Feasibility of delivering foot and ankle surgical courses in a partnership in Eastern, Central and Sothern Africa.

BACKGROUND: Foot and ankle pathology if not treated appropriately and in a timely manner can adversely affect both disability and quality adjusted life years. More so in the low- and middle-income countries where ambulation is the predominant means of getting around for the majority of the population in order to earn a livelihood. This has necessitated the equipping of the new generation of orthopaedic surgeons with the expertise and skills set to manage these conditions. To address this need, surgeons from the British Orthopaedic Foot & Ankle Society (BOFAS) and College of Surgeons of Eastern, Central and Southern Africa (COSECSA) transferred the "Principles of Foot and Ankle Surgery" course to an African regional setting. The course was offered to surgical trainees from 14-member countries of the COSECSA region and previously in the UK. The faculty was drawn from practicing surgeons experienced in both surgical education and foot and ankle surgery. The course comprises didactic lectures, case-based discussions in small groups, patient evaluations and guided surgical dissections on human cadavers. It was offered free to all participants. The feasibility of the course was evaluated using the model defined by Bowen considering the eight facets of acceptability, demand, implementation, practicality, adaptation, integration, expansion and limited efficacy. At the end of the course participants were expected to give verbal subjective feedback and objective feedback using a cloud based digital feedback questionnaire. The course content was evaluated by the participants as "Poor", "Below average", "Average", "Good" and "Excellent", which was converted into a value from 1-5 for analysis. The non-parametric categorical data was analysed using the Two-sample Wilcoxon rank-sum (Mann-Whitney) test, and significance was considered to be p < 0.05. RESULTS: Six courses in total were held between 2018 and 2020. Three in the UK and three in the COSECSA region. There were 78 participants in the three UK courses and 96 in the three courses run in the COSECSA region. Hundred percent of the UK participants and 97% of the COSECSA participants completed the feedback. Male to female ratio was 4:1 for the UK courses and 10:1 for the COSECSA Courses. In both regions all the participants responded that they would recommend the course to their colleagues. Among the COSECSA participants 91% reported that the course was pitched at the right level, which is similar to the 89% of the UK participants (p = 0.28). CONCLUSION: The BOFAS Principles of Foot and Ankle Surgery course design provides core knowledge, with an emphasis on clinical examination techniques of the foot and ankle, while at the same time, caters for the anticipated difference in the local clinical case mix and resources. This study establishes that by attending the course surgical trainees can achieve their learning goals in foot and ankle surgery with the same high quality qualitative and quantitative feedback in both regions. This would improve their clinical practice and confidence. The multifaceted approach adopted in this course blending didactic teaching, small group discussions, interactive sessions, case-based discussions, cadaveric surgical skills training printed educational materials and feedback helped fulfil these educational objectives. Working in partnership with local expert orthopaedic surgeons from a number of Sub-Saharan countries, was key to adapting the course to local pathology and the COSECSA setting.

Water Sensitive Cities Index: A diagnostic tool to assess water sensitivity and guide management actions.

Cities are wrestling with the practical challenges of transitioning urban water services to become water sensitive; capable of enhancing liveability, sustainability, resilience and productivity in the face of climate change, rapid urbanisation, degraded ecosystems and ageing infrastructure. Indicators can be valuable for guiding actions for improvement, but there is not yet an established index that measures the full suite of attributes that constitute water sensitive performance. This paper therefore presents the Water Sensitive Cities (WSC) Index, a new benchmarking and diagnostic tool to assess the water sensitivity of a municipal or metropolitan city, set aspirational targets and inform management responses to improve water sensitive practices. Its 34 indicators are organised into seven goals: ensure good water sensitive governance, increase community capital, achieve equity of essential services, improve productivity and resource efficiency, improve ecological health, ensure quality urban spaces, and promote adaptive infrastructure. The WSC Index design as a quantitative framework based on qualitative rating descriptions and a participatory assessment methodology enables local contextual interpretations of the indicators, while maintaining a robust universal framework for city comparison and benchmarking. The paper demonstrates its application on three illustrative cases. Rapid uptake of the WSC Index in Australia highlights its value in helping stakeholders develop collective commitment and evidence-based priorities for action to accelerate their city's water sensitive transition. Early testing in cities in Asia and the Pacific has also showed the potential of the WSC Index internationally.

Water Sensitive Cities Index: A diagnostic tool to assess water sensitivity and guide management actions.

