Community-based Institutions Research Articles

Climate Change Adaptation Among Tibetan Pastoralists: Challenges in Enhancing Local Adaptation Through Policy Support

While researchers are aware that a mix of Local Ecological Knowledge (LEK), community-based resource management institutions, and higher-level institutions and policies can facilitate pastoralists' adaptation to climate change, policy makers have been slow to understand these linkages. Two critical issues are to what extent these factors play a role, and how to enhance local adaptation through government support. We investigated these issues through a case study of two pastoral communities on the Tibetan Plateau in China employing an analytical framework to understand local climate adaptation processes. We concluded that LEK and community-based institutions improve adaptation outcomes for Tibetan pastoralists through shaping and mobilizing resource availability to reduce risks. Higher-level institutions and policies contribute by providing resources from outside communities. There are dynamic interrelationships among these factors that can lead to support, conflict, and fragmentation. Government policy could enhance local adaptation through improvement of supportive relationships among these factors. While central government policies allow only limited room for overt integration of local knowledge/institutions, local governments often have some flexibility to buffer conflicts. In addition, government policies to support market-based economic development have greatly benefited adaptation outcomes for pastoralists. Overall, in China, there are still questions over how to create innovative institutions that blend LEK and community-based institutions with government policy making.

Anaphylaxis in the community setting: determining risk factors for admission

BackgroundAlthough the identification and management of anaphylaxis in an emergency department setting has been well studied, our understanding of the risk factors for admission in a community-based hospital is lacking. ObjectiveTo determine the demographics and the predictors of hospitalization, in patients presenting with anaphylaxis to a community-based emergency department (ED). MethodsWe performed a five-year retrospective chart review of all patients seen in the ED of Winthrop University Hospital, a community-based institution, with an International Classification of Diseases, 9thEdition code related to anaphylaxis. ResultsFifty-eight visits met inclusion criteria, of which 34% resulted in hospital admission (95% CI: 22–48%). Univariate predictors for admission included (1) the involvement of 2, 3, and 4 organ systems (26%, 55%, and 75%, respectively; P < .02); (2) gastrointestinal symptoms vs no symptoms (59% vs 24%, P < .02); (3) non-sting (ingested and other allergens) vs insect sting allergen (50% vs 12.5%, P < .005); and (4) a history of an ED visit for anaphylaxis vs none (67% vs 30%, P < .05). Multivariate analysis (logistic regression) confirmed non-sting allergens (p < 0.02) and number of organ systems involved (P < .05) as independent predictors of hospitalization. ConclusionIn our study population, the involvement of multiple organ systems, particularly gastrointestinal involvement, a history of ED visits for anaphylaxis, and involvement of ingested or other allergens (non-sting) demonstrated higher admission rates.

The Role of Educational Institutions in the Development of Critical Literacy and Transformative Action

This article seeks to explore how community-based institutions can serve as contexts for the development of critical literacy frameworks among youth. Using examples from research conducted by the authors in a Puerto Rican community, we elaborate ways that schools can serve as counter-storytelling institutions that encourage students to critically examine society.

Investigation of offered images between community-based medical institutions in a central community hospital in Tokyo

Investigation of offered images between community-based medical institutions in a central community hospital in Tokyo

A Multi-Institutional Study of Feasibility, Implementation, and Early Clinical Results With Noninvasive Breast Brachytherapy for Tumor Bed Boost

