Regulation of nursing professionals in Cambodia: strategies to overcome underpinning challenges.

AIMS: To elucidate (i) the challenges and constraints in the development and implementation of the regulatory framework for nursing professionals in Cambodia and (ii) the specific strategies adopted to address the challenges experienced in Cambodia. INTRODUCTION: The health workforce will be critical to achieving the health-related and wider Sustainable Development Goals in the years up to 2030. BACKGROUND: In 2006, the countries of the Association of Southeast Asian Nations signed a Mutual Recognition Arrangement in relation to nursing services in the region with the main aim of facilitating the mobility of nursing professionals between countries. To ensure the competency of the health workforce and the quality and safety of health services, member states are required to establish an appropriate regulatory framework. METHODS: This is a qualitative descriptive study. Eighteen key informant interviews were conducted in Cambodia in 2018. Walt and Gilson's policy analysis model was applied to organize and synthesize the data. FINDINGS: Major challenges were identified such as conceptual and cultural issues, limited capacity of Cambodian stakeholders and an unstandardized system with limited coordination. DISCUSSION: In Cambodia, the nursing regulatory environment has expanded greatly over the last decade. Strategies adopted were 'political leadership', optimal utilization of 'outsider's capacity', strengthening 'insider's capacity', and 'dedicated consultation and collaboration and consensus building' involving all players. IMPLICATIONS FOR NURSING AND HEALTH POLICIES: Policymakers in similar resource-limited countries could apply and adapt similar strategic efforts when formulating and implementing health policies, legislation and regulations. 'Outsiders', in this case, represented by development partners can play a vital role in the process, but should not be leading the charge. They should be aligned with national priority to support recipient countries. It is imperative for these countries and development partners to invest in increasing the quantity and quality of nursing leaders who can develop and advance regulatory functions.

Opportunities for the development of drowning interventions in West Bengal, India: a review of policy and government programs.

BACKGROUND: Four million people living in the Indian Sundarbans region in the state of West Bengal face a particularly high risk of drowning due to rurality, presence of open water, lack of accessible health systems and poor infrastructure. Although the World Health Organization has identified several interventions that may prevent drowning in rural low-and middle-income country contexts, none are currently implemented in this region. This study aims to conduct contextual policy analysis for the development of a drowning program. Implementation of a drowning program should consider leveraging existing structures and resources, as interventions that build on policy targets or government programs are more likely to be sustainable and scalable. METHODS: A detailed content review of national and state policy (West Bengal) was conducted to identify policy principles and/or specific government programs that may be leveraged for drowning interventions. The enablers and barriers of these programs as well as their implementation reach were assessed through a systematic literature review. Identified policies and programs were also assessed to understand how they catered for underserved groups and their implications for equity. RESULTS: Three programs were identified that may be leveraged for the implementation of drowning interventions such as supervised childcare, provision of home-based barriers, swim and rescue skills training and community first responder training: the Integrated Child Development Scheme (ICDS), Self-Help Group (SHG) and Accredited Social Health Activist (ASHA) programs. All three had high coverage in West Bengal and considered underserved groups such as women and rural populations. Possible barriers to using these programs were poor government monitoring, inadequate resource provision and overburdening of community-based workers. CONCLUSIONS: This is the first systematic analysis of both policy content and execution of government programs to provide comprehensive insights into possible implementation strategies for a health intervention, in this case drowning. Programs targeting specific health outcomes should consider interventions outside of the health sector that address social determinants of health. This may enable the program to better align with relevant government agendas and increase sustainability.

Socioeconomic inequalities in oral health among adults in Tehran, Iran.