Cities are wrestling with the practical challenges of transitioning urban water services to become water sensitive; capable of enhancing liveability, sustainability, resilience and productivity in the face of climate change, rapid urbanisation, degraded ecosystems and ageing infrastructure. Indicators can be valuable for guiding actions for improvement, but there is not yet an established index that measures the full suite of attributes that constitute water sensitive performance. This paper therefore presents the Water Sensitive Cities (WSC) Index, a new benchmarking and diagnostic tool to assess the water sensitivity of a municipal or metropolitan city, set aspirational targets and inform management responses to improve water sensitive practices. Its 34 indicators are organised into seven goals: ensure good water sensitive governance, increase community capital, achieve equity of essential services, improve productivity and resource efficiency, improve ecological health, ensure quality urban spaces, and promote adaptive infrastructure. The WSC Index design is a quantitative framework based on qualitative rating descriptions and a participatory assessment methodology, enabling local contextual interpretations of the indicators while maintaining a robust universal framework for city comparison and benchmarking. The paper demonstrates its application on three illustrative cases. Rapid uptake of the WSC Index in Australia highlights its value in helping stakeholders develop collective commitment and evidence-based priorities for action to accelerate their city's water sensitive transition. Early testing in cities in Asia, the Pacific and South Africa has also showed the potential of the WSC Index internationally.

Modelling transitions in urban water systems.

Long term planning of urban water infrastructure requires acknowledgement that transitions in the water system are driven by changes in the urban environment, as well as societal dynamics. Inherent to the complexity of these underlying processes is that the dynamics of a system's evolution cannot be explained by linear cause-effect relationships and cannot be predicted under narrow sets of assumptions. Planning therefore needs to consider the functional behaviour and performance of integrated flexible infrastructure systems under a wide range of future conditions. This paper presents the first step towards a new generation of integrated planning tools that take such an exploratory planning approach. The spatially explicit model, denoted DAnCE4Water, integrates urban development patterns, water infrastructure changes and the dynamics of socio-institutional changes. While the individual components of the DAnCE4Water model (i.e. modules for simulation of urban development, societal dynamics and evolution/performance of water infrastructure) have been developed elsewhere, this paper presents their integration into a single model. We explain the modelling framework of DAnCE4Water, its potential utility and its software implementation. The integrated model is validated for the case study of an urban catchment located in Melbourne, Australia.

Towards water sensitive cities in Asia: an interdisciplinary journey.

Rapid urbanisation, population growth and the effects of climate change drive the need for sustainable urban water management (SUWM) in Asian cities. The complexity of this challenge calls for the integration of knowledge from different disciplines and collaborative approaches. This paper identifies key issues and sets the stage for interdisciplinary research on SUWM in Asia. It reports on the initial stages of a SUWM research programme being undertaken at Monash University, Australia, and proposes a framework to guide the process of interdisciplinary research in urban water management. Three key themes are identified: (1) Technology and Innovation, (2) Urban Planning and Design, and (3) Governance and Society. Within these themes 12 research projects are being undertaken across Indonesia, China, India and Bangladesh. This outward-looking, interdisciplinary approach guides our research in an effort to transgress single-discipline solutions and contribute on-ground impact to SUWM practices in Asia.

The impact of the Major Trauma Network: will trauma units continue to treat complex foot and ankle injuries?

INTRODUCTION: April 1st 2012 saw the introduction of National Trauma Networks in England. The aim to optimise the management of major trauma. Patients with an ISS≥16 would be transferred to the regional Major Trauma Centre (level 1). Our premise was that trauma units (level 2) would no longer manage complex foot and ankle injuries thereby obviating the need for a foot and ankle specialist service. METHODS: Retrospective analysis of the epidemiology of foot and ankle injuries, using the Gloucestershire trauma database, from a trauma unit with a population of 750,000. Rates of open fractures, complex foot and ankle injuries and requirement for stabilisation with external fixation were reviewed before and after the introduction of the regional Trauma Network. Secondly, using the Trauma Audit & Research Network (TARN) database, all foot and ankle injuries triaged to the regional Major Trauma Centre (MTC) were reviewed. RESULTS: Incidence of open foot and ankle injuries was 2.9 per 100,000 per year. There were 5.1% open injuries before the network and 3.2% after (p>0.05). Frequency of complex foot and ankle injuries was 4.2% before and 7.5% after the network commenced, showing no significant change. There was no statistically significant change in the numbers of patients with complex foot and ankle injuries treated by application of external fixators. Analysis of TARN data revealed that only 18% of patients with foot and ankle injuries taken to the MTC had an ISS≥16. The majority of these patients were identified as requiring plastic surgical intervention for open fractures (69%) or were polytrauma patients (43%). Only 4.5% of patients had isolated, closed foot and ankle injuries. CONCLUSION: We found that at the trauma unit there was no decrease in the numbers of complex foot and ankle injuries, open fractures, or the applications of external fixators, following the introduction of the Trauma Network. These patients will continue to attend trauma units as they usually have an ISS<16. Our findings suggest that there is still a need for foot and ankle specialists at trauma units, in order to manage patients with complex foot and ankle injuries.

