Need For Greater Focus Research Articles

Big data for omni-channel supply chain management: the need for greater focus on people and process

Omni-channel retailing is reshaping consumers' purchasing experiences, and expectations. Supply chain management plays a large role in enabling this experience, where big data is used to optimise fulfilment and other key functions. While discussions on the role of big data in support of supply chain management have centred upon the technological aspects required to enable these functions, less attention has been paid to important people and process aspects. The purpose of this conceptual paper is to demonstrate the need for a broader discussion of the people and process aspects of big data employment for supply chain management in general and omni-channel in particular. These two dimensions are described in greater detail, and areas for further research are identified.

The Quest for a Multidimensional African Standby Force

One of the most novel ideas within the emerging African Peace and Security Architecture (APSA) was the creation and adoption of the African Standby Force (ASF) policy framework in 2003–04. Since its adoption by the African Chiefs of Defense in May 2004, the focus has been on developing a multidimensional peace support operation platform. However, more than a decade after the adoption of the African common defense policy, the ASF’s plan to achieve multidimensional capacities by 2015 or beyond remains elusive. This delay has been attributed to several factors, including civil-military tensions. While the ASF structures have made significant efforts in training peacekeepers, the possibility for a multidimensional force in the foreseeable future has not only been delayed, but also significantly undermined. This article points to the need for greater focus on developing civilian and police personnel in order to equip the ASF with the right mix of capacities to respond to the unprecedented asymmetric conflicts in Africa.

Novel therapies for the treatment of pertussis disease.

Whooping cough, or pertussis, incidence has reached levels not seen since the 1950s. Previous studies have shown that antibiotics fail to improve the course of disease unless diagnosed early. Early diagnosis is complicated by the non-diagnostic presentation of disease early in infection. This review focuses on previous attempts at developing novel host-directed therapies for the treatment of pertussis. In addition, two novel approaches from our group are discussed. Manipulation of the signaling pathway of sphingosine-1-phosphate, a lipid involved in many immune processes, has shown great promise, but is in its infancy. Pendrin, a host epithelial anion exchanger upregulated in the airways with B. pertussis infection, appears to drive mucus production and dysregulation of airway surface liquid pH and salinity. In addition to detailing these potential new therapeutic targets, the need for greater focus on the neonatal model of disease is highlighted.

Intervenções para a aquisição do autocuidado terapêutico da pessoa com diabetes mellitus: revisão sistemática da literatura

In Portugal, diabetes has a prevalence of 13.0%, implying huge costs which reflect how each person relates to the disease. Many interventions developed by health care professionals focus on the acquisition of therapeutic self‐care skills. However, there is no systemization of interventions which may be overall accepted in clinical practice.With the aim of validating which interventions have an impact on the acquisition of self‐care skills, a systematic literature review was conducted following the Prisma Statement® methodology. A total of 36 articles were selected based on predefined criteria and among the studies published between January 2006 and November 2013 and accessed through Medline and other databases using ESBSCOhost.The evidence emphasizes the need for greater focus on the person, their personal characteristics, the meaning they assign to the disease or how they position it in their lives. Culturally designed interventions, such as diabetes nurse case management, nurse‐led telephone follow‐up and support provided by reference people (role‐model), are some of the interventions with greater impact on health gains. The benefits of programs co‐created by patients and health care professionals, which include interactive and problem‐solving approaches, were demonstrated. Nurses are the professionals who are more often considered as major facilitators of educational support and self‐care.

Physical Activity Level and Associated Factors Among Higher Secondary School Students in Banke, Nepal: A Cross-Sectional Study.

This study was carried out to assess physical activity level and identify associated factors among higher secondary school students in Banke district, Nepal. A school-based, cross-sectional descriptive study was conducted among 405 students studying in grades 11 and 12 in 7 higher secondary schools selected randomly. A self-administered questionnaire based on the International Physical Activity Questionnaire was used to measure physical activity level. Only 5% of students were found to be inactive, and domestic and transport-related activities were major contributors to total physical activity score. No significant difference existed for total physical activity and domain-specific and activity-specific scores across different age groups when males and females were tested separately. Being male (P = .046), lower economic status (P = .026), living at a distance of less than 30 minutes (P = .007), walking/cycling to school (P < .001), and studying in government school (P < .001) were associated with increased physical activity scores on multivariate logistic regression analysis. Routine activities such as transport and household chores contributed greatly to total physical activity among students. This study highlights the need for physical activity promotion interventions at school addressing the associated factors and a need for greater focus on leisure-time physical activities.

