Applications and Consequences of Transparency in the Health Systems: A Systematic Scoping Review

This scoping review aims to determine the size and scope of the published literature on shared decision-making (SDM) using personal health record (PHR) technology and to map the literature in terms of system design and outcomes. Literature from Medline, Google Scholar, Cumulative Index to Nursing and Allied Health Literature, Engineering Village, and Web of Science (2005-2015) using the search terms "personal health records," "shared decision making," "patient-provider communication," "decision aid," and "decision support" was included. Articles ( n = 38) addressed the efficacy or effectiveness of PHRs for SDM in engaging patients in self-care and decision-making or ways patients can be supported in SDM via PHR. Analysis resulted in an integrated SDM-PHR conceptual framework. An increased interest in SDM via PHR is apparent, with 55% of articles published within last 3 years. Sixty percent of the literature originates from the United States. Twenty-six articles address a particular clinical condition, with 10 focused on diabetes, and one-third offer empirical evidence of patient outcomes. The tethered and standalone PHR architectural types were most studied, while the interconnected PHR type was the focus of more recently published methodological approaches and discussion articles. The study reveals a scarcity of rigorous research on SDM via PHR. Research has focused on one or a few of the SDM elements and not on the intended complete process. Just as PHR technology designed on an interconnected architecture has the potential to facilitate SDM, integrating the SDM process into PHR technology has the potential to drive PHR value.

Legal issues pertaining to the collection of sociodemographic data in emergency departments.

From Hippocrates to HIPAA: Privacy and confidentiality in Emergency Medicine—Part I: Conceptual, moral, and legal foundations