Enabling sustainable urban water management through governance experimentation.

A shift towards sustainable urban water management is widely advocated but poorly understood. There is a growing body of literature claiming that social learning is of high importance in restructuring conventional systems. In particular, governance experimentation, which explicitly aims for social learning, has been suggested as an approach for enabling the translation of sustainability ideas into practice. This type of experimentation requires a very different dynamic within societal relations and necessitates a changed role for professionals engaged in such a process. This empirically focused paper investigates a contemporary governance experiment, the Cooks River Sustainability Initiative, and determines its outcome in terms of enabling social learning for attaining sustainable water practice in an urban catchment. Drawing on the qualitative insights of the actors directly involved in this novel process, this paper provides evidence of changes in individual and collective understanding generated through diverse forms of social interaction. Furthermore, the research reveals perceived key-factors that foster and/or hamper the execution of this new form of experimentation, including project complexity, resource intensity and leadership. Overall, this paper highlights that, while implementation of governance experimentation in a conventional setting can be highly challenging, it can also be highly rewarding in terms of learning.

Realising sustainable urban water management: can social theory help?

It has been acknowledged, in Australia and beyond, that existing urban water systems and management lead to unsustainable outcomes. Therefore, our current socio-technical systems, consisting of institutions, structures and rules, which guide traditional urban water practices, need to change. If a change towards sustainable urban water management (SUWM) practices is to occur, a transformation of our established social-technical configuration that shapes the behaviour and decision making of actors is needed. While some constructive innovations that support this transformation have occurred, most innovations remain of a technical nature. These innovative projects do not manage to achieve the widespread social and institutional change needed for further diffusion and uptake of SUWM practices. Social theory, and its research, is increasingly being recognised as important in responding to the challenges associated with evolving to a more sustainable form of urban water management. This paper integrates three areas of social theories around change in order to provide a conceptual framework that can assist with socio-technical system change. This framework can be utilised by urban water practitioners in the design of interventions to stimulate transitions towards SUWM.

Transitioning to a waterways city: municipal context, capacity and commitment.

In Melbourne, Australia, the adoption of Water Sensitive Urban Design (WSUD) and the inclusion of best practice in new urban development has shifted the "drained city" of the 1960s toward an environmentally-oriented "waterways city" for the future. However, the "waterways city" is tenuous owing to the variable commitment of local municipalities to WSUD. This paper reports on the first phase of a social research project, which aims to secure a model of the waterways city by addressing the commitment and capacity deficits of local municipalities. Municipal commitment and capacity across three geographical areas in Melbourne are measured quantitatively using an innovative, comprehensive, and replicable assessment technique. The results show variability in municipal capacity and commitment across the areas, with a pronounced deficit in the rural-regional area. Consequently, intergovernmental attempts to normalise modes of integrated urban water management (such as WSUD) need to include innovative and flexible mechanisms that are responsive to the dynamics of municipal commitment and capacity. These principles have broader application to cities internationally where the management of urban stormwater is the shared responsibility of multiple governments.

Capacity attributes of future urban water management regimes: projections from Australian sustainability practitioners.

Transitioning to more sustainable urban water management is widely accepted as an essential societal objective. While there has been significant progress in developing technical solutions to the challenges faced, numerous barriers remain at the regime level, indicating that further investigation into the regime is required. This paper reports on a social research project aimed at identifying capacity attributes of a more sustainable urban water management regime. Attributes were identified for the administrative and regulatory framework, inter- and intra-organisational and individual regime spheres. Over 125 urban water practitioners specialising in sustainability in Sydney and Melbourne were interviewed to identify the attributes of a more sustainable regime. The attributes reveal that a sustainable urban water management regime emphasises learning, diverse policy tools and institutional arrangements, together with interaction among stakeholders and professional disciplines. The interaction is characterised by respect, trust and mutual understanding. The sustainable regime attributes are compared to the traditional regime and reveal that while progress has been made towards a sustainable regime, additional improvement is required. Attributes identified across multiple regime spheres indicate potential focus areas for capacity building programs or reform efforts to more effectively enable regime change towards sustainable urban water management.