A Pilot Study of a Method for Teaching Clinical Psychology Trainees to Conceptualise and Manage Countertransference

There is evidence that therapists' countertransference responses can affect the therapeutic relationship. There is also evidence that trainee therapists can experience difficulty understanding and managing countertransference. This evidence suggests the need for greater focus on countertransference in the training of professionals, such as psychologists, for whom therapy is a core activity. However, little is currently known about the best way of providing such training or the impact of such training on recipients. This pilot study examined clinical psychology trainees' responses to a teaching and learning method for conceptualising and managing countertransference. The method was designed to be accessible to a range of psychology trainees including those in cognitive behavioural therapy programmes. This article outlines the method and its pilot evaluation. An anonymous online questionnaire was completed by 55 trainees pre‐intervention and 40 post‐intervention. Qualitative methods were used to examine changes in trainees' analyses of countertransference pre‐ and post‐intervention, and their reports of understanding and managing countertransference. Trainees also rated the intervention. The majority of participants who completed the post‐intervention questionnaire reported that training increased awareness of or the ability to conceptualise countertransference. They reported strategies for managing countertransference, although they were less confident in this area.

Maternal Mental Health Symptoms are Positively Related to Emotional and Restrained Eating Attitudes in a Statewide Sample of WIC Participants

The objective is to examine the association between maternal mental health and emotional and restrained eating attitudes. Data on 700 mothers of infants &lt; 1 y from a statewide sample of the Maryland Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants were collected via a telephone survey. Maternal mental health symptoms were measured on continuous scales for depression (PRIME‐MD), stress (Perceived Stress Scale), and anxiety (Spielberger State‐Trait Anxiety Inventory). Emotional and restrained eating were measured with questions adapted from the Dutch Eating Behavior Questionnaire, with respondents scoring in the upper quartile categorized as high emotional or restrained eating. Multivariate logistic regression was used in the analysis, adjusting for race/ethnicity, infant age, education level, and marital status. Mothers reporting emotional eating reported higher symptoms of depression (OR=4.65; 95% CI 3.12‐6.95), anxiety (OR=2.36; 95% CI 1.7‐3.23), stress (OR= 2.35; 95% CI 1.82‐3.01), and higher overall mental health symptomology (OR= 4.58; 95% CI 2.94‐7.15). There were significant associations between odds of higher restrained eating and symptoms of depression (OR=1.59, 95% CI 1.14‐2.27). Mothers who report symptoms of depression, stress, and anxiety are at risk for emotional and restrained eating attitudes, which may increase their risk of a poor diet. These findings underscore the need for greater focus on addressing mental health symptomology to promote healthy eating attitudes in the postpartum period. The study was funded by the Maryland WIC Program.

Variation in emergency department admission rates in US children's hospitals.

To measure the hospital-level variation in admission rates for children receiving treatment of common pediatric illnesses across emergency departments (EDs) in US children's hospitals. We performed a multi-center cross sectional study of children presenting to the EDs of 35 pediatric tertiary-care hospitals participating in the Pediatric Health Information System (PHIS). Admission rates were calculated for visits occurring between January 1, 2009, and December 31, 2012, associated with 1 of 7 common conditions, and corrected to adjust for hospital-level severity of illness. Conditions were selected systematically based on frequency of visits and admission rates. A total of 1288706 ED encounters (13.8% of all encounters) were associated with 1 of the 7 conditions of interest. After adjusting for hospital-level severity, the greatest variation in admission rates was observed for concussion (range 5%-72%), followed by pneumonia (19%-69%), and bronchiolitis (19%-65%). The least variation was found among patients presenting with seizures (7%-37%) and kidney and urinary tract infections (6%-37%). Although variability existed in disease-specific admission rates, certain hospitals had consistently higher, and others consistently lower, admission rates. We observed greater than threefold variation in severity-adjusted admission rates for common pediatric conditions across US children's hospitals. Although local practices and hospital-level factors may partly explain this variation, our findings highlight the need for greater focus on the standardization of decisions regarding admission.