Over the last decade, researchers have become increasingly interested in students' beliefs about the nature of knowledge and how these beliefs develop. Although initial psychological accounts portrayed epistemic development as a domain-independent process of cognitive maturation, recent studies have found trajectories of epistemic development to vary considerably across contexts. However, few studies have focused on cultural context. This article examines the role community values and practices play in fostering particular epistemological orientations by comparing the epistemological beliefs of 5th, 8th, and 12th graders (N = 200) from General and Religious schools in Israel regarding 2 controversies: belief in God and punishment of children. In both controversies, older participants were less likely than younger participants to consider the controversy rationally decidable. However, this shift emerged earlier in the God controversy than in the punishment controversy. In the God controversy, General pupils were less likely than Religious pupils to consider the question rationally decidable or their own beliefs infallible. But no such school differences were observed in the punishment controversy. Qualitative and quantitative analyses linked these differences to divergent discourse practices at General and Religious schools, suggesting that the relations between learning and epistemic development are more intricate than has been assumed hitherto. Epistemology is an area of philosophy concerned with questions of what knowledge is and how it is justified. Although few people give these questions such detailed and sustained attention as professional philosophers, anyone attempting to acquire, produce, or evaluate knowledge relies, at least implicitly, on some set of epistemological beliefs. Such beliefs are of obvious interest to educators. To understand how students acquire, evaluate, and justify knowledge, we need to understand what they consider knowledge to be. And to help students become discerning consumers and responsible producers of knowledge, we need to understand how people learn to exercise reflective judgment in the face of competing claims. The psychological study of epistemic development is undergoing something of a renaissance. Interest in this area can be traced back to Piaget (1970) Piaget, J. 1970. Genetic epistemology New York: Columbia University Press. [Crossref] , [Google Scholar], Dewey (1933) Dewey, J. 1933. How we think Lexington, MA: D. C. Heath and Co. [Crossref] , [Google Scholar], and beyond (e.g., Plato's Theaetetus). But only recently have psychologists begun to draw together hitherto disparate strands of empirical inquiry to chart in detail the course of epistemic development from infancy to adulthood (see, e.g., Hallett, Chandler, & Krettenauer, 2002 Hallett, D., Chandler, M. J. and Krettenauer, T. 2002. Disentangling the course of epistemic development: Parsing knowledge by epistemic content. New Ideas in Psychology, 20(2-3): 285–307. [Crossref], [Web of Science ®] , [Google Scholar]; Kuhn, Cheney, & Weinstock, 2000 Kuhn, D. 2000. Metacognitive development. Current Directions in Psychological Science, 9(5): 178–181. [Crossref], [Web of Science ®] , [Google Scholar]; Wainryb, Shaw, Langley, Cottam, & Lewis, 2004 Wainryb, C., Shaw, L. A., Langley, M., Cottam, K. and Lewis, R. 2004. Children's thinking about diversity of belief in the early school years: Judgments of relativism, tolerance, and disagreeing persons. Child Development, 75(3): 687–703. [Crossref], [PubMed], [Web of Science ®] , [Google Scholar]). Initial research in this field was conducted largely within a neo-Piagetian paradigm. Epistemic development was characterized as a progression through discrete stages or levels of epistemological understanding, each following the other in invariant sequence and constituting a comprehensive transformation of the individual's conception of knowledge (see, e.g., Chandler, 1975 Chandler, M. J. 1975. Relativism and the problem of epistemological loneliness. Human Development, 18(3): 171–180. [Crossref], [Web of Science ®] , [Google Scholar]; Kitchener & King, 1981 Kitchener, K. S. and King, P. M. 1981. Reflective judgment: Concepts of justification and their relationship to age and education. Journal of Applied Developmental Psychology, 2: 89–116. [Crossref] , [Google Scholar]; Perry, 1970 Perry, W. G. 1970. Forms of intellectual and ethical development in the college years: A scheme Troy, MO: Holt, Rinehart & Winston. [Google Scholar]). Researchers differed somewhat in their nomenclatures and in their criteria for distinguishing levels of epistemological sophistication, but they concurred broadly in positing at least two major shifts in epistemological understanding (for recent reviews, see Hofer & Pintrich, 1997 Hofer, B. K. and Pintrich, P. R. 1997. The development of epistemological theories: Beliefs about knowledge and knowing and their relation to learning. Review of Educational Research, 67(1): 88–140. [Crossref], [Web of Science ®] , [Google Scholar], 2002 Hammer, D. and Elby, A. 2002. "On the form of a personal epistemology.". In Personal epistemology: The psychology of beliefs about knowledge and knowing Edited by: Hofer, B. K. and Pintrich, P. R. 169–190. Mahwah, NJ: Lawrence Erlbaum Associates, Inc. [Google Scholar]). Initially, the individual subscribes to an objectivist conception of knowledge, in which every question is believed to have a single, correct answer that is knowable with absolute certainty. Subsequently, in a radical shift, objectivism is abandoned in favor of subjectivism, and the individual equates all knowledge claims with matters of personal taste or preference. Finally, a balance is achieved in which objective and subjective aspects of knowing are coordinated. At this "evaluativist" stage (cf. Kuhn, 1991 Kuhn, D. 1991. The skills of argument Cambridge, , England: Cambridge University Press. [Crossref] , [Google Scholar]), the individual sees knowledge as something that is constructed tentatively by evaluating the evidence for and against competing beliefs and points of view. There was some debate about the precise relations of these stages to Piaget's stages of intellectual development (see, e.g., Boyes & Chandler, 1992 Boyes, M. C. and Chandler, M. 1992. Cognitive development, epistemic doubt, and identity formation in adolescence. Journal of Youth and Adolescence, 21(3): 277–304. [Crossref], [PubMed], [Web of Science ®] , [Google Scholar]). However, they were viewed by most researchers as a kind of "post-formal operations" taking up the formal operational attainments of hypothetical thinking and perspective-taking and applying them wholesale to knowledge claims as such, in a form of meta-metacognition (see, e.g., Kitchener, 1983 Kitchener, K. S. 1983. Cognition, metacognition and epistemic cognition: A three-level model of cognitive processing. Human Development, 26: 222–232. [Crossref], [Web of Science ®] , [Google Scholar]; Kuhn, 2000 Kuhn, D. 2000. Metacognitive development. Current Directions in Psychological Science, 9(5): 178–181. [Crossref], [Web of Science ®] , [Google Scholar]; Moshman, 2003 Moshman, D. 2003. Intellectual freedom for intellectual development. Liberal Education, 89(3): 30–38. [Google Scholar]). Empirical support for this model of epistemic development came from several parallel research programs. Overall, these studies provided substantial evidence of development in the hypothesized direction (Hallett et al., 2002 Hallett, D., Chandler, M. J. and Krettenauer, T. 2002. Disentangling the course of epistemic development: Parsing knowledge by epistemic content. New Ideas in Psychology, 20(2-3): 285–307. [Crossref], [Web of Science ®] , [Google Scholar]; Hofer & Pintrich, 1997 Hofer, B. K. and Pintrich, P. R. 1997. The development of epistemological theories: Beliefs about knowledge and knowing and their relation to learning. Review of Educational Research, 67(1): 88–140. [Crossref], [Web of Science ®] , [Google Scholar]; King & Kitchener, 1994 King, P. M. and Kitchener, K. S. 1994. Developing reflective judgment San Francisco: Jossey-Bass. [Google Scholar]). However, the ages at which the key shifts in epistemological understanding were observed varied enormously from program to program. As Hallett et al. (2002) Hallett, D., Chandler, M. J. and Krettenauer, T. 2002. Disentangling the course of epistemic development: Parsing knowledge by epistemic content. New Ideas in Psychology, 20(2-3): 285–307. [Crossref], [Web of Science ®] , [Google Scholar] noted regarding the emergence of subjectivism, "one could read selectively from the literature and, with good reason, conclude that such abilities put in their appearance at either 4 or 6 or 8 or 12 or 16 or 20, or in receipt of a Ph.D." (p. 289). These vast discrepancies have led researchers to reexamine some of the assump-tions underlying their models and measures of epistemic development. In particular, researchers have begun to question the comprehensiveness of shifts in epistemological understanding and to attend more closely to the variety of contexts within which epistemic beliefs are held, employed, and articulated (cf.Elby&Ham-mer, 2001 Elby, A. and Hammer, D. 2001. On the substance of a sophisticated epistemology. Science Education, 85(5): 554–567. [Crossref], [Web of Science ®] , [Google Scholar]; Hammer&Elby, 2002 Hammer, D. and Elby, A. 2002. "On the form of a personal epistemology.". In Personal epistemology: The psychology of beliefs about knowledge and knowing Edited by: Hofer, B. K. and Pintrich, P. R. 169–190. Mahwah, NJ: Lawrence Erlbaum Associates, Inc. [Google Scholar], 2003 Hammer, D. and Elby, A. 2003. Tapping epistemological resources for learning physics. Journal of the Learning Sciences, 12(1): 53–90. [Taylor & Francis Online], [Web of Science ®] , [Google Scholar]). This attention to context has taken several forms. One line of research has sought to show that epistemic development is a some-what domain-dependent process that occurs with respect to some kinds of knowledge claim before others. For example, it has been proposed that subjectivism emerges in relation to aesthetic claims before it emerges in relation to claims about the physical world (e.g., Hallett et al., 2002 Hallett, D., Chandler, M. J. and Krettenauer, T. 2002. Disentangling the course of epistemic development: Parsing knowledge by epistemic content. New Ideas in Psychology, 20(2-3): 285–307. [Crossref], [Web of Science ®] , [Google Scholar]; Kuhn et al., 2000 Kuhn, D. 2000. Metacognitive development. Current Directions in Psychological Science, 9(5): 178–181. [Crossref], [Web of Science ®] , [Google Scholar]; Wainryb et al., 2004 Wainryb, C., Shaw, L. A., Langley, M., Cottam, K. and Lewis, R. 2004. Children's thinking about diversity of belief in the early school years: Judgments of relativism, tolerance, and disagreeing persons. Child Development, 75(3): 687–703. [Crossref], [PubMed], [Web of Science ®] , [Google Scholar]). Another line of research has sought to show that epistemological beliefs are multi di-mensional rather than unitary. For example, it has been proposed that people's beliefs about the complexity of knowledge develop more or less independently of their beliefs about its certainty (e.g., Schommer, 1990 Schommer, M. 1990. Effects of beliefs about the nature of knowledge on comprehension. Journal of Educational Psychology, 82(3): 498–504. [Crossref], [Web of Science ®] , [Google Scholar], 1993 Schommer, M. 1993. Comparisons of beliefs about the nature of knowledge and learning amongst post-secondary students. Research in Higher Education, 34(3): 355–370. [Crossref], [Web of Science ®] , [Google Scholar]). Although the accumulated empirical evidence is as yet suggestive rather than conclusive (see Elby&Hammer, 2001 Elby, A. and Hammer, D. 2001. On the substance of a sophisticated epistemology. Science Education, 85(5): 554–567. [Crossref], [Web of Science ®] , [Google Scholar]; Hallett et al., 2002 Hallett, D., Chandler, M. J. and Krettenauer, T. 2002. Disentangling the course of epistemic development: Parsing knowledge by epistemic content. New Ideas in Psychology, 20(2-3): 285–307. [Crossref], [Web of Science ®] , [Google Scholar], pp. 303–304; Kuhn et al., 2000 Kuhn, D. 2000. Metacognitive development. Current Directions in Psychological Science, 9(5): 178–181. [Crossref], [Web of Science ®] , [Google Scholar], pp. 321–322), both research programs hold out the possibility