What do the narratives tell us? Exploring the implementation of the Athena SWAN Ireland Charter.

Due to the systemic inequalities enduring in career progression pathways in the Irish higher education sector, the Athena SWAN Ireland Charter (ASIC), a gender equality accreditation program, is being implemented. Using a theoretical approach, blending insights from feminist institutionalism with literature on the role of narratives in policy implementation, this article reveals the complex nature of subjective engagement with policy implementation processes. This article discusses an empirical study of Athena SWAN Ireland Charter implementation across three purposively chosen Irish universities, interviewing 26 key institutional actors tasked with implementing the ASIC locally. Narrative themes emerging as dominant from the data include a lack of operational knowledge, desire for a nationally contextualized program, ambiguity, championing, "happy talk," and identifying points of resistance. Literature on the role of narrative accounts highlighting a diversity of perceptions in policy and program implementation is strengthened by this study's findings. A feminist institutionalist lens highlight the gendered nature of the operationalization of the Charter work and the vague and detached "happy talk" engaged predominantly by senior men leaders. Findings from this empirical study highlight the importance of exploring the narrative accounts of key actors in order to gain a holistic understanding of the nuanced implementation process, beyond the normative assumptions inherent in the Charter implementation.

'It sounds like a great idea but ': a qualitative study of GPs' attitudes towards the development of a national diabetes register.

OBJECTIVE: The aim of this study was to investigate the attitudes of general practitioners (GPs) to the development of a national diabetes register as a way of improving the quality of care. DESIGN: Qualitative study using semistructured interviews. SETTING: General practice, Ireland. PARTICIPANTS: Purposive sample of 29 GPs and two practice nurses. Participants' practices varied by (a) location (rural/urban), (b) size (single-handed/group practice) and (c) extent of computerisation. METHODS: The semistructured topic guide focused on experiences of change in the health system at a local and national level and attitudes towards the development of a national diabetes register. Analysis was conducted using the Framework approach. RESULTS: Participants were sceptical about the development of a national diabetes register. The main advantage was 'knowing the numbers' for epidemiological and policy purposes. However, participants questioned the benefits for their practice and patients. There were concerns that it would drain resources from other priorities and distract from patient management. These attitudes were strongly influenced by previous experience of change in the health system. Participants felt that remuneration would be necessary to ensure full engagement, reflecting wider frustrations with payment structures for general practice. There was a sense of wariness towards health service administration which was not specific to diabetes care but which coloured some participants' attitudes towards a national register. In contrast, participants referred to positive experiences of change at a local level, facilitated by a 'practice ethos' and professional leadership. CONCLUSIONS: This study highlights the growing sense of scepticism and inertia towards change within the health system. This inertia stems from previous experience and the competing demands of maintaining versus improving care in a system with dwindling resources.

Implementing the legal provisions for HIA in Slovakia: an exploration of practitioner perspectives.

BACKGROUND: Health Impact Assessment (HIA) is an instrument used in many countries across the world to assess and report on negative and positive health impacts of projects, programmes and policies. It was included in the Protection, Support and Development of Public Health Act (355/2007) of the Slovak Republic in 2007, thus legislating for HIA. Due to this novel move to legislate for HIA, exploratory research was conducted in order to inquire into the perceptions of key informants and practitioners of the upcoming enforcement of the HIA part of legislation (to take place from January 2011). This paper presents results from the survey of practitioners in the Slovak Regional Public Health Authorities. METHODS: A postal questionnaire was administered to the Heads of Environmental Health Departments of the 37 Regional Public Health Authorities. Open-ended questions were contained in the survey. The response rate was 38%. RESULTS: Results show that a number of respondents are uncertain as to how HIA would be implemented in practice, with varying views on the technical and institutional barriers to comprehensive implementation of HIA. CONCLUSION: Although the public hygiene and sanitation networks in the public health system in Slovakia operate smoothly, the readiness of the public health infrastructure for HIA, which is based broadly on the social model of health, is dubious. Although HIA is contained within legislation, time will tell whether its implementation in practice will be as comprehensive as is hoped. Recommendations for further integration of HIA into the public health system include further training and education, national HIA resource centres and cross-country support.

Differences in the structure of outpatient diabetes care between endocrinologist-led and general physician-led services.