To evaluate the feasibility, implementation, and early results of noninvasive breast brachytherapy (NIBB) for tumor bed boost with whole breast radiation therapy (WBRT). NIBB is a commercially available (AccuBoost, Billerica, MA) mammography-based, brachytherapy system in which the treatment applicators are centered on the planning target volume (PTV) to direct (192)Ir emissions along orthogonal axes. A privacy-encrypted online data registry collected information from 8 independent academic and community-based institutions. Data were from 146 consecutive women with early-stage breast cancer after lumpectomy and WBRT receiving boost with NIBB between July 2007 and March 2010. Toxicity and cosmesis were graded according to the Common Toxicity Criteria (v. 3.0) and the Harvard scale. Median follow-up was 6 months (1-39 months). Grade 1-2 skin toxicity was observed in 64%, 48%, and 21% during the acute (1-3 weeks), intermediate (4-26 weeks), and late-intermediate (>26 weeks) periods. There was no Grade 4 toxicity. At 6 months, for the entire cohort, cosmesis was excellent/good in 62%/38%. The subset receiving NIBB before WBRT had cosmetic scores of 32% and 63%, whereas during WBRT, 58% and 37% were rated as excellent and good, respectively. Breast compression was scored as "uncomfortable" in 12%, 29%, and 59% when NIBB was delivered before, during, or after WBRT. For each patient, the fraction-to-fraction variability in PTV was low. Skin flash was associated with a higher proportion of excellent cosmesis (58% vs. 42%) relative to having the applicator all within breast tissue. These data indicate that NIBB is feasible and can be consistently implemented in a broad array of practice settings. Preliminary evaluation suggests that NIBB is associated with acceptably mild normal tissue toxicity and favorable early cosmesis. The application of NIBB before WBRT may be associated with better patient tolerance at the expense of less favorable cosmetic outcome.

Governing Poverty Amidst Plenty: Participatory Development and Private Philanthropy

This paper explores the current debates surrounding how large-scale poverty programs structure the actions and strategies of regional community-based institutions. I specifically interrogate how processes of professionalization and ‘participatory’ ideas promoted through public and private funders are negotiated by institutional ‘grantees’, and ultimately structure the ways in which historic social movement organizations build institutions and organizing strategies. A review of the major debates surrounding ‘participatory development’ in the fields of critical development studies and American poverty scholarship is approached through a specific case study in California’s Central Valley. By highlighting the case of the historic Farm Worker Movement and its’ legacy institutions I show how social movement actors negotiate theories of participation, institutional structures, and regional alliances promoted through public and private funding. It is argued that organizing the poor through participatory philanthropic initiatives provides a certain range of opportunities as well as firm limits to changing the political-economic relationships that produce regional poverty. Both the consensus based approach popular with the most recent philanthropic initiatives and the self-help model of the 1960s bring a certain range of political openings and firm limits proscribed by what funders will and won’t do in the context of funding social movement institutions to confront structures of economic inequality produced through industrial capital.

Measures to improve safety of an elastomeric infusion system for pain management

Measures to improve the safe implementation and utilization of an elastomeric infusion system for pain management are described. Due to the multiple safety concerns associated with the use of the On-Q infusion systems (I-Flow Corporation, Lake Forest, CA) in a community-based teaching institution, a multidisciplinary team of physicians, pharmacists, clinical nurses, nurse educators, and computer informatics personnel was formed to develop a standardized policy and procedure to ensure the safe use of On-Q pumps. The policy addressed several problems concerning prescribing, dispensing, administration, and monitoring of these pumps. The patient care policy for use of On-Q pumps dictates how the pumps are stocked, ordered, dispensed, administered, and monitored and the drugs approved for use in the pumps. Education bulletins, a summary of the new policy and procedure, and a formal presentation of the policy and procedure to unit-based nurse educators were provided. The focus was on a consistent message of safety by reiterating the problems described with these pumps in the literature and in the health care system itself. The physicians ordering the devices have provided positive feedback regarding the simplified ordering process and standardization of the pumps, medications, and concentrations. Both dispensing pharmacists and bedside nurses have noted that the orders are clearly communicated via the computerized system. The addition of documentation in the computer system and education regarding potential signs and symptoms of adverse events with the medication used with the pumps was greatly appreciated by the nursing staff. A health care system instituted measures to enhance the safety of using an elastomeric infusion system for pain management.