of disentangling the course of epistemic de-velopment by identifying elements of epistemological understanding that emerge at different points in the lifespan(cf.Hallett et al.,2002 Hallett, D., Chandler, M. J. and Krettenauer, T. 2002. Disentangling the course of epistemic development: Parsing knowledge by epistemic content. New Ideas in Psychology, 20(2-3): 285–307. [Crossref], [Web of Science ®] , [Google Scholar], p. 290; Wainryb et al. 2004 Wainryb, C., Shaw, L. A., Langley, M., Cottam, K. and Lewis, R. 2004. Children's thinking about diversity of belief in the early school years: Judgments of relativism, tolerance, and disagreeing persons. Child Development, 75(3): 687–703. [Crossref], [PubMed], [Web of Science ®] , [Google Scholar]). However, "domains" and "dimensions" are not the only contexts within which epistemic beliefs are situated. Just as people's epistemic beliefs may be affected by the particular content of the knowledge claims being evaluated, so too may they be affected by the particular procedures of knowledge evaluation practiced in, and sanctioned by, the communities in which they participate (cf. Hammer & Elby, 2003 Hammer, D. and Elby, A. 2003. Tapping epistemological resources for learning physics. Journal of the Learning Sciences, 12(1): 53–90. [Taylor & Francis Online], [Web of Science ®] , [Google Scholar]). Few studies have directly examined cross-cultural variation in epistemological beliefs. And those that have done so have tended to focus on comparisons between U.S. and East Asian college students (e.g., Chan & Elliott, 2002 Chan, K. and Elliott, R. G. 2002. Exploratory study of Hong Kong teacher education students' epistemological beliefs: Cultural perspectives and implications on beliefs research. Contemporary Educational Psychology, 27(3): 392–414. [Crossref], [Web of Science ®] , [Google Scholar], 2004 Chan, K. and Elliott, R. G. 2004. Epistemological beliefs across cultures: Critique and analysis of beliefs structure studies. Educational Psychology, 24(2): 123–142. [Taylor & Francis Online] , [Google Scholar]; Nisbett, Peng, Choi, & Norenzayan, 2001 Nisbett, R. E., Peng, K., Choi, I. and Norenzayan, A. 2001. Culture and systems of thought: Holistic versus analytic cognition. Psychological Review, 108(2): 291–310. [Crossref], [PubMed], [Web of Science ®] , [Google Scholar]; Zhang, 1999 Zhang, L. F. 1999. A comparison of U. S. and Chinese university students' cognitive development: The cross-cultural applicability of Perry's theory. Journal of Psychology, 133(4): 425–439. [Taylor & Francis Online], [Web of Science ®] , [Google Scholar]). Nonetheless, the findings of such studies are highly suggestive. Especially striking is Zhang's finding that Chinese students' epistemological beliefs shifted over the college years in exactly the opposite direction to those of their U.S. counterparts. Specifically, rather than moving from objectivist to subjectivist conceptions of knowledge, similar to their peers at U.S. universities, Chinese students appeared to shift from more subjectivist conceptions of knowledge to more objectivist ones. Such findings raise intriguing questions about the relations between culture and epistemic development, and about the relations between learning and epistemic development more generally. For a field of inquiry dominated by educational psychologists, remarkably little is known about these relations. As Hofer and Pintrich(1997) Hofer, B. K. and Pintrich, P. R. 1997. The development of epistemological theories: Beliefs about knowledge and knowing and their relation to learning. Review of Educational Research, 67(1): 88–140. [Crossref], [Web of Science ®] , [Google Scholar] noted, "there is little empirical evidence for precisely what fosters epistemological development or how epistemological beliefs are altered" (p. 123). Research has shown that schooling makes a difference(e.g. Bell&Linn, 2002 Bell, P. and Linn, M. C. 2002. "Beliefs about science: How does instruction contribute?". In Personal epistemology: The psychology of beliefs about knowledge and knowing Edited by: Hofer, B. K. and Pintrich, P. R. 321–346. Mahwah, NJ: Lawrence Erlbaum Associates, Inc. [Google Scholar]; King&Kitchener, 1994 King, P. M. and Kitchener, K. S. 1994. Developing reflective judgment San Francisco: Jossey-Bass. [Google Scholar]), but it has yielded little insight into how or why it makes a difference. Moreover, researchers have tended to equivocate between viewing epistemological beliefs as causes and effects of learning—as age-dependent constraints on instruction on one hand andasoutcomesof instructionon the other hand (cf. Kuhn, 1991 Kuhn, D. 1991. The skills of argument Cambridge, , England: Cambridge University Press. [Crossref] , [Google Scholar], 2003 Kuhn, D. 2003. Understanding and valuing knowing as developmental goals. Liberal Education, 89(3): 16–22. [Google Scholar]; Schommer, 1990 Schommer, M. 1990. Effects of beliefs about the nature of knowledge on comprehension. Journal of Educational Psychology, 82(3): 498–504. [Crossref], [Web of Science ®] , [Google Scholar], 1993 Schommer, M. 1993. Comparisons of beliefs about the nature of knowledge and learning amongst post-secondary students. Research in Higher Education, 34(3): 355–370. [Crossref], [Web of Science ®] , [Google Scholar]). Cross-cultural studies of age trends in epistemological belief are one way to investigate systematically the relations between age, learning, and epistemic development. If the nature and timing of age-related shifts in epistemological belief vary cross-culturally, then this is presumably because participants in different cultures learn, through participation in practices particular to their respective communities, to treat knowledge claims in different ways. To the extent that researchers can pinpoint such practices and measure their impact on individuals' epistemological beliefs, we can begin to characterize more precisely the relations between learning and epistemic development. However, in designing such studies, researchers must take great care to distinguish between reportage and editorial. "Development" is a value-laden term. Theoretical models of psychological development do more than describe a sequence; they attach