The water sensitive city: principles for practice.

With the widespread realisation of the significance of climate change, urban communities are increasingly seeking to ensure resilience to future uncertainties in urban water supplies, yet change seems slow with many cities facing ongoing investment in the conventional approach. This is because transforming cities to more sustainable urban water cities, or to Water Sensitive Cities, requires a major overhaul of the hydro-social contract that underpins conventional approaches. This paper provides an overview of the emerging research and practice focused on system resilience and principles of sustainable urban water management Three key pillars that need to underpin the development and practice of a Water Sensitive City are proposed: (i) access to a diversity of water sources underpinned by a diversity of centralised and decentralised infrastructure; (ii) provision of ecosystem services for the built and natural environment; and (iii) socio-political capital for sustainability and water sensitive behaviours. While there is not one example in the world of a Water Sensitive City, there are cities that lead on distinct and varying attributes of the water sensitive approach and examples from Australia and Singapore are presented.

Exploring sustainable urban water governance: a case study of institutional capacity.

The sustainable urban water management system is likely to be characterised by complex and flexible governance arrangements, increased inter-organisational interaction and wide stakeholder participation, which contrasts significantly with the traditional approach. Recently there has been significant financial investment in urban water reform, however the reforms have not been as successful as anticipated and numerous institutional barriers remain. Understanding and assessing institutional capacity is central to addressing institutional impediments. Institutional capacity comprises individual, intra- and inter-organisational and external rules and incentives capacities. This paper reports on the first case study of a social research project that aims to develop an institutional capacity assessment framework. Empirical data from semi-structured interviews with 59 water industry experts in Sydney, Australia, and a broad literature survey were used. The key capacity attributes identified could form the basis of an institutional capacity assessment tool and reveal common and differing attributes across stakeholder groups which provide insight into stakeholder relations. Synthesis of the results revealed that intra- and inter-organisational capacities were facing particular challenges and should be explicitly addressed in reform, policy and capacity development initiatives.

Extreme events: being prepared for the pitfalls with progressing sustainable urban water management.

It is widely accepted that new, more sustainable approaches to urban water management are required if cities and ecosystems are to become resilient to the effects of growing urban populations and global warming. Climate change predictions show that it is likely that cities around the world will be subject to an increasing number of extreme and less predictable events including flooding and drought. Historical transition studies have shown that major events such as extremes can expedite the adoption of new practices by destabilising existing management regimes and opening up new windows of opportunity for change. Yet, they can also act to reinforce and further entrench old practices. This case study of two Australian cities responding to extreme water scarcity reveals that being unprepared for extremes can undermine progress towards sustainable outcomes. The results showed that despite evidence of significant progress towards sustainable urban water management in Brisbane and Melbourne, the extreme water scarcity acted to reinforce traditional practices at the expense of emerging sustainability niches. Drawing upon empirical research and transitions literature, recommendations are provided for developing institutional mechanisms that are able to respond proactively to extreme events and be a catalyst for SUWM when such opportunities for change arise.

Delivering sustainable urban water management: a review of the hurdles we face.

Sustainable urban water management (SUWM) requires an integrated, adaptive, coordinated and participatory approach. Current urban water policies are beginning to reflect this understanding yet the rhetoric is often not translated to implementation. Despite the 'new' philosophy, urban water management remains a complex and fragmented area relying on traditional, technical, linear management approaches. Despite widespread acknowledgement of the barriers to change, there has been little systematic review of what constitutes the scope of such barriers and how these should be addressed to advance SUWM. To better understand why implementation fails to occur beyond ad hoc project interventions, an extensive literature review of observed and studied barriers was conducted. Drawing on local, national and international literature from the field of integrated urban water management and other similar fields, 53 studies were assessed, resulting in a typology of 12 barrier types. The analysis revealed the barriers are largely socio-institutional rather than technical, reflecting issues related to community, resources, responsibility, knowledge, vision, commitment and coordination. Furthermore, the meta-analysis demonstrated a paucity of targeted strategies for overcoming the stated institutional barriers. Evaluation of the typology in relation to capacity building suggests that these systemic issues require a sophisticated programme of change that focuses on fostering social capital, inter-sectoral professional development, and inter-organisational coordination.

Urban water management in cities: historical, current and future regimes.