OBJECTIVE: To identify the socioeconomic distribution of perceived oral health among adults in Tehran, Iran. BASIC RESEARCH DESIGN: A cross-sectional population study. PARTICIPANTS: A stratified random sample of 1,100 adults aged 18-84 years living in Tehran. METHODS: Self-report data were obtained from the 2010 dental telephone interview survey. Oral health was evaluated using self-assessed non-replaced extracted teeth (NRET), and a three-item perceived dental health instrument. Socioeconomic status was measured by combining the variables of education and assets using principal component analysis. Inequalities in oral health were examined using prevalence ratios and concentration index. RESULTS: The poorest quintile was 1.60 (95% confidence interval, CI, 1.30; 1.98) times as likely to have any NRET compared with the richest quintile, indicating a disparity. Inequality was most pronounced in the 35-59 age group with prevalence ratio 2.01 (95% CI 1.26; 3.05). The concentration index of NRET in adults in Tehran was -0.22 (95% CI -0.28; -0.16). No significant differences were found in perceived dental health between socioeconomic classes. CONCLUSIONS: Adults from lower socioeconomic classes experienced more disabilities due to missing their teeth, specifically in the middle-age group. Inequalities in perceived dental health were not apparent in the studied population.

Six months after routine screening for intimate partner violence: attitude change, useful and adverse effects.

This evaluative study measured self-reported changes in abuse-related measures six months after routine screening for intimate partner violence. Participants were 122 women who disclosed abuse and 241 who did not report abuse, screened in antenatal, substance abuse, and mental health services according to an existing standardized protocol used in New South Wales, Australia. Six months after initial screening, abused women were more likely to report increased agreement with a number of attitudes relating to abuse, in particular that being hurt by a partner affects a woman's health and that health services should ask about abuse. The proportion reporting current abuse was significantly lower after six months. While 6% (7/119) reported negative emotional reactions, 34% (41/120) reported useful effects-most frequently re-evaluating their situation and reducing isolation. Women who had experienced abuse, but elected not to disclose it reported similar effects. The results of this study lend support to the use of protocols for asking about abuse and responding to disclosures of abuse.

Factors influencing resource allocation decisions and equity in the health system of Ghana.

OBJECTIVE: Allocation of financial resources in the health sector is often seen as a formula-driven activity. However, the decision to allocate a certain amount of resources to a particular health jurisdiction or facility may be based on a broader range of factors, sometimes not reflected in the existing resource allocation formula. This study explores the 'other' factors that influence the equity of resource allocation in the health system of Ghana. The extent to which these factors are, or can be, accounted for in the resource allocation process is analysed. STUDY DESIGN: An exploratory design focusing on different levels of the health system and diverse stakeholders. METHODS: Data were gathered through semi-structured qualitative interviews with health authorities at national, regional and district levels, and with donor representatives and local government officials in 2003 and 2004. RESULTS: The availability of human resources for health, local capacity to utilize funds, donor involvement in the health sector, and commitment to promote equity have considerable influence on resource allocation decisions and affect the equity of funding allocations. However, these factors are not accounted for adequately in the resource allocation process. CONCLUSION: This study highlights the need for a more transparent resource allocation system in Ghana based on needs, and takes into account key issues such as capacity constraints, the inequitable human resource distribution and donor-earmarked funding.

An Australian childhood obesity summit: the role of data and evidence in 'public' policy making.

BACKGROUND: Overweight and obesity in Australia has risen at an alarming rate over the last 20 years as in other industrialised countries around the world, yet the policy response, locally and globally, has been limited. Using a childhood obesity summit held in Australia in 2002 as a case study, this paper examines how evidence was used in setting the agenda, influencing the Summit debate and shaping the policy responses which emerged. The study used multiple methods of data collection including documentary analysis, key informant interviews, a focus group discussion and media analysis. The resulting data were content analysed to examine the types of evidence used in the Summit and how the state of the evidence base contributed to policy-making. RESULTS: Empirical research evidence concerning the magnitude of the problem was widely reported and largely uncontested in the media and in the Summit debates. In contrast, the evidence base for action was mostly opinion and ideas as empirical data was lacking. Opinions and ideas were generally found to be an acceptable basis for agreeing policy action coupled with thorough evaluation. However, the analysis revealed that the evidence was fiercely contested around food advertising to children and action agreed was therefore limited. CONCLUSION: The Summit demonstrated that policy action will move forward in the absence of strong research evidence. Where powerful and competing groups contest possible policy options, however, the evidence base required for action needs to be substantial. As with tobacco control, obesity control efforts are likely to face ongoing challenges around the nature of the evidence and interventions proposed to tackle the problem. Overcoming the challenges in controlling obesity will be more likely if researchers and public health advocates enhance their understanding of the policy process, including the role different types of evidence can play in influencing public debate and policy decisions, the interests and tactics of the different stakeholders involved and the part that can be played by time-limited yet high profile events such as Summits.