values to different points along the sequence. Specifically, they define some psychological states or capacities as more mature, adequate, or sophisticated than others. When developmental studies are restricted to homogeneous cultural settings, within which there is little serious disagreement among experts about the relative adequacy of different psychological states or capacities, the risk of bias in diagnosing participants' levels of development is relatively slight. However, as the cultural heterogeneity of the sample increases, so too does the risk that the model on the basis of which participants' development is diagnosed is ethnocentrically biased against a portion of the sample. For example, beliefs that are defined as immature by the developmental model might be considered mature within one of the cultures from which the sample is drawn, or vice versa. These dangers exist to some extent in all cross-cultural studies of psychological development (see Cole & Scribner, 1974 Cole, M. and Scribner, S. 1974. Culture and thought: A psychological introduction New York: Wiley. [Google Scholar]; Greenfield & Bruner, 1966 Greenfield, P. M. and Bruner, J. S. 1966. Culture and cognitive growth. International Journal of Psychology, 1: 89–107. [Taylor & Francis Online], [Web of Science ®] , [Google Scholar]; Shweder, Mahapatra, & Miller, 1990 Shweder, R. A., Mahapatra, M. and Miller, J. G. 1990. "Culture and moral development.". In Cultural psychology: Essays on comparative human development Edited by: Stigler, J. W. 130–204. New York: Cambridge University Press. [Crossref] , [Google Scholar]). However, in cross-cultural studies of epistemic development the danger is even more clear and present. This is because there are at least four levels at which epistemological judgments can be made, and as one ascends from the first level to the fourth, the value assumptions implicit in these judgments become less visible to the naked eye but never quite disappear. At the first, most basic level, there arejudgments about the epistemic status of par-ticular claims, such as whether a given assertion (e.g., "Eating people is wrong") is known or merely believed (e.g., "John doesn't know that eating people is wrong; he merely believes that eating people is wrong"). At one level of abstraction up from such judgments, there are judgments about the epistemic status of general classes of claim, such as judgments about whether knowledge is possible about, say, matters of aesthetics or morality (e.g., "There are no such things as moral truths or moral knowledge; morality is a question of commitment—not of what is or is not the case"). At yet another level of abstraction up from such judgments, there are further judgments about the criteria by which epistemic states are distinguished one from another, such as judgments about what differentiates knowledge from belief or opin-ion (e.g., "Knowledge is justified true belief;if a belief is true but not justified, or jus-tified but not true, then it isn't known"). And beyond this third level, there is a fourth level of judgments about the relative adequacy of particular criteria for distinguishing between epistemic states, such as judgments about whether the subjectivist equation of knowledge with opinion is less adequate than the evaluativist's insistence that knowledge differs from opinion in being supported by evidence (e.g., "Subjectivism is inferior to evaluativism because it fails to account for our belief that some claims are better supported than others"). According to this analysis, authors of contemporary models of epistemic development are themselves exercising a form of epistemological judgment in articulating their models. Specifically, they are operating at the fourth level (outlined previously), expressing their own beliefs about the relative adequacy of particular epistemological orientations. This is all well and good as long as the beliefs in question are compatible with the epistemological beliefs, values, and practices of the communities to which the model is applied. However, in cross-cultural studies of epistemic development, such compatibility cannot be assumed in advance of the investigation itself. Accordingly, if one wishes to avoid ethnocentrism, one cannot conduct a cross-cultural study of epistemic development without suspending, at least temporarily, one's hierarchical assumptions about the relative adequacy of particular epistemological orientations. This is not to say that researchers are not entitled to opinions of their own about the relative adequacy of particular epistemological beliefs or that all talk of epistemic development is inherently ethnocentric. It is merely to point out that because standards of epistemological maturity may themselves vary across cultures, assumptions about the relative adequacy of particular epistemological beliefs must not be built into the design of cross-cultural studies. This study, therefore, departs from previous studies of epistemic development by dropping the assumption that some epistemological beliefs are inherently more adequate than others. By dropping this assumption, I do not affirm the contrary assumption that all epistemological beliefs are equally adequate. Rather, I adopt a form of methodological agnosticism to reduce the scope for ethnocentric bias in the study'sdesign. In the Discussion section, I return to the question of hierarchy and review the assumptions of contemporary models of epistemic development in light of my findings. This study investigates the relations between age, learning, and epistemic devel-opment by comparing the epistemological beliefs of pupil sat Religious schools and General schools in Israel about two controversies: one religious and the other nonre-ligious. Specifically, this study asks three questions. First, how do beliefs about the nature of religious claims vary with age and school? Second, to what extent are these age and school differences attributable to underlying group differences in religious commitment and general epistemological sophistication? Third, how are variations in epistemological belief across ages, schools, and controversies related to educational practices at Religious and General schools, respectively?

