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OBJECTIVES: Despite scientific evidence that confirms their effectiveness, use of vaccines and microbiological mass testing during the COVID-19 pandemic has been associated with social and moral controversies. In this commentary, it is suggested how such conflicts originating from moral/normative imperatives can be managed in infectious disease control. STUDY DESIGN: This was a commentary analysis. METHODS: A case example of scientific and public debate regarding infectious disease control and policy-making during the early pandemic response is first presented. The case is used to characterize how conflicts arising from moral constraints occurred during the COVID-19 pandemic. These features are thereafter used as a basis for outlining a strategy for moral conflict prevention and management. RESULTS: A challenge for infectious disease control throughout the pandemic was how to manage persuasive initiatives originating from social forces competing with science for influence. Purposively maneuvered information distributed through social media and internet websites could predispose population factions to contest legitimate (evidence and legally based) pandemic response measures. During the pandemic, fact-based criticism of professionals responsible for infectious disease control was mixed with a critique of their moral standards and intentions so as to diminish effectiveness and credibility. Such blending could be curtailed if infectious disease control professionals are made accountable for public health decisions made in the light of prevalent scientific evidence and legislation. CONCLUSIONS: If the infectious disease control community would embrace the international code of medical professional ethics, this would help to deal with moral conflicts, especially ones arising from external threats, in modern public health.
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COVID-19 , Enfermedades Transmisibles , Humanos , COVID-19/prevención & control , Pandemias/prevención & control , Ética Profesional , Principios Morales , Práctica de Salud PúblicaRESUMEN
Little is known about provision of medical services to adolescents prior to participating in international top-level sports. This study aimed to investigate experiences of medical service provision among high-level adolescent athletics (track and field) athletes from three continents. A thematic narrative analysis was applied to data collected from 14 athletes by semi-structured interviews. Although competing at the highest international level, these adolescent athletes had difficulties making sense of symptoms of ill health, especially on their own. With increasing exercise loads, the athletes' medical support needs had extended beyond the capacity of parents and local communities. As there was no organized transfer of the responsibility for medical support to sports organizations, the athletes often had to manage their health problems by themselves. There were major variations among the adolescent athletes with regards to medical service access and quality. The services used ranged from sophisticated computer-assisted biomechanical analyses to traditional healers. Decreased exercise load was the common sports injury treatment. The results of this study demonstrate how the ethical standards underpinning youth sports as well as the equal provision of medical services to adolescents are challenged across the world. Further research on health service provision to adolescent top-level athletes is warranted.
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Traumatismos en Atletas , Medicina Deportiva , Atletismo , Deportes Juveniles , Adolescente , Atletas , HumanosRESUMEN
During public emergencies, a door can open on the fundamental elements upon which a society's social order is built. The Covid-19 pandemic has opened such a door in societies worldwide. We outline in this commentary some of these social elements and how they may have influenced face mask use during the early stages of the pandemic. The purpose is to expand the perspective on mechanisms that are relevant to consider in pandemic response planning. Our look at these fundamental elements showed that latent aspects of the dominant culture and various symbolic meanings of behaviors can reduce adherence with public health recommendations if they are overlooked in the strategic health plans. We conclude that when policymakers decide non-pharmacological interventions during pandemics, they should take into account fundamental attitudes and beliefs that may influence population behavior. This will require paying attention to variations in things like culture and symbolic meanings of behavior.