Identifying competencies for Australian health professionals working in international health.

A profile of the roles performed by Australian health professionals working in international health was constructed to identify the core competencies they require, and the implications for education and training of international health practitioners. The methods used included: literature review and document analysis of available training and education; an analysis of competencies required in job descriptions for international health positions; and consultations with key informants. The international health roles identified were classified in four main groups: Program Directors, Program Managers, Team Leaders and Health Specialists. Thirteen 'core' competencies were identified from the job analysis and key informant/group interviews. Contributing to international health development in resource poor countries requires high level cultural, interpersonal and teamwork competencies. Technical expertise in health disciplines is required, with flexibility to adapt to new situations. International health professionals need to combine public health competencies with high level personal maturity to respond to emerging challenges.

Mesothelioma in South Africa, 1976-84: incidence and case characteristics.

Malignant mesothelioma is a rare tumour known to be associated with prior exposure to asbestos. Previous studies have described the occupational and clinical features of cases of mesothelioma in the Republic of South Africa (RSA) but none has set out to determine incidence of this disease. To estimate incidence, a case register was compiled for 1976-84 by contacting all medical practitioners and institutions likely to have seen cases of mesothelioma in this period; demographic, diagnostic and exposure details were sought. Cases were accepted if they provided evidence of histological diagnosis of mesothelioma. Fifty-two per cent of 1347 cases identified were in whites, 31% in blacks, 16% in coloureds and 1% in Asians. Seventy-three per cent of cases occurred in males. The majority of whites were aged 51-70 years, while the majority in other race groups were aged 41-60 years. The ratio of only pleural to only peritoneal mesothelioma was 11:1, although there were marked differences by race. Eighty-five per cent of males with exposure information available had prior exposure to asbestos, mostly occupational. A similar proportion of women had contact with asbestos but mostly through other types of exposure. Standardized incidence rates per million population aged 15 years and over were calculated for sex-race subgroups and were highest in white males (32.9 per million per year, 95% Cl 22.7-46.4), coloured males (24.8 per million per year, 95% Cl 16.2-36.9) and coloured females (13.9 per million per year, 95% Cl 7.7-23.5). These incidence rates are amongst the highest ever reported for a national population. Age-specific standardized incidence rates were highest in white males (over 100 per million per year in men over 55 years). Reasons for the differing rates by population group are likely to include differential access to health services. More rigorous control of asbestos exposure in the RSA is recommended.

The political abuse of medicine and the challenge of opposing it.

A fundamental aim of medicine is to protect and promote health. The practice of medicine has, however, been used to promote political aims which may be detrimental to health. The article attempts to isolate the ways in which political abuses may interfere with good medical practice: by allowing health policies to be influenced by undemocratic political considerations; by using health services to reward or punish political supporters or opponents; by direct medical involvement in political acts which contradict accepted medical ethics; and by the support which conventional medical practises give to perpetuating inequalities in health and social services. Each of these is examined with the use of a number of examples. The ways in which medical personnel have opposed the political abuse of medicine is explored by a brief review of the opposition of Chilean doctors to torture, the involvement of South African doctors in opposing the abuse of health services in perpetuating apartheid, and the growing medical movement in opposition to nuclear war. Some comments concerning the monitoring of a multitude of medical disciplines which are open to political abuse are made. The purpose of the paper is primarily to stimulate debate around this important issue and it does not attempt to provide a comprehensive review of the political abuse of medicine.

A triple burden for health sector reform: 'post'-conflict rehabilitation in Uganda.

While conflict continues to threaten health development in many countries, relative peace has been secured in others. The transition from war to peace carries important political and economic opportunities for the reappraisal of social policy in general, and of health policy in particular. The health systems of countries recovering from prolonged periods of conflict often carry a double burden: the inheritance of an inappropriate and unaffordable health system developed in the pre-conflict era, and the particular, long-term effects of conflict on health and health services. This paper reports on the particular policies designed to rehabilitate the Ugandan health system, and argues that they exacerbated, rather than alleviated, the health crisis inherited in 1986. In this way they posed a third burden. By analyzing the context and process of policy formulation in the immediate post-conflict period, it explores the rationale which lay behind the adoption of these policies and identifies potential strategies for strengthening policy development in these unstable, resource-poor and health-deprived situations.