The Lancet Commission on cancer and health systems: harnessing synergies to achieve solutions

Addressing Antibiotic Overuse in the Outpatient Setting: Lessons From Behavioral Economics

Understanding health systems as comprising interacting elements of hardware and software acknowledges health systems as complex adaptive systems (CASs). Hardware represents the concrete components of systems, whereas software represents the elements that influence actions and underpin relationships, such as processes, values, and norms. As a specific call for research on health system software was made in 2011, we conducted a qualitative scoping review considering how and for what purpose the concept has been used since then. Our overall purpose was to synthesize current knowledge and generate lessons about how to deepen research on, and understanding of, health system software. The review consisted of two phases: first, for the period 2011-23, all papers that explicitly used the concept of health system software were identified and mapped; second, drawing on a subset of papers from Phase 1, we explored how the concept was purposively used within research. The databases PubMed, Scopus, EBSCOhost, Web of Science, and Google Scholar were systematically searched using a strategy developed by a skilled librarian. In Phase 1, data were extracted from 98 papers. Our analysis revealed that a third of the papers used the software concept rather superficially; a third used it to conceptualize the importance of selected software elements; and a third used it in examining a specific health system experience, such as preparedness or resilience. In Phase 2, our analysis confirmed that researchers have found value in proactively using the software concept within studies, demonstrating two patterns of use. However, a limited understanding of how to investigate interactions among hardware and software elements was also revealed. Future health policy and systems research should purposively investigate hardware-software interactions in order to gain a greater understanding of the complex, adaptive nature of health systems, understand their operations, and institutionalize thinking that considers health systems as CASs.