Demanding and challenging: Men’s experiences of living with a pregnant woman with pelvic girdle pain: An interview study

Background: Pelvic girdle pain (PGP) is a universally disabling condition affecting approximately 50% of pregnant women. Qualitative research describes how PGP leads to struggle in women’s daily lives, makes them question and doubt their roles and identities as professionals and mothers, and test their (marital) relationships. The purpose of this study was to describe men’s experiences of living with a pregnant woman with PGP. Methods: Participants were men whose pregnant partners participated in a project containing both qualitative and quantitative studies in 2009 to 2011. Interviews were conducted in person (n=18) or by telephone (n=8), lasting approximately 20 - 50 minutes. Sixteen men were interviewed during their wive’s pregnancies (M age = 30 years), eight men were re-interviewed within 12 months postpartum and two men were interviewed only postpartum (26 interviews). Results: Three major categories emerged: having no knowledge of PGP, a period of emotional and physical strain, and merging. Pregnancy in a woman with PGP caused men to alter focus from themselves to their partners and family. They expressed worry, powerlessness, inadequacy, and a need for support. They had to adapt and cope, both demanding and challenging. However, they stressed that relationships with their older children improved, and that they and their partners had succeeded in becoming a team. Conclusions: The findings indicated a need for greater focus from midwives and other health care providers on the psychological impact of PGP on the man/partner. This is important, not only for men but for their respective women as well, whereby men influence their partner’s health.

Scoping the context of programs and services for maintaining wellness of older people in rural areas of Indonesia.

Ageing and problems concerning the aged are an increasing and concerning reality in developing and underdeveloped countries such as Indonesia. Improving service quality is important to promote and maintain wellness of older persons, especially in rural areas. To explore programs and services offered to the elderly in a rural area of Indonesia to support them in promoting and maintaining their wellness. To describe roles and practices of health professionals and teams responsible for delivering services to older people. Action research was used with mixed method data collection (interview and survey). Results demonstrated that activities related to the elderly health programs were limited due to budget and facilities. Practices of health staff for elderly in the community focused on intervention tasks, rather than prevention. Lack of available information on the range of programs and services implemented in Indonesia for the elderly in community settings was a limitation of this study. Programs and services for older people have been implemented in Indonesia. However, these do not yet meet their needs, especially in rural areas. There is a need for greater focus on health promotion and illness prevention. Findings contribute to development of international knowledge in community health nursing, as these issues may not be only relevant to Indonesia. It is timely for governments, including in Indonesia, to evaluate health workforce needs in the community and appropriate educational qualifications for delivering optimal health services for older people.

Learning mathematics in two dimensions: a review and look ahead at teaching and learning early childhood mathematics with children's literature.

In the past 25 years an identifiable interest in using children’s literature in mathematics learning emerged (Clyne and Griffiths, 1991; Welchman-Tischler, 1992; Hong, 1996; Hellwig etal., 2000; Haury, 2001). We critically review the rationales given for the use of picture books in mathematics learning, with a special focus on geometry due to its underrepresentation in this body of literature and the need for greater focus on this topic. The benefits and effectiveness of using picture books for children’s mathematics learning and interest have been documented (Hong, 1996; O’Neill etal., 2004; Young-Loveridge, 2004). For geometry, although much learning of shape ideas should be hands-on, two-dimensional figures are essential to develop children’s understanding of plane geometry. Books may effectively engage pre-literate children with plane shapes (van den Heuvel-Panhuizen and van den Boogaard, 2008; Skoumpourdi and Mpakopoulou, 2011) and shapes as gestalt wholes or prototypes (van Hiele, 1986; Clements etal., 1999; Hannibal, 1999). We review several guidelines and evaluative criteria for book selection, including Cianciolo (2000), Schiro (1997), Hunsader (2004), and van den Heuvel-Panhuizen and Elia (2012). Geometry concepts have proven challenging for young students, but their difficulties may stem, in part, from inadequate teacher training and professional development (Clements and Sarama, 2000; Chard etal., 2008) which lead to misconceptions (Oberdorf and Taylor-Cox, 1999; Inan and Dogan-Temur, 2010). Using picture books in teacher training may be an inviting way for early childhood teachers to enhance their own knowledge. We will examine the literature for guidance on incorporating children’s literature into teacher training. In closing we will outline a comprehensive, multi-pronged agenda for best instructional practices for selection and use of children’s books in mathematics activities and for teacher training.