Women and Tenure Transition: An Examination of Land Access and Gendered Land Rights in Kanungu District, Uganda

Access to land and land rights are critical to development and poverty reduction. Currently Uganda, like many countries around the globe, is undergoing transformation of its land tenure systems, away from traditional, community-based institutions towards private individual freehold property. Privatizing land rights, however, is controversial; critics fear that this will negatively impact vulnerable groups, such as women. In the Ugandan context while new privatization reforms have passed, they have not been fully implemented. This tenure transition is creating confusion and reportedly leading to a weakening of the traditional systems and an erosion of women’s land rights. I examine women’s land rights in rural southwestern Uganda, with a specific focus on women’s ability to access land subsequent to the 1998 Land Act. In my work I ask: how do women perceive their land rights? What strategies have women developed to facilitate their access to land? Do women believe the 1998 Land Act inhibited or aided in their struggle for land? The research utilized three data collection methods: document analysis, informant interviews with local elites, and semi-structured interviews with rural female farmers. Data analysis revealed three main themes: women lack awareness of the new land laws, issues around security of tenure occurred due to the transitioning tenure system combined with gender inequality, and women are utilizing informal channels to access land tenure while focusing on development. Faculty Mentor: Ellen Bassett

Modeling choice of fuelwood source among rural households in Malawi: A multinomial probit analysis

This paper addresses two questions: what determines household's choice of fuelwood source and, what are the environmental consequences of fuelwood collection choices? We address these questions by estimating the multinomial probit model using survey data for households surrounding Chimaliro and Liwonde forest reserves in Malawi. After controlling for heterogeneity among households, we find strong substitution opportunities across fuelwood collection sources. Attributes of the fuelwood sources (size and species composition) and distance to the sources are the most important determinants of fuelwood choice. Further results show that customary managed forests generate environmental benefits by reducing pressure on both plantation forests and forest reserves. These findings support the need to strengthen community-based institutions to manage local forest resources.

Abstract P4-11-13: A Multi-Institutional Assessment of the Feasibility, Implementation, and Early Clinical Results with Noninvasive Image-Guided Breast Brachytherapy for Tumor Bed Boost

Abstract Background: Noninvasive image-guided breast brachytherapy (NIIGBB) is an FDA-approved, commercially available (AccuBoost®, Billerica, MA) mammography-based, breast brachytherapy system whereby the treatment applicators are centered on the planning target volume (PTV) to direct 192Ir emissions along orthogonal axes. This study evaluates the feasibility, implementation, and early results of NIIGBB for breast tumor bed boost in combination with external beam whole breast radiation therapy (WBRT), as part of post-lumpectomy radiation. Material and Methods: A privacy-encrypted online data registry was created to collect clinical and technical information from 8 independent academic and community-based institutions. Data were collected from consecutive 110 individual women with early stage breast cancer after breast conserving surgery, who received adjuvant WBRT (mean dose 48.3 ± 2.5 Gy) and tumor bed boost with NIIGBB between July, 2007 and March, 2010. Of the patients, 74% had invasive cancer, with 80% ER+ and 34% HER2+. NIIGBB was delivered before, during, or after WBRT in 57%, 39%, or 4% of the patients. Patient age and lumpectomy cavity size ranged from 32-88 yrs and 0.1-5.3 cm, respectively. Boost dose was delivered in 1.9 ± 0.3 Gy/fx for a total of 12.9 ± 3.4Gy. Toxicity and cosmesis were evaluated after radiation therapy and graded according to the Common Toxicity Criteria (v3.0) and the Harvard scale. Median follow up was 6 months (1-17 months). Results: Grade 1-2 skin toxicity was observed in 18%, 7%, and 0% during the acute (1-3wks), intermediate (4-26 wks), and late-intermediate (&amp;gt;26wks) periods. There were no Grade 3 or higher skin toxicity events. At 6 months, for the entire cohort, cosmetic grading was excellent, good, fair/poor in 52%, 48%, and 0%. The breast compression achieved for each treatment session was remarkably consistent with a mean mammographic plate separation of 6.4 ± 0.3 cm. Breast compression was scored as “uncomfortable” when NIIGBB was delivered before or during WBRT. The mean total duration of set-up and treatment per fraction was 16.7 ± 2.1 min. For each patient, the fraction-to-fraction variability in estimated PTV was low as 69% of treatments were completed with the same applicator size. Discussion: These data indicate that NIIGBB is feasible and can be consistently implemented in a broad array of practice settings. Preliminary evaluation suggests that NIIGBB is associated with acceptably mild normal tissue toxicity and favorable early cosmetic results. The application of NIIGBB before completion of WBRT may be associated with better patient tolerance at the expense of slightly less favorable short-term cosmetic outcome. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-11-13.

