top-down flow of communication, high staff turnover) to QI implementation and research. APPROACH: This methods article describes the theory and practical application of blended facilitation and its components (external facilitation, internal facilitation, relationship building, and skill building), using examples from a mixed QI and research intervention in Veterans Health Administration nursing homes. CONCLUSIONS: Blended facilitation invites nursing home stakeholders to be equal partners in QI and research processes. Its intentional use may overcome many existing barriers to QI and research performed in nursing homes and, by strengthening relationships between researchers and stakeholders, may accelerate implementation of innovative care practices.

Resident Choice: A Nursing Home Staff Perspective on Tensions and Resolutions.

A central component of person-centered care, resident choice in daily life, has received little research attention in the U.S. CONTEXT: This study investigated nursing home staff experiences in realizing resident choice. Twenty-six qualitative staff interviews were conducted in an opportunistic sample from two Veterans Health Administration (VHA) Community Living Centers (CLCs, i.e., nursing homes) implementing the Green House Model. Thematic content analysis surfaced several key tensions at the intra-personal, inter-personal, and organizational levels. Most salient were staff mental models within the intra-personal level. Staff conveyed a lack of clarity on how to realize resident choice when faced with varying tensions, especially the competing goal of resident medical and safety needs. Staff-employed resolutions to resident choice-related tensions also emerged (e.g., preventive practices, staff reinforcement, and staff deliberation). This study offers specific and concrete insights on how resident choice in daily life, and thus resident quality of life, can be advanced.

Autonomous Exploration and Mapping with RFS Occupancy-Grid SLAM.

This short note addresses the problem of autonomous on-line path-panning for exploration and occupancy-grid mapping using a mobile robot. The underlying algorithm for simultaneous localisation and mapping (SLAM) is based on random-finite set (RFS) modelling of ranging sensor measurements, implemented as a Rao-Blackwellised particle filter. Path-planning in general must trade-off between exploration (which reduces the uncertainty in the map) and exploitation (which reduces the uncertainty in the robot pose). In this note we propose a reward function based on the Rényi divergence between the prior and the posterior densities, with RFS modelling of sensor measurements. This approach results in a joint map-pose uncertainty measure without a need to scale and tune their weights.

Autonomous Multi-Robot Search for a Hazardous Source in a Turbulent Environment.

Finding the source of an accidental or deliberate release of a toxic substance into the atmosphere is of great importance for national security. The paper presents a search algorithm for turbulent environments which falls into the class of cognitive (infotaxi) algorithms. Bayesian estimation of the source parameter vector is carried out using the Rao-Blackwell dimension-reduction method, while the robots are controlled autonomously to move in a scalable formation. Estimation and control are carried out in a centralised replicated fusion architecture assuming all-to-all communication. The paper presents a comprehensive numerical analysis of the proposed algorithm, including the search-time and displacement statistics.

Boosting Social and Emotional Development In and Out of School.

(1) Illinois' state ESSA plan reflects the state's whole-child approach, adding references to the social, emotional and behavioral needs of students, along with high expectations for student achievement. (2) Massachusetts' state ESSA plan lists supporting socialemotional learning, health and safety as among the state's core educational strategies. (3) South Carolina's ESSA plan develops a framework identifying self-direction, perseverance, global perspective and interpersonal skills to be among the characteristics that every student should have when he or she graduates from high school.

Circumventing 'free care' and 'shouting louder': using a health systems approach to study eye health system sustainability in government and mission facilities of north-west Tanzania.

BACKGROUND: Little is known about the contributions of faith-based organisations (FBOs) to health systems in Africa. In the specialist area of eye health, international and domestic Christian FBOs have been important contributors as service providers and donors, but they are also commonly critiqued as having developed eye health systems parallel to government structures which are unsustainable. METHODS: In this study, we use a health systems approach (quarterly interviews, a participatory sustainability analysis exercise and a social network analysis) to describe the strategies used by eye care practitioners in four hospitals of north-west Tanzania to navigate the government, church mission and donor rules that govern eye services delivery there. RESULTS: Practitioners in this region felt eye care was systemically neglected by government and therefore was 'all under the NGOs', but support from international donors was also precarious. Practitioners therefore adopted four main strategies to improve the sustainability of their services: (1) maintain 'sustainability funds' to retain financial autonomy over income; (2) avoid granting government user fee exemptions to elderly patients who are the majority of service users; (3) expand or contract outreach services as financial circumstances change; and (4) access peer support for problem-solving and advocacy. Mission-based eye teams had greater freedom to increase their income from user fees by not implementing government policies for 'free care'. Teams in all hospitals, however, found similar strategies to manage their programmes even when their management structures were unique, suggesting the importance of informal rules shared through a peer network in governing eye care in this pluralistic health system. CONCLUSIONS: Health systems research can generate new evidence on the social dynamics that cross public and private sectors within a local health system. In this area of Tanzania, Christian FBOs' investments are important, not only in terms of the population health outcomes achieved by teams they support, but also in the diversity of organisational models they contribute to in the wider eye health system, which facilitates innovation.

Contextual Facilitators of and Barriers to Nursing Home Pressure Ulcer Prevention.

PURPOSE: To present findings of a study of institutional factors related to pressure ulcer (PrU) prevention in Veterans Health Administration nursing homes. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to:1. Identify the study's design, process, and purpose.2. List the factors pertaining to sites with improving performance. OBJECTIVES: Important gaps exist in the knowledge of how to achieve successful, sustained prevention of pressure ulcers (PrUs) in nursing homes. This study aimed to address those gaps by comparing nursing leadership and indirect care staff members' impressions about the context of PrU prevention in facilities with improving and declining PrU rates. SETTING: The study was conducted in a sample of 6 Veterans Health Administration nursing homes (known as community living centers) purposively selected to represent a range of PrU care performance. DESIGN AND PARTICIPANTS: One-time 30-minute semistructured interviews with 23 community living center staff were conducted. Qualitative interview data were analyzed using an analytic framework containing (a) a priori analytic constructs based on the study's conceptual framework and (b) sections for emerging constructs. MAIN RESULTS: Analysis revealed 6 key concepts differentiating sites with improving and declining PrU care performance. These concepts were (1) structures through which the change effort is initiated; (2) organizational prioritization, alignment, and support; (3) improvement culture; (4) clarity of roles and responsibilities; (5) communication strategies; and (6) staffing and clinical practices. Results also pointed to potential contextual facilitators of and barriers to successful PrU prevention. CONCLUSIONS: Leadership's visible prioritization of and support for PrU prevention and the initiation of PrU prevention activities through formal structures were the most striking components represented at sites with improving performance, but not at ones where performance declined. Sites with improving performance were more likely to align frontline staff and leadership goals for PrU prevention.