The emerging international policy agenda for reproductive health services in conflict settings.

Over the past 20 years, shifts in the nature of conflict and the sheer numbers of civilians affected have given rise to increasing concern about providing appropriate health services in unstable settings. Concurrently, international health policy attention has focused on sexual and reproductive health issues and finding effective methods of addressing them. This article reviews the background to the promotion and development of reproductive health services for conflict-affected populations. It employs qualitative methods to analyse the development of policy at international level. First we examine the extent to which reproductive health is on the policy agendas of organisations active in humanitarian contexts. We then discuss why and how this has come about, and whether the issue has sufficient support to ensure effective implementation. Our findings demonstrate that reproductive health is clearly on the agenda for agencies working in these settings, as measured by a range of established criteria including the amount of new resources being attracted to this area and the number of meetings and publications devoted to this issue. There are, however, barriers to the full and effective implementation of reproductive health services. These barriers include the hesitation of some field-workers to prioritise reproductive health and the number and diversity of the organisations involved in implementation. The reasons for these barriers are discussed in order to highlight areas for action before effective reproductive health service provision to these populations can be ensured.

Violence against women: a neglected public health issue in less developed countries.

Violence against women is a significant public health issue in countries of both the industrialized and less developed world. This paper describes the magnitude and health consequences of domestic violence and rape, with an emphasis on developing countries; it recognizes, however, that there is a dearth of documentation regarding the wide range of activity opposing violence against women which is taking place in less developed countries. It briefly explores the factors that perpetuate violence against women and the strategies that have evolved to respond to the problem. It analyses the constellation of factors that may assist violence to emerge as a legitimate public health concern, and explores opportunities and obstacles to further progress in this field. Particular attention is devoted to the role of research in the policy-making process; research areas which may assist those opposing violence against women in all its forms are tentatively suggested.

Violence against children and adolescents. International perspectives.

Selected topics of violence against children and adolescents that occur in countries outside of the United States are discussed. Focus is given to middle-income and low-income countries and emphasis is placed on the epidemiology of this pressing public health problem, particularly on conditions that are peculiar to children and adolescents in international settings, such as female genital mutilations, wars, displacements, and land mines. The discussion of child maltreatment is presented in the context of child rearing and discipline in different cultures. Recommendations for action and violence prevention are offered in the light of vast cultural differences.

PIP: This article reviews the literature on various aspects of violence against children and adolescents in middle- and low-income countries to reveal the epidemiology and public health consequences and offer recommendations. The first section of the article, on the maltreatment of children, considers how child rearing, discipline, and punishment practices differ in different cultures and then focuses on 1) child maltreatment by intentional injuries such as culturally sanctioned burning and cutting and 2) infanticide. The chapter continues with a look at studies of the epidemiology of child sexual abuse and at the practice of female genital mutilation. The next topics examined are child and adolescent homicide and assault and adolescent suicide, all of which are shown to be on the increase. Finally, the effects of wars, displacement, and ethnic cleansing as well as of land mines and other unexploded lethal weapons are reviewed. It is concluded that health practitioners should oppose all forms of violence and should apply a public health, population-level approach to efforts to prevent and control violence. Health practitioners should espouse the view that the safety of each child and adolescent is the responsibility of all.

An evaluation of sensitivity and specificity of blood alcohol concentrations obtained by a breathalyser survey in a casualty department in Kenya.

