This project is part of the Translating Research in Elder Care (TREC) program of research, a multi-level and longitudinal research program being conducted in 36 nursing homes in three Canadian Prairie Provinces. The overall goal of TREC is to improve the quality of care for older persons living in nursing homes and the quality of work life for care providers. The purpose of this paper is to report on development and evaluation of facility annual reports (FARs) from facility administrators’ perspectives on the usefulness, meaningfulness, and understandability of selected data from the TREC survey.A cross sectional survey design was used in this study. The feedback reports were developed in collaboration with participating facility administrators. FARs presented results in four contextual areas: workplace culture, feedback processes, job satisfaction, and staff burnout. Six weeks after FARs were mailed to each administrator, we conducted structured telephone interviews with administrators to elicit their evaluation of the FARs. Administrators were also asked if they had taken any actions as a result of the FAR. Descriptive and inferential statistics, as well as content analysis for open-ended questions, were used to summarize findings.Thirty-one facility administrators (representing thirty-two facilities) participated in the interviews. Six administrators had taken action and 18 were planning on taking action as a result of FARs. The majority found the four contextual areas addressed in FAR to be useful, meaningful, and understandable. They liked the comparisons made between data from years one and two and between their facility and other TREC study sites in their province. Twenty-two indicated that they would like to receive information on additional areas such as aggressive behaviours of residents and information sharing. Twenty-four administrators indicated that FARs contained enough information, while eight found FARs ‘too short’. Administrators who reported that the FAR contained enough information were more likely to take action within their facilities than administrators who reported that they needed more information.Although the FAR was brief, the presentation of the four contextual areas was relevant to the majority of administrators and prompted them to plan or to take action within their facility. In a pilot study conducted prior to the TREC research program, care managers in four participating nursing homes had been provided with a final report on survey findings from their units . This fapractice . Archer practice . Previoupractice . As the practice .The aim of the present project was to develop and evaluate a KT intervention, namely feedback reports to facility administrators, and examine whether facility administrators used the information to prompt action in their facilities to support their overall efforts to increase quality of care for residents and quality of work life for staff. In this paper we report on the development and evaluation of facility annual reports (FARs) from facility administrators’ perspectives to: determine whether facility administrators’ decision to take action based on FARs varied based on their perceptions of usefulness, meaningfulness, and understandability of the FARs, and report length; and assess whether facility administrators’ decisions to take action based on FAR varied by facility demographics, specifically size of facility, owner-operator model, province, and geographic location . The following research questions guided the study: To what extent do facility administrators: use information from the FAR to take actions in their facility?; perceive the information to be useful, meaningful and understandable?; and perceive the report to contain adequate information?e.g., site administrators, Directors of Care) from the 36 TREC study sites in the three Canadian Prairie Provinces  were invited to participate in this study. A cross-sectional survey design was used in the study.Facility administrators  for the facility along with comparative data from other TREC study sites in the same province for the first year of data collection. The first page of the report provided information about timing of the two data collection periods and sample size at each time point. The second and third pages presented the results for the contextual areas in a bar graph accompanied by brief explanatory text. An example for Job Satisfaction is presented in Figure FARs were prepared for quarterly distribution. Specifically, each facility administrator received the FAR within two months of completion of time two data collection. A cover letter introducing each FAR and an invitation to complete a short interview to evaluate the feedback reports were sent to facility administrators via express post.To evaluate their perceptions of the FAR, we conducted telephone interviews with facility administrators three to six weeks after sending the FARs. Interviews were conducted by two researchers using a structured interview guide, consisting of nine questions with fixed response alternatives. Four of these nine questions had an open-ended follow-up question. Administrators were asked the extent to which they found the presentation of each of the four contextual areas  meaningful, understandable, and useful. They were asked to rate their responses using a four-point Likert scale, from 1 = very low extent to 4 = very high extent. Administrators were also asked whether the FAR prompted them to implement any changes within their facility. They were encouraged to elaborate on their responses, for example, whether they wanted to have information about other areas, not currently included in the FAR, in the future. Responses were recorded on the interview guide. Interviews took approximately 20 to 30 minutes to complete. In addition to the interview data, facility administrative data on areas such as number of beds (size of facility) and owner-operator model were used in the analyses. These latter data are routinely collected in the TREC program.Ethical approvals for this study were obtained from Health Research Ethics Boards from the University of Alberta, University of Calgary, University of Saskatchewan, and the University of Manitoba and the operational review boards (where applicable) for all facilities participating in the study.