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.

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.

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.

Placing ethics in the centre: negotiating new spaces for ethical research in conflict situations.

Issues of power and consent, confidentiality, trust, and benefit, risks to researchers, and potential harm to participants, are all contested when working with different cultures and within environments marked by violence and insecurity. Difficulty resolving these dilemmas may paralyse ethics committees, may fail to give the guidance sought by researchers, and will not help populations who are among the world's most vulnerable. Even where efforts are made to respond to ethical guidelines and to improve practice, considerable impediments are present in many developing countries, including lack of formal ethical review structures in unstable settings, lack of required skills, limited political and institutional recognition of ethical issues, competing interests, and limitations in clinical and research practice (Elsayed 2004, Macklin 2004). In conflict settings, these limitations are more marked, and the responsibilities of the researcher for ethical practice are greater, but the mechanisms for oversight are weaker. Moreover, the constant focus on vulnerabilities and problems, and the often almost total lack of recognition of strengths and resilience, can further disempower already exploited groups and individuals. The capacity of refugees and communities in conflict to take an active role in the research process is seldom acknowledged, and undermines the potential for more innovative research which can help generate the evidence for better policy and practice.

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.

Narrowing the gap between academic professional wisdom and community lay knowledge: perceptions from partnerships.

Community involvement in health through community partnerships (CPs) has been widely advocated. Putting CPs into practice is complex and represents a challenge for all the stakeholders involved in the change process. Employing data from five CPs aiming to bring together communities, academics and health service providers in South Africa, this paper aims to examine and compare the views of the health care professionals with those of the community members with respect to each other's skills and abilities. Five domains of expertise in partnership working are examined: educational competencies; partnership fostering skills; community involvement expertise; change agents proficiencies; and strategic and management capacities. The findings suggest that the community recognizes the expertise and abilities brought by the professional staff to the CPs. Community members have a positive view of the capabilities of the professionals, in particular their abilities as resource persons in the areas of budget management, policy formulation and the introduction and management of change. The professionals, on the other hand, are cautious regarding the level of skill and capability in communities. The limited appreciation of community skills by the professionals covered all the five domains of expertise examined. The findings suggest that if joint working is to survive, the professionals will need to increase their valuation of the indigenous proficiencies inherent in their community partners. We conclude that programme models need to consciously incorporate in their design and implementation, capacity building, skills transfer and empowerment strategies.

Health system reform and the role of field sites based upon demographic and health surveillance.

Field sites for demographic and health surveillance have made well-recognized contributions to the evaluation of new or untested interventions, largely through efficacy trials involving new technologies or the delivery of selected services, e.g. vaccines, oral rehydration therapy and alternative contraceptive methods. Their role in health system reform, whether national or international, has, however, proved considerably more limited. The present article explores the characteristics and defining features of such field sites in low-income and middle-income countries and argues that many currently active sites have a largely untapped potential for contributing substantially to national and subnational health development. Since the populations covered by these sites often correspond with the boundaries of districts or subdistricts, the strategic use of information generated by demographic surveillance can inform the decentralization efforts of national and provincial health authorities. Among the areas of particular importance are the following: making population-based information available and providing an information resource; evaluating programmes and interventions; and developing applications to policy and practice. The question is posed as to whether their potential contribution to health system reform justifies arguing for adaptations to these field sites and expanded investment in them.

PIP: This article explores the characteristics and defining features of demographic and health surveillance (DHS) field sites in low-income and middle-income countries, considers their value, and examines their advantages and limitations on issues of health sector reforms. It further argues that the field sites have untapped potential for contributing substantially to national and subnational health development. Field sites for DHS have made well-recognized contributions to the evaluation of new or untested interventions, largely through efficacy trials involving new technologies or the delivery of selected services such as vaccines, oral rehydration therapy, and alternative contraceptive methods. However, despite the contributions, their role in the national and international health system have been limited. DHS field sites, whether they were originally efficacy-oriented or effectiveness-oriented share a number of core features. The populations covered by DHS field sites often correspond with the boundaries of districts or subdistricts, the strategic use of information generated by demographic surveillance can inform the decentralization efforts of national and provincial health authorities. Among the areas of particular importance are the following: 1) making population-based information and providing information resource; 2) evaluating programs and interventions; and 3) developing applications to policy. Recommendations for the improvement of DHS role in the national and subnational levels are outlined.

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.

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.

Rehabilitating health services in Cambodia: the challenge of coordination in chronic political emergencies.

The end of the Cold War brought with it opportunities to resolve a number of conflicts around the world, including those in Angola, Cambodia, El Salvador and Mozambique. International political efforts to negotiate peace in these countries were accompanied by significant aid programmes ostensibly designed to redress the worst effects of conflict and to contribute to the consolidation of peace. Such periods of political transition, and associated aid inflows, constitute an opportunity to improve health services in countries whose health indicators have been among the worst in the world and where access to basic health services is significantly diminished by war. This paper analyzes the particular constraints to effective coordination of health sector aid in situations of 'post'-conflict transition. These include: the uncertain legitimacy and competence of state structures; donor choice of implementing channels; and actions by national and international political actors which served to undermine coordination mechanisms in order to further their respective agendas. These obstacles hindered efforts by health professionals to establish an effective coordination regime, for example, through NGO mapping and the establishment of aid coordinating committees at national and provincial levels. These technical measures were unable to address the basic constitutional question of who had the authority to determine the distribution of scarce resources during a period of transition in political authority. The peculiar difficulties of establishing effective coordination mechanisms are important to address if the long-term effectiveness of rehabilitation aid is to be enhanced.

PIP: This paper analyzes the context and process of health aid coordination in Cambodia between 1991 and 1993. It emphasizes on the relationship between national political actors and several international agencies that came to work in the country during that period. It also complements the experiences faced by Cambodia in this period and features two key issues. First, the political factors affecting the type of aid supplied to the country, and the way it was governed in the period during 1991-93. These structural, political factors constrained the scope for the health profession to build effective coordination mechanisms. Second, the limited capacity of coordination mechanisms to influence resource allocation did not correspond to the national health priorities. Overcoming the hardships will be dependent on using more organized strategies and appropriate aid instruments to support rehabilitation measures. And lastly, an evaluation of the implications for the other post-conflict settings was briefly discussed.

Women, health and humanitarian aid in conflict.

The burden of political conflict on civilian populations has increased significantly over the last few decades. Increasingly, the provision of resources and services to these populations is coming under scrutiny; we highlight here the limited attention to gender in their provision. Women and men have different exposures to situations that affect health and access to health-care and have differential power to influence decisions regarding the provision of health services. We argue that the role of women in planning is central to the provision of effective, efficient and sensitive health-care to conflict-affected populations.