Whereas breathalysers have been shown to provide blood alcohol concentration (BAC) measurements comparable to those obtained by gas chromatography, such evidence has not been reported in low and middle income countries where measures for preventing alcohol-related injuries are virtually non-existent. Before promoting any method of blood alcohol evaluation, as a routine procedure for monitoring the association of alcohol with different types of injuries in Kenya, we sought to assess the reliability and validity of blood alcohol results obtained by a breathalyser, using gas chromatography analysis values as the reference, in a sample of 179 trauma-affected adults presenting to casualty departments. No differences in proportions of subjects with high levels of blood alcohol (equal to or greater than 50 mg%) were detected by breath and blood test procedures (58.7 vs 60.3%). Breathalyser readings yielded high levels of sensitivity and specificity (97.2 and 100%, respectively) with optimal positive and negative predictive values (100 and 95.9%, respectively) at higher BACs (> or = 50 mg%). The study thus reaffirms that breathalyser tests are of value in detecting high blood alcohol levels and can be used to rapidly identify intoxicated subjects. The procedure is easy to perform and can be used for monitoring the association between blood alcohol level and driving in low-income developing countries.

Drinking and driving in an urban setting in Kenya.

A roadside alcohol prevalence survey of drivers randomly selected from the general traffic was conducted in Eldoret, Kenya. Blood alcohol concentration (BAC) data obtained by a breath test in 90% of the sample (n = 479) was analysed by demographic and travel characteristics. 19.9% had a positive breath test (BAC > or = 5 mg%), 8.4% had BACs greater than 50 mg%, and 4% exceeded 80 mg%. A greater proportion of males (20%) had been drinking compared to females (12.5%): all drivers with high BACs (> or = 50 mg%) were males. The likelihood of having consumed alcohol was greater in motorists aged 25 years and above (20.4%) than in younger drivers aged 16-24 years (15.4%), their mean BACs were also more elevated (57 mg% versus 31 mg%). In comparison to operators of public service vehicles (PSV), people driving personal cars were more than twice as likely to have been drinking: with 21.9% being BAC positive against 10.8% (OR = 2.3; 95% CI, 1.0 to 6.3, p = 0.05). Educated individuals with skilled careers tended to indulge in drink-driving to a greater extent than professional drivers (operators of public transport, taxi and heavy goods vehicles), with BAC prevalence rates of 23.7% and 15.5%, respectively. Other circumstances influencing the probability of drink-driving were number of vehicle occupants, distance to destination, road location, time of the night and whether it was a weekend or weekday. These findings are discussed in relation to the potential for promotion of relevant deterrent measures, including the establishment of an appropriate BAC legal limit for drivers in Kenya.

Differences in public and private health services in a rural district of Malaysia.

A cross-sectional study, comparing the nature of services in 15 private clinics and 6 public health facilities, was undertaken in a rural district of Malaysia. Semi-structured interviews and observations using check-lists were employed. Public health facilities were run by younger doctors (mean age = 31.1 years), supported mostly by trained staff. The private clinics were run by older doctors (mean age = 41.2 years) who had served the district for much longer (8.9 years vs 1.5 years) but were supported by less well trained staff. The curative services were the main strength of the private clinics but their provision of preventive care was less comprehensive and of inferior quality. Private clinics were inclined to provide more expensive diagnostic services than the public facilities. 'Short hours' private clinics had very restricted opening hours and offered limited range of services.

Who tells and what happens: disclosure and health service responses to screening for intimate partner violence.

Routine screening of women for intimate partner violence (IPV) has been introduced in many health settings to improve identification and responsiveness to hidden abuse. This cross-sectional study aimed to understand more about how women use screening programmes to disclose and access information and services. It follows women screened in ten Australian health care settings, covering antenatal, drug and alcohol and mental health services. Two samples of women were surveyed between March 2007 and July 2008; those who reported abuse during screening 6 months previously (122) and those who did not report abuse at that time (241). Twenty-three per cent (27/120) of women who reported abuse on screening were revealing this for the first time to any other person. Of those who screened negative, 14% (34/240) had experienced recent or current abuse, but chose not to disclose this when screened. The main reasons for not telling were: not considering the abuse serious enough, fear of the offender finding out and not feeling comfortable with the health worker. Just over half of both the positive and negative screened groups received written information about IPV and 35% of the positive group accessed further services. The findings highlight the fact that much abuse remains hidden and that active efforts are required to make it possible for women to talk about their experiences and seek help. Screening programmes, particularly those with established protocols for asking and referral, offer opportunities for women to disclose abuse and receive further intervention.