© version 18.0 [Data were double entered into a PASW statistics database. Data were analyzed using PASWion 18.0 . DescripOf the 36 facility administrators, 31 participated in the study. Because one administrator was responsible for two facilities, data were obtained from 32 nursing homes (response rate 89%). Of the 32 nursing homes, 15 were in Alberta, 11 were in Saskatchewan, and 6 were in Manitoba. See Table Six administrators reported that they had taken actions in their nursing homes in response to the FAR. Actions included development of a staff survey about triggers of stress in the workplace , use of information in the facility’s business plan, implementation of a log book to improve communication processes with staff, installation of additional ceiling track lifts to improve staff resources (in an effort to reduce staff burnout), and comparison of FAR data with results of an internal facility survey conducted by the quality committee. One administrator indicated that the FAR revealed a lack of communication among staff. Another administrator reported that staff lacked social support after experiencing stressful situations at work.A further 18 administrators who reported that they intended to take actions as a result of the FAR were planning the following activities: conduct an internal employee satisfaction survey and job evaluation to compare findings with the FAR, invite a speaker to talk with staff about grief (in an effort to reduce workplace staff burnout), and conduct performance appraisals (feedback processes). Three administrators were planning to incorporate FAR findings into their facility’s business plan, while four administrators were gathering more information to inform decisions about actions to improve workplace culture.e.g., staff satisfaction). Most administrators who indicated the FAR was useful found comparisons between years one and two of data collection and within-province comparisons of study facilities useful for benchmarking. Five administrators found the staff burnout information less useful due to lack of knowledge on this area. Twenty-six administrators reported sharing the FAR with the Chief Executive Officer, care managers, the management team, and the staff. Seven administrators had shared the information with persons outside the facility, such as those at the corporate/regional office.The majority of administrators considered the FAR useful. Mean values for usefulness of the four contextual areas ranged between 3.34 and 3.06 (range 1 to 4) Table . Three aFacility administrators scoring of the FARs usefulness, meaningfulness and ease of understanding for each of the four areas  and a comparison of facility administrators scoring  of these areas based on taken actions in facility due to FAR.The majority of administrators found the four contextual areas in the FAR meaningful. Mean values for meaningfulness ranged from 3.44 to 3.13 Table . Twenty-Information contained in the FAR was perceived to be understandable by nearly all administrators. Mean values for ease of understanding ranged from 3.56 to 3.25 . Five of the six administrators who decided to take action worked in small facilities Table . The remIn this discussion we present lessons learned during the development and distribution of the FAR, and suggestions for future research on providing feedback to administrators.Previous research has stressed the importance of involving decision makers in the research process to increase the likelihood of uptake of research findings in practice . There ia priori. A useful future study might examine whether a tailored feedback report from the perspective of administrators and managers prompts a greater percentage of administrators to take action in their facilities compared with a generic template feedback report.In developing the FAR, resource constraints required that we present the same four contextual areas to all administrators. From the interviews, the majority of administrators desired information on additional areas from the TREC survey, such as resident aggressive behaviours towards staff, information sharing between staff, and overall job satisfaction. Some administrators also wanted to have quality of care indicators for future FARs. One basic principle for successful feedback is to tailor the feedback to the recipient’s needs and understanding; in this case to enhance quality of care for the residents and quality of work life for staff . Thus, aAdministrators who reported that the FAR contained enough information were more likely to have taken actions when compared with administrators who needed more information. We did not ask administrators to elaborate on the reasons why they reported that the FAR contained enough information or not. Some of them indicated that including the survey question might have helped them to understand the responses better.et al. did not provide evidence that audit and feedback combined with other interventions, such as educational meetings or outreach, were more effective than audit and feedback alone [When the FAR was mailed to administrators, we did not provide an opportunity for more detailed information about its content, such as an information session or detailed individual outreach. At the time of the follow-up phone call, the interview became the opportunity for the administrators to ask their questions about the content. Several administrators requested more information, for example, about the meaning of feedback processes and staff burnout. These two areas were also scored lowest by the administrators in relation to usefulness, meaningfulness, and ease of understanding Table . While tck alone , our intck alone .The Decision Innovation Process from Roger’s theory is helpful in interpreting findings from this study . For theOur findings suggest that future research on feedback should provide opportunities for face-to-face