Measurement and modeling of phosphorous transport in shallow groundwater environments

Leaching of phosphorus (P) from agricultural soils, especially those that are sandy, is adversely impacting P-limited ecosystems like Florida's Everglades. A more developed understanding of P and water management strategies and their effects on P leaching is needed to achieve reductions in subsurface P losses, especially from intensively managed dual cropping systems under plastic mulch in shallow water regions. We compared the effects of conservation P and water management strategies with traditional practices on P transport to groundwater. A 3-year experiment was conducted on hydrologically isolated plots with plastic-mulched successive cropping systems to compare high (HEI) and soil test based recommended (REI) external input (water and fertilizer P) systems with traditional sub-irrigation (seepage), and REI with a potential water conservation subsurface drip irrigation system (REI-SD) with regard to groundwater P concentrations above and below the low conductivity spodic horizon (Bh). The REI treatments had higher available storage for rainfall and P than HEI. Use of both REI systems (REI=2098μg/L and REI-SD=2048μg/L) reduced groundwater P concentrations above the Bh horizon by 33% compared to HEI (3090μg/L), and results were significant at the 0.05 level. Although the subsurface drip system saved water, it did not offer any groundwater quality (P) benefit. Mixing and dilution of influent P below the low conductivity Bh horizon between treatments and with the regional groundwater system resulted in no significant differences in groundwater P concentration below the Bh horizon. Groundwater P concentrations from this study were higher than reported elsewhere due to low soil P storage capacity (SPSC), high hydraulic conductivity of sandy soils, and a high water table beneath crop beds. The HEI system leached more P due to ferilizer P in excess of SPSC and used higher irrigation volumes compared with REI systems. Despite a 40% difference in the average amount of added fertilizer P between HEI (187kg P2O5/ha) and REI (124kg P2O5/ha), soil Mehlich 1 P (M1P) values were similar for both systems while they received Pinput. Soil M1P for REI and REI-SD increased to a maximum of 55mg/kg while they received Pinput, and then gradually decreased after Pinput ceased. However, M1P for HEI increased steadily to a maximum of 145mg/kg by the end of the study with continued Pinput. Mehlich-1 P measured six years after the study still showed relatively high levels of P, a legacy effect of Pinput. The main factors influencing groundwater P concentration varied by seasons. During fall with frequent rainfall, the concentrations were influenced mainly by M1P and Pinput, and highlight a need for greater focus on Pinput management (vs. water management) during this season. However, during the dry period of spring, a greater focus on irrigation management is required since depth to water table and rainfall also become contributing factors. Three multivariate models (r2=0.67 to 0.93), for spring, fall, and annual periods, were developed for predicting groundwater P concentrations for a wide range of water and P inputs (0 to 191kg P2O5/ha of Pinput). The uniqueness of these models is that they use readily available hydrologic (rainfall and water table depth), management (Pinput), and soil (M1P) data commonly monitored by growers when managing water and nutrient inputs on agricultural landscapes. The development of similar models may not be necessary for other agro-ecosystems in similar regions since long-term data collected in these regions may be applied, with verification, to the models presented here.