Art Spaces in Community and Economic Development: Connections to Neighborhoods, Artists, and the Cultural Economy

There is growing interest in the arts in community and economic development, yet little research examines the dynamics of community-based arts institutions to inform urban planning and policy. Drawing on interviews with participants and organizers of small and midsized art spaces, the study explores the factors that influence their involvement in neighborhood revitalization and outreach, support for artistic communities, and efforts to build bridges to commercial cultural sectors. Art spaces function as a conduit for building social networks that contribute to both community revitalization and artistic development. But issues pertaining to the location, organization, and management of art spaces may limit their community and economic development potential. The article concludes with proposals to craft stronger arts-based community and economic development programs.

Spending time: histories of institutional change, choice and money

Spending time: histories of institutional change, choice and money

Single-incision laparoscopic cholecystectomy is feasible: initial experience with 80 cases

Single-incision laparoscopic surgery (SILS) is a new advance wherein laparoscopic surgery is carried out through a single small incision hidden in the umbilicus. Advantages of this technique over standard laparoscopy are still under investigation. The objective of this study is to describe the short-term outcomes of SILS cholecystectomy in a single community-based institution. A retrospective review of a prospectively collected database for all patients who underwent SILS cholecystectomy was carried out. Both true single-incision and dual-incision (training) cases were included in the analysis. Operative and perioperative outcomes were analyzed. Eighty SILS cholecystectomies (4 dual incision and 76 single incision) were performed from May 30, 2008 to April 23, 2009 (indications: 48 stones, 20 cholecystitis, 11 biliary dyskinesia, and 1 polyp). Mean body mass index (BMI) was 26.5 kg/m(2) (range 17.3-39.1 kg/m(2)), mean operating room (OR) time was 69.5 min (range 29-126 min), mean estimated blood loss (EBL) was 5 cc, and mean incision length was 1.6 cm. There were no open conversions, but there were six conversions to dual-port and three conversions to four-port laparoscopic cholecystectomy due to poor visualization. Complications include three bile leaks managed with endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous drainage (3.7%). Two leaks were from accessory ducts and one was from a cystic duct stump. Number of days of postoperative oral narcotic use was described as none in 11 patients (23%), minimal (1 day) in 21 patients (45%), moderate (1-3 days) in 6 patients (13%), and heavy (≥ 4 days) in 9 patients (19%), with mean follow-up of 4.7 months in 60 patients. SILS cholecystectomy is feasible, with acceptable morbidity. Although not directly compared in this study, postoperative recovery appears shorter than after standard laparoscopy, but more studies are needed.

Growth, Collapse, and Reorganization of the Annapurna Conservation Area, Nepal: an Analysis of Institutional Resilience

Community-based conservation institutions can be conceptualized as complex adaptive systems that pass through a cycle of growth, maturation, collapse, and reorganization. We test the applicability of this four-phase adaptive cycle in the institutional context of the Annapurna Conservation Area (ACA), Nepal. We use the adaptive cycle to assess changes in structures and processes and to explore the past, present, and possible future trends in ACA. We focus on the crisis brought about by the Maoist insurgency and changes that took place in ACA during and after this period. Our analysis suggests that the conservation institution has passed through one and a half forms of the adaptive cycle in five major historical periods in the Annapurna region since 1960. It also appears to have been resilient to the insurgency because the system maintained its identity throughout, avoided alternative undesirable states, and entered into the reorganization phase following collapse. All forms of capital and institutional performance decreased to some extent during collapse, but flexible nested governance structures, including the devolution of responsibility to local entities, the maintenance of capital stocks, the retention of institutional memory, and the perceptions of institutional legitimacy among constituencies, facilitated reorganization. The institutional system is reorganizing along the original regime, but it has also developed an alternative pathway that will transform it in the near term. We evaluate the usefulness, strengths, and weaknesses of the adaptive cycle analogy in this application.