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COVID-19 , Máscaras , Humanos , Pandemias/prevención & control , Salud Pública , SARS-CoV-2RESUMEN
BACKGROUND: The development of expertise in anaesthesia requires personal contact between a mentor and a learner. Because mentors often are experienced clinicians, they may find it difficult to understand the challenges novices face during their first months of clinical practice. As a result, novices' perspectives may be an important source of pedagogical information for the expert. The aim of this study was to explore novice and expert anaesthetists understanding of expertise in anaesthesia using qualitative methods. METHODS: Semi-structured interviews were conducted with 9 novice and 9 expert anaesthetists from a German University Hospital. Novices were included if they had between 3 and 6 months of clinical experience and experts were determined by peer assessment. Interviews were intended to answer the following research questions: What do novices think expertise entails and what do they think they will need to become an expert? What do experts think made them the expert person and how did that happen? How do both groups value evidence-based standards and how do they negotiate following written guidance with following one's experience? RESULTS: The clinical experience in both groups differed significantly (novices: 4.3 mean months vs. experts: 26.7 mean years; p < 0.001). Novices struggled with translating theoretical knowledge into action and found it difficult to talk about expertise. Experts no longer seem to remember being challenged as novice by the complexity of routine tasks. Both groups shared the understanding that the development of expertise was a socially embedded process. Novices assumed that written procedures were specific enough to address every clinical contingency whereas experts stated that rules and standards were essentially underspecified. For novices the challenge was less to familiarise oneself with written standards than to learn the unwritten, quasi-normative rules of their supervising consultant(s). Novices conceptualized decision making as a rational, linear process whereas experts added to this understanding of tacit knowledge and intuitive decision making. CONCLUSIONS: Major qualitative differences between a novice and an expert anaesthetist's understanding of expertise can create challenges during the first months of clinical training. Experts should be aware of the problems novices may have with negotiating evidence-based standards and quasi-normative rules.
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Anestesia , Anestesiología , Anestesistas , Humanos , Aprendizaje , Investigación CualitativaRESUMEN
Value-based purchasing is increasingly discussed in association with efforts to develop modern healthcare systems. These models are the most recent example of models derived from health economics research intended to reform collectively financed healthcare. Previous examples have ranged from creation of pseudo-markets to opening these markets for competition between publicly and privately owned enterprises. Most value-based purchasing models tend to ignore that health service provision in collectively financed settings is based on an insurance with political, social obligations attached that challenge the notion of free market and individualist premises which these models rest on. Central social issues related to healthcare in any modern complex society, such as inequality in service provision, can all too easily "disappear" in value-based reform efforts. Based on an analysis of Swedish policy development, we contend that management information systems need to be extended to allow routine monitoring of socioeconomic data when models such as value-based purchasing are introduced in collectively financed health services. The experiences from Sweden are important for health policy in Europe and other regions with collectively financed healthcare plans.
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Análisis de Datos , Atención a la Salud/economía , Política de Salud/economía , Disparidades en Atención de Salud/economía , Compra Basada en Calidad/economía , Atención a la Salud/métodos , Humanos , Suecia/epidemiologíaRESUMEN
OBJECTIVES: An estimated 7.4% of patients admitted to acute care facilities in Canada experience injury or death due to health care mishaps, and 38% of these events are deemed preventable. Commitment of executive leaders to a culture of safety is important for the reduction of risk to Canadian patients. The purpose of this study was to examine the safety climate from a leader's perspective in 2 Canadian acute care settings, with attention paid to high reliability organization (HRO) principles. METHODS: The Patient Safety Culture in Healthcare Organizations questionnaire was administered to leaders in 2 acute care hospitals in Ontario between June and January 2009. The primary outcome measures were senior leadership support for safety and supervisory leadership support for safety. Misalignment between the safety climate and HRO principles was defined as greater than 10% of respondents reporting problematic or neutral leadership support for safety. RESULTS: Of the 142 respondents (67% response rate), both medical/nursing leaders and tertiary care clinical leaders were significantly more likely than board/administrative leaders to report problematic/neutral responses. Overall, executive leadership perceptions of the safety climate were not aligned with HRO principles. CONCLUSIONS: The significant differences in response between board/administrative leaders and those involved in frontline patient care suggest that a weak safety culture exists in these 2 health care organizations. The cultivation of a stronger organizational safety culture, in alignment with HRO principles, could lead to lower rates of preventable mishaps and support risk identification and mitigation in perioperative settings.