The Art, Science and Philosophy of Newborn Care

Neonates truly constitute the foundation of a nation and no sensible government can afford to neglect their needs and rights. In the last 50y, technology has revolutionized neonatology and we have moved from an exceedingly passive or "hands-off" philosophy to an extremely aggressive or mechanistic approach. Deaths during first 28d of life account for over 60% of all infant deaths and 40% of all deaths of under-5 children. If we have to further reduce infant mortality rate in our country we must focus our strategies to improve health and survival of newborn babies. There should be equitable distribution of resources for the care of mothers and babies in the community and establishment of high-tech newborn care facilities. In 21st century, we must delink and sever our dependence on traditional birth attendants or dais and develop necessary infrastructure and facilities to ensure that every pregnant woman is provided with essential antenatal care and all deliveries take place at health care facilities and they are conducted by trained health care professionals. In the best pediatric tradition, there is a need for greater focus on preventive rather than curative health care strategies because a large number of neonatal deaths occur due to potentially preventable disorders like birth asphyxia, hypothermia, hypoglycemia and infections. The art and science of neonatology should be integrated and we should follow a "middle path" and strike a balance between art and technology in the care of newborns.

Central Bank Independence, Policies and Reforms: Addressing Political and Economic Linkages

Whilst economic, political linkages and relationships constitute the theme of this paper, the paper also attempts to address why central bank independence still lacks certain vital attributes which embody adequate governance and accountability mechanisms - which are necessary if better results in relation to longer term economic and political objectives, in particular, are to be achieved. From this perspective, the growing importance of the shift to a focus on distinguishing between micro and macro prudential regulation is illustrated. The need for such distinction is not just evidenced through the creation of agencies responsible for such affairs within particular jurisdictions which are considered in this paper, but also through the increased realisation and need for greater focus on decision making responsibilities which are to be assigned to political and economic entities at supra national levels. Financial stability, it appears, has more to do with a mere focus on longer term objectives. Financial stability is also concerned with the ability to sustain long term policy objectives whilst being flexible enough to respond effectively to short term unpredictabilities.

Bringing it all together: researcher dialogue to improve synthesis in regional climate adaptation in South-East Queensland, Australia

The effectiveness of climate adaptation policies in one sector can be compromised or aided by policies developed in another sector. When the focus of adaptation is a single geographical region, this potential for interaction between sectoral policies is heightened due to spatial, political and functional proximities. This paper analyses interactions within three suites of climate adaptation options developed for Australia’s ‘South-East Queensland’ region relating to: (1) wetland migration, coastal infrastructure and planned retreat; (2) urban water security and energy demand; and (3) terrestrial biodiversity and agricultural viability. Using the concept of ‘institutional interplay’ to structure a process of dialogue amongst researchers, we identify a number of critical implementation requirements for successful regional-scale adaptation. There is a need for greater focus on neighbourhood or sub-regional scales of policy design and intervention, particularly for the coordination of adapted infrastructure and services to households. Policy-makers must also be more explicit in considering broader drivers of land-use change and economic adjustment likely to impact on proposed adaptations. In considering these issues, our paper also demonstrates a process for conducting cross-sectoral syntheses that can be employed in other regional-scale adaptation studies.