Growth, Collapse, and Reorganization of the Annapurna Conservation Area, Nepal: An Analysis of Institutional Resilience

Community-based conservation institutions can be conceptualized as complex adaptive systems that pass through a cycle of growth, maturation, collapse, and reorganization. We test the applicability of this four-phase adaptive cycle in the institutional context of the Annapurna Conservation Area (ACA), Nepal. We use the adaptive cycle to assess changes in structures and processes and to explore the past, present, and possible future trends in ACA. We focus on the crisis brought about by the Maoist insurgency and changes that took place in ACA during and after this period. Our analysis suggests that the conservation institution has passed through one and a half forms of the adaptive cycle in five major historical periods in the Annapurna region since 1960. It also appears to have been resilient to the insurgency because the system maintained its identity throughout, avoided alternative undesirable states, and entered into the reorganization phase following collapse. All forms of capital and institutional performance decreased to some extent during collapse, but flexible nested governance structures, including the devolution of responsibility to local entities, the maintenance of capital stocks, the retention of institutional memory, and the perceptions of institutional legitimacy among constituencies, facilitated reorganization. The institutional system is reorganizing along the original regime, but it has also developed an alternative pathway that will transform it in the near term. We evaluate the usefulness, strengths, and weaknesses of the adaptive cycle analogy in this application.

Accrual to National Cancer Institute—Sponsored Non–Small-Cell Lung Cancer Trials: Insights and Contributions From the CCOP Program

Background The Community Clinical Oncology Program (CCOP) has been a success in augmenting accrual to cooperative group research trials from community-based institutions. We analyzed accruals to selected phase II and III cooperative group Non–Small-lung cancer (NSCLC) trials to determine specific accrual patterns that might guide the implementation of future studies and their application to community settings. Patients and Methods Data from each of the adult multispecialty cooperative group trials that studied treatment interventions in NSCLC and completed accrual from 2000 to 2005 were gathered. We tabulated and analyzed information regarding the percentage of total accrual that derived from CCOPs according to cooperative group, extent of disease, trial phase, and modality of treatment. Results CCOP contributions did not seem to vary greatly by phase of study or by extent of disease. In general, CCOP accrual to Radiation Therapy Oncology Group trials was lower than for the other cooperative groups. CCOP accrual to multimodality trials, in which systemic treatment was not the primary study question, was poorer. Trials of standard therapy with or without a new therapeutic agent in advanced disease tend to enjoy better accrual. Conclusion Multidisciplinary studies in NSCLC provide challenges for CCOPs and will require more effort and greater incentives. CCOP leaders should participate more actively in the design and implementation of cooperative group NSCLC trials in order to maximize their participation.

Magnetic resonance imaging and magnetic resonance arthrography of the shoulder: dependence on the level of training of the performing radiologist for diagnostic accuracy

Discrepancies were identified between magnetic resonance (MR) imaging and clinical findings in patients who had MR imaging examinations evaluated by community-based general radiologists. The purpose of this study was to evaluate the diagnostic performance of MR imaging examinations of the shoulder with regard to the training level of the performing radiologist. A review of patient charts identified 238 patients (male/female, 175/63; mean age, 40.4 years) in whom 250 arthroscopies were performed and who underwent MR imaging or direct MR arthrography in either a community-based or hospital-based institution prior to surgery. All MR imaging and surgical reports were reviewed and the diagnostic performance for the detection of labral, rotator cuff, biceps, and Hill-Sachs lesions was determined. Kappa and Student's t test analyses were performed in a subset of cases in which initial community-based MR images were re-evaluated by hospital-based musculoskeletal radiologists, to determine the interobserver agreement and any differences in image interpretation. The diagnostic performance of community-based general radiologists was lower than that of hospital-based sub-specialized musculoskeletal radiologists. A sub-analysis of re-evaluated cases showed that musculoskeletal radiologists performed better. kappa values were 0.208, 0.396, 0.376, and 0.788 for labral, rotator cuff, biceps, and Hill-Sachs lesions (t test statistics: p = <0.001, 0.004, 0.019, and 0.235). Our results indicate that the diagnostic performance of MR imaging and MR arthrography of the shoulder depends on the training level of the performing radiologist, with sub-specialized musculoskeletal radiologists having a better diagnostic performance than general radiologists.