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Centros Médicos Académicos , Actitud , Liderazgo , Errores Médicos , Cultura Organizacional , Seguridad del Paciente , Administración de la Seguridad , Actitud del Personal de Salud , Femenino , Humanos , Masculino , Persona de Mediana Edad , Ontario , Percepción , Reproducibilidad de los Resultados , Encuestas y CuestionariosRESUMEN
BACKGROUND: There is abundant global interest in using syndromic data from population-wide health information systems--referred to as eHealth resources--to improve infectious disease surveillance. Recently, the necessity for these systems to achieve two potentially conflicting requirements has been emphasized. First, they must be evidence-based; second, they must be adjusted for the diversity of populations, lifestyles, and environments. OBJECTIVE: The primary objective was to examine correlations between data from Google Flu Trends (GFT), computer-supported telenursing centers, health service websites, and influenza case rates during seasonal and pandemic influenza outbreaks. The secondary objective was to investigate associations between eHealth data, media coverage, and the interaction between circulating influenza strain(s) and the age-related population immunity. METHODS: An open cohort design was used for a five-year study in a Swedish county (population 427,000). Syndromic eHealth data were collected from GFT, telenursing call centers, and local health service website visits at page level. Data on mass media coverage of influenza was collected from the major regional newspaper. The performance of eHealth data in surveillance was measured by correlation effect size and time lag to clinically diagnosed influenza cases. RESULTS: Local media coverage data and influenza case rates showed correlations with large effect sizes only for the influenza A (A) pH1N1 outbreak in 2009 (r=.74, 95% CI .42-.90; P<.001) and the severe seasonal A H3N2 outbreak in 2011-2012 (r=.79, 95% CI .42-.93; P=.001), with media coverage preceding case rates with one week. Correlations between GFT and influenza case data showed large effect sizes for all outbreaks, the largest being the seasonal A H3N2 outbreak in 2008-2009 (r=.96, 95% CI .88-.99; P<.001). The preceding time lag decreased from two weeks during the first outbreaks to one week from the 2009 A pH1N1 pandemic. Telenursing data and influenza case data showed correlations with large effect sizes for all outbreaks after the seasonal B and A H1 outbreak in 2007-2008, with a time lag decreasing from two weeks for the seasonal A H3N2 outbreak in 2008-2009 (r=.95, 95% CI .82-.98; P<.001) to none for the A p H1N1 outbreak in 2009 (r=.84, 95% CI .62-.94; P<.001). Large effect sizes were also observed between website visits and influenza case data. CONCLUSIONS: Correlations between the eHealth data and influenza case rates in a Swedish county showed large effect sizes throughout a five-year period, while the time lag between signals in eHealth data and influenza rates changed. Further research is needed on analytic methods for adjusting eHealth surveillance systems to shifts in media coverage and to variations in age-group related immunity between virus strains. The results can be used to inform the development of alert-generating eHealth surveillance systems that can be subject for prospective evaluations in routine public health practice.
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Brotes de Enfermedades , Sistemas de Información en Salud , Gripe Humana/epidemiología , Internet , Vigilancia de la Población/métodos , Telemedicina , Adolescente , Adulto , Distribución por Edad , Anciano , Anciano de 80 o más Años , Preescolar , Estudios de Cohortes , Recolección de Datos , Humanos , Lactante , Subtipo H1N1 del Virus de la Influenza A , Subtipo H3N2 del Virus de la Influenza A , Medios de Comunicación de Masas , Persona de Mediana Edad , Motor de Búsqueda , Suecia/epidemiología , Adulto JovenRESUMEN
The concept of culture is now widely used by those who conduct research on safety and work-related injury outcomes. We argue that as the term has been applied by an increasingly diverse set of disciplines, its scope has broadened beyond how it was defined and intended for use by sociologists and anthropologists. As a result, this more inclusive concept has lost some of its precision and analytic power. We suggest that the utility of this "new" understanding of culture could be improved if researchers more clearly delineated the ideological - the socially constructed abstract systems of meaning, norms, beliefs and values (which we refer to as culture) - from concrete behaviors, social relations and other properties of workplaces (e.g., organizational structures) and of society itself. This may help researchers investigate how culture and social structures can affect safety and injury outcomes with increased analytic rigor. In addition, maintaining an analytical distinction between culture and other social factors can help intervention efforts better understand the target of the intervention and therefore may improve chances of both scientific and instrumental success.