Eating Disorders May Pose Greater Risk in Type 1 Diabetes

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessEating Disorders May Pose Greater Risk in Type 1 DiabetesLeslie SinclairLeslie SinclairSearch for more papers by this authorPublished Online:25 Jun 2013https://doi.org/10.1176/appi.pn.2013.6b18AbstractClinicians must discern whether poor diabetic control is just that, or something more troubling in patients with type 1 diabetes.When treating patients with type 1 diabetes (DM-1), clinicians often focus on the potential for microvascular and macrovascular complications, such as retinopathy and cardiovascular disease. But many DM-1 patients are at much greater risk for a different complication: an eating disorder.DM-1 is among the most common chronic illnesses of childhood, with a prevalence of 0.1 percent in the general population, affecting both genders equally. “The highest risk for an eating disorder appears when patients are diagnosed with DM-1 between ages 7 and 18 years,” explained Erin Sterenson, M.D., a psychosomatic medicine fellow at the Mayo Clinic in Rochester, Minn., who led the Academy of Psychosomatic Medicine’s seminar “Eating Disorders Through the Lifespan” at APA’s 2013 annual meeting in San Francisco in May. Routine methods for monitoring and controlling blood glucose levels can be mistaken for signs of an eating disorder in DM-1 patients.Dmitry Lobanov/ShutterstockSterenson explained that although the prevalence of anorexia nervosa in DM-1 patients is thought to be equal to that in non-DM-1 patients—which she noted are between 0 percent and 3.2 percent—the prevalence of bulimia nervosa is much higher, up to 35 percent compared with 1 percent to 2 percent in the general population. DM-1 patients with disordered eating, informally known as diabulimia, have an unusual and potentially dangerous method for purging calories at their disposal: insulin restriction or omission. When insulin is underdosed in these patients, muscle and fat are broken down into ketone bodies, sugar is unable to enter cells and be used for energy, and sugar (calories) is purged via urination, resulting in weight loss. How common are eating disorders in DM-1 patients? Sterenson pointed out that studies suggest DM-1 patients are two to four times more likely to experience an eating disorder than are nondiabetics. Consistent with other forms of eating disorders, 95 percent of DM-1 patients with eating disorders are female, and 45 percent are aged 15 and 30. Rates of insulin omission also appear to peak between the ages of 15 and 30 in diabulimic patients. But detecting an eating disorder in a DM-1 patient can be challenging, Sterenson said. There are many legitimate reasons why DM-1 patients might restrict their insulin intake, such as simply forgetting to dose themselves. Fear of hypoglycemia and its social implications, uncertainty about carbohydrate counts, increased physical activity, and limited access to food or medical supplies in certain settings can also result in insulin restriction.Identifying DM-1 patients with eating disorders is made even more complicated by the lack of a validated screening tool. Tools designed for non-DM-1 patients can be misleading. “The general screening tools often ask questions that most of our patients with DM-1 are encouraged to incorporate into their daily life, such as being aware of calorie content and carbohydrate content,” said Sterenson. “On the other hand, these screening measures don’t evaluate patients for insulin omission or underdosing.” Normal aspects of management of DM-1 can also create risk factors for an eating disorder. Dietary restraint and preoccupation with food, disregard for hunger and satiety cues, perceived and actual loss of control and independence, and a focus on exercise are all aspects of daily management of DM-1, as well as potential triggers for an eating disorder. But there are signs and symptoms that should raise a clinician’s “index of suspicion” for an eating disorder in a DM-1 patient, Sterenson emphasized, including extreme concerns about body shape or weight, intense exercise regimens, and low-calorie meal plans. Unexplained elevations in HbA1c, repeated episodes of diabetic ketoacidosis, and resistance to treating hypoglycemia should also be investigated. And while detection of an eating disorder in a DM-1 patient can be tricky, treatment and prevention are even more complicated, she noted. Psychotherapy, assessment and treatment of psychiatric comorbidities, and less-intensive dietary management are some appropriate approaches, but little information about the effectiveness of any specific treatment is available, and Sterenson stressed the need for greater focus on evaluating and treating diabulimic patients. “For many DM-1 patients, eating disorders present a much greater risk than the microvascular and macrovascular complications on which we so often focus,” she said. ■To watch a video interview of Sterenson, go to http://www.youtube.com/watch?v=eAW5wqDxeyE. ISSUES NewArchived

État des lieux de la formation des internes en DES de dermato-vénéréologie en France (2005–2010)

Training procedures for dermatology residents have never been evaluated in French university hospitals. The present study describes the methods used over the last 5 years. This was a retrospective survey using a questionnaire sent to French dermatology-residents completing their residency between 2005 and 2010. The data collated included information on theoretical aspects (courses, local, regional or national seminars, meetings) and on practical training (consultations, surgery, laser and cosmetic dermatology), research, post-residency assistantship and additional university diplomas, as well as overall opinions on dermatology training. Statistical analysis was descriptive and comparative according to the number of dermatology teachers (professors, senior lecturers) in the region in which training was given. One hundred and twenty-two questionnaires were analyzed: 72 from regions with two or less than two university hospital dermatology teachers (group 1) and 50 with more than two such teachers (group 2). Fewer residents had completed a research year in group 1 (19% vs 40%; P=0.01), but the two groups were comparable concerning post-graduate training (DESC) (16%) or post-residency (87%) placement. There were no differences concerning local theoretical training or participation in seminars or meetings, apart from inter-regional seminars, which were more frequent in group 2 (24% vs 3%; P<0.001). There were no differences between the two groups in terms of personal consultations (91%), surgery (62%), laser treatment (13%) or cosmetic dermatology (3%). Satisfaction rates regarding theoretical and practical training were similar in both groups (69% vs 70% and 72% vs 78%, respectively). This is the first survey carried out with the aim of evaluating suitability of training for dermatology residents in France with regard to the "reference" dermatological practice recently submitted to the French health ministry. The present results, obtained from 47% of residents receiving training during this period, show only very few differences concerning dermatology residency training with respect to the number of university hospital dermatology teachers, apart from research training. Despite an overall good opinion on their residency, the dermatology residents involved underlined the need for greater focus on teaching of technical skills (surgery, laser, cosmetic dermatology).