Postpandemic Psychological Recovery and Emergency Nursing: Creating a Narrative for Change

Fellowship Training in Adult Cardiothoracic Anesthesiology: Navigating the New Educational Landscape as a Result of the Coronavirus Crisis

Background Climate-induced environmental changes, and their potential impact on population health, are among the most pressing challenges affecting health systems. These health impacts put additional strain on health systems, putting their resilience and capacity to deal with increased shocks and stresses to the test. Implementing reforms to address the vulnerabilities in the health system can help build its capacity to cope with these shocks. We conducted a scoping review to explore the literature on health sector reforms in Bangladesh and understand their impact on health systems. Methods A scoping review was conducted by searching through academic (MEDLINE, SCOPUS, Web of Science and Google Scholar) and grey literature published in English and French between 1991 and 2021 that addressed national health sector reforms impacting the health system and access to care. Results Our search yielded 2688 articles for screening and 22 were included in our scoping review. One of the major health sector reforms was the shift from a project-based approach to a sector-wide approach (SWAp) in health. Studies found that implementing initiatives such as community clinics, a voucher scheme for pregnant women, increase in hospital beds at public facilities improved health care access and delivery of care, especially for rural districts. Despite government efforts, the health system continues to be vulnerable to shocks due to a significant shortage of formally qualified health professionals especially nurses and technologists and relatively low public financing. Conclusions Evidence suggests that health sector reforms implemented as part of SWAp have had a limited improvement on the health system. More emphasis should be placed in the future on implementing reforms to address critical issues such as human resources for health and health financing, which may contribute to building their capacity to cope with emerging threats due to climate change and improving access to care. Key messages Building a resilient health system may involve assessing the system's vulnerabilities, strengths and limitations through the perspective of health sector reforms. Current health sector reforms have had limited impact in addressing the vulnerabilities of the health system.

Reducing Implicit Bias in Maternity Care: A Framework for Action

What Really Matters for Cancer Care – Health Systems Strengthening or Technological Innovation?

Given the rising burden of global diseases and the resulting need to strengthen and shift health systems functioning, we examined the use and application of the World Health Organisation Framework on integrated people-centred health services (IPCHS), assessing its role in fostering sustainability and resilience. Our research is intended for healthcare professionals, policymakers, academics, and advocates for integrated health services and people-centred care. Those wishing to transform health and care systems towards sustainability and resilience will find our research particularly useful. This research was conceptualised, designed, and mentored by experts at the George Institute for Global Health in collaboration with members from King's College London. The review comprehensively examined a number of studies that covered diverse perspectives and experiences with the IPCHS framework, even though it did not specifically delve into public participation or co-design methodologies. Our initiative was a comprehensive examination of the usage, application, and global impact of the IPCHS framework through a systematic scoping review covering a period from 2016 through January 2023. To gain an in-depth understanding of the IPCHS framework in the context of global health systems, we analysed academic literature using database searches and articles found on the IPCHS website. To ensure that we synthesised all the important lessons learned, we performed content analysis and descriptive analysis of the data that was extracted. The findings of this research revealed that the IPCHS has been implemented in various health settings globally, across different cultural and socioeconomic contexts, yielding diverse but also consistent results. The insight of our study also provides light on the successful strategies and common barriers in implementing the framework thereby serving as a valuable reference for future efforts for people-centred integrated care. The international community can gain insights into the application and existing knowledge of the IPCHS framework, as well as its potential for optimising health services. Through our work, global health policy and practice can be guided by promoting person-centred and integrated health services. Furthermore, we have identified a consolidated research tool kit that will be useful in facilitating and evaluating the five key strategies of the IPCHS framework. Finally, our study is the first to examine the IPCHS framework and provides potential directions for further examination. On the basis of our findings, the next steps consist of conducting additional research on the individual five strategies in various geographic locations, health system components, and determining how the IPCHS is adapted to each context. To foster a shared understanding and ensure that the transformation of the health system is effective and sustainable, we propose the development of an international collaboration platform where individuals can share their knowledge, experiences, and strategies related to the IPCHS framework.

Medical Malpractice and the Chest Physician

Evaluation and Epidemiological Research in Tuberculosis Control: Linking Medical Care and Public Health