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Accidentes de Trabajo/prevención & control , Salud Laboral , Cultura Organizacional , Administración de la Seguridad , Causalidad , Conductas Relacionadas con la Salud , Humanos , Modelos OrganizacionalesRESUMEN
The development of physiologic monitors has contributed to the decline in morbidity and mortality in patients undergoing anaesthesia. Diverse factors (physiologic, technical, historical and medico-legal) create challenges for monitor alarm designers. Indeed, a growing body of literature suggests that alarms function sub-optimally in supporting the human operator. Despite existing technology that could allow more appropriate design, most anaesthesia alarms still operate on simple, pre-set thresholds. Arguing that more alarms do not necessarily make for safer alarms is difficult in a litigious medico-legal environment and a competitive marketplace. The resultant commitment to the status quo exposes the risks that a lack of an evidence-based theoretical framework for anaesthesia alarm design presents. In this review, two specific theoretical foundations with relevance to anaesthesia alarms are summarised. The potential significance that signal detection theory and cognitive systems engineering could have in improving anaesthesia alarm design is outlined and future research directions are suggested. PRACTITIONER SUMMARY: The development of physiologic monitors has increased safety for patients undergoing anaesthesia. Evidence suggests that the full potential of the alarms embedded within those monitors is not being realised. In this review article, the authors propose a theoretical framework that could lead to the development of more ergonomic anaesthesia alarms.
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Anestesiología/instrumentación , Alarmas Clínicas , Monitoreo Fisiológico/instrumentación , Diseño de Equipo , Ergonomía , Humanos , Seguridad del PacienteRESUMEN
BACKGROUND: This study identifies a promising, new focus for the crisis management research in the health care domain. After reviewing the literature on health care crisis management, there seems to be a knowledge-gap regarding organisational change and adaption, especially when health care situations goes from normal, to non-normal, to pathological and further into a state of emergency or crisis. DISCUSSION: Based on studies of escalating situations in obstetric care it is suggested that two theoretical perspectives (contingency theory and the idea of failure as a result of incomplete interaction) tend to simplify the issue of escalation rather than attend to its complexities (including the various power relations among the stakeholders involved). However studying the process of escalation as inherently complex and social allows us to see the definition of a situation as normal or non-normal as an exercise of power in itself, rather than representing a putatively correct response to a particular emergency. IMPLICATIONS: The concept of escalation, when treated this way, can help us further the analysis of clinical and institutional acts and competence. It can also turn our attention to some important elements in a class of social phenomenon, crises and emergencies, that so far have not received the attention they deserve. Focusing on organisational choreography, that interplay of potential factors such as power, professional identity, organisational accountability, and experience, is not only a promising focus for future naturalistic research but also for developing more pragmatic strategies that can enhance organisational coordination and response in complex events.
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Urgencias Médicas , Servicios Médicos de Urgencia/organización & administración , Investigación sobre Servicios de Salud , Humanos , Modelos Teóricos , Administración de PersonalRESUMEN
Social medicine deals with the interplay between medicine and society. An awareness of how analytical categories have emerged historically can strengthen the role the discipline can play in the societal reinventions of health care now under way around the world. This study examines the categories that informed social medicine in Sweden during the 20th century. An anthropological field study was conducted over a 12-year period in a Swedish academic clinical setting. Historical documents were used to link local-level issues with macro-level (here, national and European) contexts. Social medicine, modernity, and social democracy were found to share a common history and a common vision of what society should be. As a result, concepts from politics, ideology, economy, and science tended to be conflated. As a clinician at the study site explained, "samhälle [community] is both society and state". The consequence for social medicine is that culture has become neglected as an analytical category. This institutional amnesia has strongly influenced how 21st century social medicine, in this region of the world, has defined itself and its interests. To return a cultural perspective to social medicine, a critical distance must be kept between the analyses the discipline undertakes and the prevailing societal ideologies.