Drawing from three phases of a social research programme between 2002 and 2008, this paper proposes a framework for underpinning the development of urban water transitions policy and city-scale benchmarking at the macro scale. Through detailed historical, contemporary and futures research involving Australian cities, a transitions framework is proposed, presenting a typology of six city states, namely the 'Water Supply City', the 'Sewered City', the 'Drained City', the 'Waterways City', the 'Water Cycle City', and the 'Water Sensitive City'. This framework recognises the temporal, ideological and technological contexts that cities transition through when moving towards sustainable urban water conditions. The aim of this research is to assist urban water managers with understanding the scope of the hydro-social contracts currently operating across cities in order to determine the capacity development and cultural reform initiatives needed to effectively expedite the transition to more sustainable water management and ultimately to Water Sensitive Cities. One of the values of this framework is that it can be used by strategists and policy makers as a heuristic device and/or the basis for a future city state benchmarking tool. From a research perspective it can be an underpinning framework for future work on transitions policy research.

Challenges ahead: social and institutional factors influencing sustainable urban stormwater management in Australia.

In a time of climate uncertainty and drought in Australia, improved urban stormwater quality management practices are required not only for protecting waterway health, but also as a fit-for-purpose supply source. To conceive of urban stormwater as an environmental threat as well as a water supply source requires a substantial shift in our traditional linear supply and wastewater structures towards more hybrid and complex infrastructure systems. To understand what drives and limits treatment technology adoption for stormwater management, over 800 urban water professionals in three Australian capital cities completed an online questionnaire survey in November 2006. Using the conceptual framework of receptivity assessment, the results revealed the professional community to be highly associated with the importance of improving stormwater quality for receiving waterway health, yet they do not consider that politicians share this perspective by placing a substantially lower level of importance on stormwater quality management. Significant acquisition barriers within each city, including institutional arrangements, costs, responsibilities, and regulations and approvals processes were all identified as constraining more sustainable practices. Capacity building programs, fostering greater socio-political capital and developing key demonstration projects with training events are recommended as useful policy interventions for addressing current institutional impediments.

Understanding community receptivity to water re-use: Ku-ring-gai Council case study.

This social research project investigated community receptivity to using rainwater and greywater as alternative domestic water sources. It was focused in the Ku-ring-gai local government area in northern Sydney, and involved a household questionnaire followed by community leader interviews and resident focus groups. Trends, such as a prolonged drought and increasing population, compound the current crisis and concern facing Sydney's available water supply. Substitution of domestic potable water has been promoted as part of the solution. The research results revealed that community receptivity was highest for external uses, such as watering gardens and flushing toilets, and progressively decreased with increasing personal contact. Receptivity to greywater reuse fell more rapidly with the community believing there was a higher health risk associated with its use. Gender and cultural background were revealed as significant variables and give insight into the design of strategies to target these demographic groups. This evidence provides a reliable stocktake of current receptivity revealing that the community has good awareness and positive association with water reuse for many household activities. This now needs to be harnessed through programs targeted at developing skills, resources and motivation for new water reuse practices and technologies across diverse social groupings.

Slipped capital femoral epiphysis.

Slipped capital femoral epiphysis is a condition likely to be encountered by all practising orthopaedic surgeons. A sound knowledge of the risk factors, presentation, investigation and management is essential to prevent the potentially significant consequences of missing the diagnosis. We present an overview of the condition, along with a review of the relevant literature to date.

Implementation impediments to institutionalising the practice of sustainable urban water management.

It is now well accepted that there are significant challenges to realising the widespread and self-sustaining implementation of sustainable urban water management. It is argued that these challenges are entrenched within the broader socio-political framework, yet often unsuccessfully addressed within the more narrow scope of improving technical knowledge and design capacity. This hypothesis is investigated through a comparative analysis of three independent research projects investigating different dimensions of the water cycle, including stormwater management in Australia and sanitary waste management and implementation of innovative technologies in the U.K. The analysis reveals significant and common socio-political impediments to improved practice. It was evident that the administrative regime, including implementing professionals and institutions, appears to be largely driven by an implicit expectation that there is a technical solution to solve water management issues. This is in contrast to addressing the issues through broader strategies such as political leadership, institutional reform and social change. It is recognised that this technocratic culture is inadvertently underpinned by the need to demonstrate implementation success within short-term political cycles that conflict with both urban renewal and ecological cycles. Addressing this dilemma demands dedicated socio-technical research programs to enable the much needed shift towards a more sustainable regime.