Community-based enterprises: The significance of partnerships and institutional linkages

Community-based institutions used to be driven by local needs, but in recent decades, some of them have been responding to national and global economic opportunities. These cases are of interest because they make it possible to investigate how local institutions can evolve in response to new challenges. A promising set of cases comes from the UNDP Equator Initiative, a program that holds biennial searches to find and reward entrepreneurship cases that seek to reduce poverty and conserve biodiversity at the same time. What can we learn from these local entrepreneurship cases that seem to be playing at the global level? Here we focus on partnerships and horizontal and vertical linkages in a sample of ten Equator Initiative projects. We find that successful projects tend to interact with a large array of support groups, typically 10 to 15 partners. Based on information from on-site research, these partners include local and national NGOs; local, regional and (less commonly) national governments; international donor agencies and other organizations; and universities and research centers. These partners provide a range of services and support functions, including raising start-up funds; institution building; business networking and marketing; innovation and knowledge transfer; and technical training. These findings indicate that a diverse variety of partners are needed to help satisfy a diversity of needs, and highlight the importance of networks and support groups in the evolution of commons institutions.

Community-based enterprises: The significance of partnerships and institutional linkages

Community-based institutions used to be driven by local needs, but in recent decades, some of them have been responding to national and global economic opportunities. These cases are of interest because they make it possible to investigate how local institutions can evolve in response to new challenges. A promising set of cases comes from the UNDP Equator Initiative, a program that holds biennial searches to find and reward entrepreneurship cases that seek to reduce poverty and conserve biodiversity at the same time. What can we learn from these local entrepreneurship cases that seem to be playing at the global level? Here we focus on partnerships and horizontal and vertical linkages in a sample of ten Equator Initiative projects. We find that successful projects tend to interact with a large array of support groups, typically 10 to 15 partners. Based on information from on-site research, these partners include local and national NGOs; local, regional and (less commonly) national governments; international donor agencies and other organizations; and universities and research centers. These partners provide a range of services and support functions, including raising start-up funds; institution building; business networking and marketing; innovation and knowledge transfer; and technical training. These findings indicate that a diverse variety of partners are needed to help satisfy a diversity of needs, and highlight the importance of networks and support groups in the evolution of commons institutions.

Commentary: A Need for Leadership in Primary Health Care for the Underserved: A Call to Action

Health system reform and efforts to achieve universal health coverage are under way. Community health centers have become the centerpiece of the nation's efforts to provide access to primary care for all, and the Massachusetts experience in health care reform has reinforced the need for these safety-net providers. When access is expanded, community health centers experience a greater need for primary care providers, who already are in short supply. To address this need, medical education must become a core part of the community health center mission. Academic medical centers must facilitate this process, and government agencies must provide new regulatory and funding mechanisms. Universal access also requires skilled physician leadership for underserved settings. Leadership training has a direct impact on the ability of medical directors to make continual system improvements. New programs are needed to develop this workforce. To respond to the looming crisis in primary care staffing and leadership for community health centers, we propose as a blueprint a five-step call to action: (1) build horizontally and vertically integrated collaborations between academic medical centers and community health centers, (2) increase opportunities for trainees in underserved primary care settings, (3) offer leadership training for physicians committed to care for the underserved, (4) create a national program to provide longitudinal training and mentorship for potential primary care physician-leaders, and (5) identify new funding mechanisms for medical education in community health centers. This blueprint outlines a process for developing collaborations among academic medicine, community-based safety-net institutions, and government that are needed to achieve meaningful health system reform.