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Cultura , Reforma de la Atención de Salud/organización & administración , Política de Salud , Política , Medicina Social , Humanos , SueciaRESUMEN
BACKGROUND: Advanced technical systems and analytic methods promise to provide policy makers with information to help them recognize the consequences of alternative courses of action during pandemics. Evaluations still show that response programs are insufficiently supported by information systems. This paper sets out to derive a protocol for implementation of integrated information infrastructures supporting regional and local pandemic response programs at the stage(s) when the outbreak no longer can be contained at its source. METHODS: Nominal group methods for reaching consensus on complex problems were used to transform requirements data obtained from international experts into an implementation protocol. The analysis was performed in a cyclical process in which the experts first individually provided input to working documents and then discussed them in conferences calls. Argument-based representation in design patterns was used to define the protocol at technical, system, and pandemic evidence levels. RESULTS: The Protocol for a Standardized information infrastructure for Pandemic and Emerging infectious disease Response (PROSPER) outlines the implementation of information infrastructure aligned with pandemic response programs. The protocol covers analyses of the community at risk, the response processes, and response impacts. For each of these, the protocol outlines the implementation of a supporting information infrastructure in hierarchical patterns ranging from technical components and system functions to pandemic evidence production. CONCLUSIONS: The PROSPER protocol provides guidelines for implementation of an information infrastructure for pandemic response programs both in settings where sophisticated health information systems already are used and in developing communities where there is limited access to financial and technical resources. The protocol is based on a generic health service model and its functions are adjusted for community-level analyses of outbreak detection and progress, and response program effectiveness. Scientifically grounded reporting principles need to be established for interpretation of information derived from outbreak detection algorithms and predictive modeling.
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Enfermedades Transmisibles/epidemiología , Implementación de Plan de Salud/métodos , Sistemas de Información , Pandemias/prevención & control , Humanos , Bases del Conocimiento , Evaluación de Necesidades , Vigilancia de la Población , Evaluación de Programas y Proyectos de Salud , Estándares de ReferenciaRESUMEN
The global spread of a novel A (H1N1) influenza virus in 2009 has highlighted the possibility of a devastating pandemic similar to the 'Spanish flu' of 1917-1918. Responding to such pandemics requires careful planning for the early phases where there is no availability of pandemic vaccine. We set out to compute a Neighborhood Influenza Susceptibility Index (NISI) describing the vulnerability of local communities of different geo-socio-physical structure to a pandemic influenza outbreak. We used a spatially explicit geo-physical model of Linköping municipality (pop. 136,240) in Sweden, and employed an ontology-modeling tool to define simulation models and transmission settings. We found considerable differences in NISI between neighborhoods corresponding to primary care areas with regard to early progress of the outbreak, as well as in terms of the total accumulated share of infected residents counted after the outbreak. The NISI can be used in local preparations of physical response measures during pandemics.
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Subtipo H1N1 del Virus de la Influenza A , Gripe Humana , Brotes de Enfermedades , Hispánicos o Latinos , Humanos , Gripe Humana/epidemiología , Pandemias , Atención Primaria de SaludRESUMEN
OBJECTIVE: To examine the validity and usefulness of pandemic simulations aimed at informing practical decision-making in public health. METHODS: We recruited a multidisciplinary group of nine experts to assess a case-study simulation of influenza transmission in a Swedish county. We used a non-statistical nominal group technique to generate evaluations of the plausibility, formal validity (verification) and predictive validity of the simulation. A health-effect assessment structure was used as a framework for data collection. FINDINGS: The unpredictability of social order during disasters was not adequately addressed by simulation methods; even minor disruptions of the social order may invalidate key infrastructural assumptions underpinning current pandemic simulation models. Further, a direct relationship between model flexibility and computation time was noted. Consequently, simulation methods cannot, in practice, support integrated modifications of microbiological, epidemiological and spatial submodels or handle multiple parallel scenarios. CONCLUSION: The combination of incomplete surveillance data and simulation methods that neglect social dynamics limits the ability of national public health agencies to provide policy-makers and the general public with the critical and timely information needed during a pandemic.