Project risk and appeals in U.S. Forest Service planning

The National Environmental Policy Act (NEPA) requires U.S. Forest Service planning processes to be conducted by interdisciplinary teams of resource specialists to analyze and disclose the likely environmental impacts of proposed natural resource management actions on Forest Service lands. Multiple challenges associated with these processes have been a source of frustration for the agency. One of these challenges involves administrative appeals through which public entities can challenge a Forest Service decision following a NEPA process. These appeals instigate an internal review process and can result in an affirmation of the Forest Service decision, a reversal of that decision, or additional work that re-initiates all or part of the NEPA process. We examine the best predictors of appeals and their outcomes on a representative sample of 489 Forest Service NEPA processes that were decided between 2007 and 2009. While certain factors associated with pre-existing social contexts (such as a history of controversy) or pre-determined elements of a proposed action (such as the extraction of forest products) predispose certain processes to a higher risk of appeals, other practices and process-related strategies within the control of the agency also appear to bear meaningful influence on the occurrence of appeals and their outcomes. Appeals and their outcomes were most strongly related to programmatic, structural (turnover of personnel in particular), and relationship risks (both internal and external) within the processes, suggesting the need for greater focus within the agency on cultivating positive internal and external relationships to manage the risk of appeals.

Socio-ecological Influences on Health-Care Access and Navigation Among Persons of Mexican Descent Living on the U.S./Mexico Border

The study reported here examines factors influencing decision-making concerning health care access and navigation among persons of Mexican origin living along the U.S./Mexico border. Specifically, the study examined how persons with limited financial resources accessed these two systems. Seven focus groups were held with 52 low income Mexican American people aged 18-65 years. Transcripts were analyzed to identify themes in Atlasti 5.0 software and the theory used included a socio-ecological framework and complemented by constructed from the Social Cognitive Theory. We found that in addition to a lack of insurance and financial resources to pay for health care; fear, embarrassment and denial associated with a diagnosis of illness; poor medical personnel interactions, and desire for quality but streamlined health care also influenced decision making. This theory-based study raises important issues if health care is to improve the health and welfare of disadvantaged populations and points to the need for greater focus on medical homes and prevention and early intervention approaches.

Exposed or not exposed? Exploring exposure classification in studies using administrative data to investigate outcomes following medication use during pregnancy

The aim of this systematic review was to examine and compare differences in the way medication exposures are classified in studies using linked administrative data to investigate outcomes following medication use during pregnancy. This was undertaken with a focus on studies investigating specific neonatal outcomes following prenatal exposure to selective serotonin reuptake inhibitors (SSRIs). We searched Medline and Embase to identify studies that used linked administrative data to investigate specific neonatal outcomes (congenital malformations, birth weight, gestational age) following prenatal exposure to SSRIs. Key factors such as dose, duration and timing of exposure were inconsistently addressed in the studies identified. In addition, there was a great deal of variability in the way medication exposures were classified and how women who stop taking their medication before or during early pregnancy are handled in analyses. Furthermore, there are issues in assuming how and when women who receive a dispensing for a medication actually take it during pregnancy. This creates a great deal of uncertainty around medication exposure during pregnancy in studies using linked administrative data, potentially resulting in biased risk estimates. There is a need for greater focus on determining the most effective and accurate way of using linked administrative data to investigate outcomes following medication use during pregnancy in an effort to minimise potential biases.