BACKGROUND: Despite a shift in diabetes care internationally from secondary to primary care, diabetes care in the Republic of Ireland remains very hospital-based. Significant variation in the facilities and resources available to hospitals providing outpatient diabetes care have been reported in the UK. The aim of this study was to ascertain the structure of outpatient diabetes care in public hospitals in the Republic of Ireland and whether differences existed in services provided across hospitals. METHODS: We conducted a cross sectional observational study of the 36 public general hospitals providing adult outpatient diabetes care in the Republic of Ireland. Data relating to numbers of specialist medical, nursing and allied health professionals, waiting times for new and return patients, patterns of discharge back to primary care and engagement in quality improvement initiatives were recorded. RESULTS: Thirty-five of the 36 eligible hospitals participated in the study. Sixty percent of these had at least one consultant endocrinologist in post, otherwise care delivery was led by a general physician. Waiting times for newly diagnosed patients exceeded six months in 30% of hospitals and this was higher where an endocrinologist was in place (47% V 7%, p = 0.013). Endocrinologists were more likely to have developed subspecialty clinics, access to allied health professionals and engage more in quality improvement initiatives but less likely to discharge patients back to primary care than general physicians (76 v 29%, p = 0.005). CONCLUSIONS: Variations exist in the structure and provision of diabetes care in Irish hospitals. Endocrinology-led services have more developed subspecialty structures and access to specialist allied health professionals and engage more in quality improvement initiatives. Nonetheless, waiting times are longer and discharge rates to primary care are lower than for non-specialty led services. Further studies to determine the extent to which case-mix variation accounts for these observations are warranted. Aspects of hospital-based outpatient care could be developed further to ensure equitable services are provided nationally. At a time when the delivery of diabetes services in primary care is being promoted, further research is warranted on the factors influencing the successful transition to primary care.

Trends in age-adjusted coronary heart disease mortality rates in Slovakia between 1993 and 2009.

Cardiovascular diseases (CVD) and especially coronary heart disease (CHD) are the main causes of death in the Slovak Republic (SR). The aim of this study is to explore trends in age-adjusted coronary heart disease mortality rates in the whole Slovak population and in the population of working age between the years 1993 and 2009. A related indicator - potential years of life lost (PYLL) due to CHD--was calculated in the same period for males and females. Crude CHD mortality rates were age-adjusted using European standard population. The joinpoint Poisson regression was performed in order to find out the annual percentage change in trends. The age-adjusted CHD mortality rates decreased in the Slovak population and also in the population of working age. The change was significant only within the working-age sub-group. We found that partial diagnoses (myocardial infarction and chronic ischaemic heart disease) developed in the mirror-like manner. PYLL per 100,000 decreased during the observed period and the decline was more prominent in males. For further research we recommend to focus on several other issues, namely, to examine the validity of cause of death codes, to examine the development of mortality rates in selected age groups, to find out the cause of differential development of mortality rates in the Slovak Republic in comparison with the Czech Republic and Poland, and to explain the causes of decrease of the age-adjusted CHD mortality rates in younger age groups in Slovakia.

Barriers to, and facilitators in, introducing integrated diabetes care in Ireland: a qualitative study of views in general practice.

OBJECTIVE: To examine the barriers to, and facilitators in, improving diabetes management from the general practice perspective, in advance of the implementation of an integrated model of care in Ireland. DESIGN: Qualitative using semistructured interviews. SETTING: Primary care in the Republic of Ireland. PARTICIPANTS: Purposive sample of 29 general practitioners (GPs) and two practice nurses. METHODS: Data were analysed using a framework approach. RESULTS: The main barriers and facilitators occurred at the level of the health system but had a ripple effect at an organisational, professional and patient level. The lack of targeted remuneration for diabetes management in the Irish health system created apathy in general practice and was perceived to be indicative of the lack of value placed on chronic disease management in the health system. There were 'pockets of interest' among GPs motivated by 'vocational' incentives such as a sense of professional duty; however, this was not sufficient to drive widespread improvement. The hospital service was seen as an essential support for primary care management, although some participants referred to emerging tension between settings. The lack of coordination at the primary-secondary interface resulted in avoidable duplication and an 'in the meantime' period of uncertainty around when patients would be called or recalled by specialist services. Facilitators included the availability of nursing support and serendipitous access to services. The lack of resources in the community was considered to be at odds with policy to shift routine management to general practice, which is fast reaching saturation. CONCLUSIONS: At present, intrinsic motivation is driving the improvement of diabetes care in Ireland. This will not be sufficient to implement the proposed reform including a national model of integrated care. Policymakers need to assess and prepare for the disparate levels of interest and infrastructure in primary care in Ireland to support this change.