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Brotes de Enfermedades , Planificación en Salud/métodos , Política de Salud , Gripe Humana/epidemiología , Salud Pública/métodos , Antivirales/provisión & distribución , Antivirales/uso terapéutico , Simulación por Computador , Humanos , Gripe Humana/tratamiento farmacológico , Reproducibilidad de los Resultados , Suecia/epidemiologíaRESUMEN
OBJECTIVE: The aim of this study was to investigate how the clinical use of visualization technology can be advanced by the application of a situated cognition perspective. METHODS AND MATERIALS: The data were collected in the GammaKnife radiosurgery setting and analyzed using qualitative methods. Observations and in-depth interviews with neurosurgeons and physicists were performed at three clinics using the Leksell GammaKnife. RESULT: The users' ability to perform cognitive tasks was found to be reduced each time visualizations incongruent with the particular user's perception of clinical reality were used. The main issue here was a lack of transparency, i.e. a black box problem where machine representations "stood between" users and the cognitive tasks they wanted to perform. For neurosurgeons, transparency meant their previous experience from traditional surgery could be applied, i.e. that they were not forced to perform additional cognitive work. From the view of the physicists, on the other hand, the concept of transparency was associated with mathematical precision and avoiding creating a cognitive distance between basic patient data and what is experienced as clinical reality. The physicists approached clinical visualization technology as though it was a laboratory apparatus--one that required continual adjustment and assessment in order to "capture" a quantitative clinical reality. CONCLUSION: Designers of visualization technology need to compare the cognitive interpretations generated by the new visualization systems to conceptions generated during "traditional" clinical work. This means that the viewpoint of different clinical user groups involved in a given clinical task would have to be taken into account as well. A way forward would be to acknowledge that visualization is a socio-cognitive function that has practice-based antecedents and consequences, and to reconsider what analytical and scientific challenges this presents us with.
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Cognición , Radiocirugia , Planificación de la Radioterapia Asistida por Computador , HumanosRESUMEN
This study investigates the use of 3D representation and haptic technology in radiosurgery. The users, experienced users of the Leksell GammaKnife, prefer the 3D representation for constructing a first draft of their plan for neurosurgical intervention. When it comes to the final adjustments, however, they still choose the traditional 2D representation and interaction devices. The perceived control over the radiosurgical process is not considered adequate using the 3D interaction methods. Practitioners do not consider the haptic forces implemented in this test system useful. Possible explanations for these findings are discussed in the paper.
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Imagenología Tridimensional , Radiocirugia , Humanos , Imagen por Resonancia Magnética , Informática MédicaRESUMEN
In this study we investigated safety-related usability issues of an advanced medical technology, a radiosurgery system. We were interested in which criteria are important for users when a system's usability and safety is to be improved. The data collection was based on interviews and observations at three different sites where the Leksell GammaKnife is used. The analysis was qualitative. The main finding was that the user's identity or professional background has a significant impact both on how he or she views his or her role in the clinical setting, and on how he or she defines what improvements are necessary and general safety issues. In fact, the opinion even of users experienced in safety-related problems was highly influenced by how they related to the technology and its development. None of the users actually considered Leksell GammaKnife as lacking in safety, instead, their assessment was directed towards potential future system improvements. Our findings suggest that the importance of user identity or professional background cannot be neglected during the development of advanced technology. They also suggest that the user feedback should always be related to user background and identity in order to understand how important different issues are for particular users.