Predictors of depression symptoms in patients with diabetes in Slovakia.

OBJECTIVE: The patterns of relationships between diabetes and depression in countries of central and eastern Europe (CEE) might differ from those in countries of western Europe and the United States. Among the reasons are specifics of transitioning healthcare systems (including mental health) and the general social, cultural, and economic background of these countries. The aim of this article is to analyze the prevalence of depression symptoms in patients with diabetes in Slovakia and to identify its predictors. METHOD: Diabetes patients (N= 1043) from two diabetes outpatient-care offices were recruited for the study. The Patient Health Questionnaire 9 (PHQ-9) was applied to screen for depression symptoms. Patients were categorized into four categories based on depression symptom severity. Demographic and disease-related factors were analyzed as predictors of depression symptoms. RESULTS: In the univariate analysis, a number of factors were associated with increasing severity of depression symptoms. In the multivariate analysis, lower education (OR 0.52; Cl 95% 0.33-0.81), and high degree of self-perceived severity of illness (OR 5.33; CI 95% 2.47-12.12) were confirmed as independent predictors of depression symptoms in our patients. CONCLUSIONS: Demographic and psychological factors have an important role in developing depression symptoms in patients with diabetes in our population. Further studies into the topic are needed to gain further clues on this topic throughout the Central European region. The findings of this study should be considered by mental health service providers and public health authorities to raise awareness about this important issue.

Informing the development of a national diabetes register in Ireland: a literature review of the impact of patient registration on diabetes care.

BACKGROUND: Research suggests that a structured approach to diabetes care can lead to improved patient outcomes. In order to enable greater organisation of care, an electronic patient registration system is required. As part of the development of a national disease register in Ireland, we conducted a review of literature relating to the impact of registration systems on processes and outcomes of care. OBJECTIVE: The aim of the review is to establish the impact of a registration system on patient care and clinical outcomes. The review explores the role played by a patient registration system, particularly in the primary care setting. METHODS: The literature review applied a search strategy to six identified databases. Included studies were those based on original research, including a patient registration system and published between 1999 and 2009 in the English language. Studies including only patients with type 2 diabetes or those with both type 1 and type 2 diabetes were included. Some papers did not specify which type of diabetes was included. FINDINGS: In interventions of structured care which used a patient registration system, modest results for clinical outcomes were demonstrated as well as significant improvements in the processes of care. A patient register was a necessary step along the path towards improved patient clinical outcomes, notably glycated haemoglobin (HbA1c), blood pressure and cholesterol measurements. CONCLUSIONS: This review suggested that registers are generally assumed to be an essential element of quality improvement interventions rather than an optional addition. A diabetes register is central to the development of a comprehensive diabetes management system in primary care, which can lead to improvements in the processes and outcomes of diabetes care.

Diabetes care in Ireland: a survey of general practitioners.

AIM: To investigate the organisation of diabetes care in general practice in Ireland and identify areas for future development. METHODS: Survey of a representative sample of 600 general practitioners (GPs). The questionnaire contained closed and open-ended questions addressing 4 topics; characteristics of the practice, diabetes care delivery, use of services and opportunities for developing diabetes care. RESULTS: The response rate was 44% (n=262). There were an additional 86 responses to a follow-up shortened version of the survey resulting in a 58% response rate for 9 key questions. The majority of respondents were from an urban (43%, n=112) or a mixed area (39%, n=101) and 19% of practices were single-handed (n=66). The reported prevalence in participating practices was 0.7% for Type 1 diabetes and 2.8% for Type 2 diabetes. Forty-five percent of GPs maintained a diabetes register (n=157) while 53% reported using guidelines (n=140). A formal call recall system was reported by 30% (n=78) with a further 20% (n=54) reporting a regular if informal approach to calling patients for review. With regard to the use of diabetes related services 63% reported direct access to a dietician (n=165), 57% direct access to chiropody services (n=149) and 89% had direct access to retinopathy screening (n=234). There was a significant association between maintaining a diabetes register and other aspects of care delivery such as engaging in formal recall (p<0.001), using guidelines (p<0.001) and a declared special interest in diabetes (p=0.001). Of a number of choices 75% of GPs thought that training was the principal opportunity for improving diabetes care. In response to the open-ended questions GPs cited lack of resources, time constraints and workload as barriers to effective care delivery. CONCLUSIONS: Delivery of diabetes care in Ireland remains largely unstructured. Key challenges to improving diabetes care appear to extend to the system and organisational level of care delivery.