conversations with administrators in areas such as: describing more about the content of presented areas and data; discussing the importance of this area in relation to quality of care for residents and quality of work life for staff; and facilitating decisions about what actions could be taken by facility administrators. Future research should also explore, from the perspective of administrators and managers, what constitutes the optimal amount of information in a feedback report to inform decision making.Twenty-six administrators reported that they had shared the information with their management group or team in the facility. Some of them had also shared the FAR with front-line staff. In the information letter which was sent together with the FAR we did not recommend that the administrators share the FAR or take any action. The FAR was looked upon by the investigators as the administrator’s privileged report, and it was up to the administrator to decide what to do, with whom, and when. Although we received responses that some of the information in FAR was a bit unclear, the administrators did share the FAR with care managers and staff. We believe that the sharing of the FAR is an important step in the process of enhancing quality of care for residents and quality of work life for staff. Several researchers have suggested that leadership is crucial to successful quality improvement and the implementation of research findings in practice -28. ImpoWe note some study limitations. First, although nearly all administrators of the 36 facilities in the TREC research program participated in this study (response rate was 89%), the sample size was small (n = 31). This limited our statistical analysis because we were unable to conduct advanced statistical modeling. We conducted ANOVA analysis for some of the research questions however the small sample means we have greater risk for type I error. The findings from these analyses must be interpreted with caution. Second, interviews were conducted by phone using a structured interview guide with several questions including fixed response alternatives. This was done in order to keep the interviews short, given administrators’ limited time. However, this approach limited the opportunity for in-depth exploration of some areas. For example, respondents’ perceptions of what was ‘enough’ information in the report. Third, potential for social desirability bias may have led to overestimation of the FAR’s usefulness. In future research, investigators should include interviews with other staff, such as care managers to add a variety of perspectives and enrich the evaluation of the feedback reports. Furthermore, a larger sample of facility administrators would be needed to conduct advanced statistical analysis.Although the FAR was a short four-page brochure with brief text and tables the presentation from the four contextual areas made sense for the majority of administrators and prompted them to plan or to take actions within their facility. The findings of the FAR project have important implications for providing feedback to facility administrators. First, clarity is needed on data to include in feedback reports, and how to tailor feedback to the needs of the administrators. In particular, relevance of content and level of detail may potentially influence the likelihood of findings being used to inform change. Second, means of distribution should be considered. Just sending a feedback report without opportunity for support or discussion with a knowledgeable person will likely reduce its usefulness. Finally, expectations on the extent and type of actions that administrators will undertake due to the feedback report must be realistic. The report will be one information source among many that inform decision-making processes.TREC: Translating Research in Elder Care; FAR: facility annuals report; LTC: long-term care; KT: knowledge translation; MBI: Maslach Burnout Inventory.The authors declare that they have no competing interests.AMB designed the study, provided leadership for the study and lead the manuscript development. LAC assisted in data collection and analysis, and manuscript development. AMH contributed to the design of the feedback reports and manuscript development. GGC is provincial site lead for the TREC research program in Alberta. PN is co-lead investigator for project one of the TREC research program. CAE is the principal investigator for the TREC research program and conceived the FAR study. CAE, PN and GGC participated in securing the funding for the TREC research program. CAE, GGC and PN provided commentary on the final submitted manuscript. All authors read and approved the final submitted manuscript.


Home care of under-five children is one of the most important interventions in the control of diarrheal diseases. It has a significant impact in reducing childhood mortality and morbidity.This study was conducted to evaluate the effect of health education on home care of under- five children with diarrheal disease.This is a quasi- experimental study, held in Al Maki neighborhood, which is located in Greater Wad Medani locality, Gezira State, Central Sudan. The study targeted a random sample of 118 mothers who have at least one child under- five years of age with diarrhea needing home management. The study was conducted in three phases. Phase one was a base line survey for the mothers. Intervention phase including different health education approaches, home visits, group sessions and distribution of mother cards through community volunteers and researchers. Post intervention survey using the same pre-intervention questionnaire, and observation of mothers managing their children.Results showed that knowledge of mothers about definition of diarrhea, its danger, when to seek medical help and the three rules of home management which was found to be 35, 28, 13 and 29% improved significantly after intervention to 91, 94, 92 and 93% respectively with a very high significant level.We recommended that volunteers are effective health education provider especially on household based intervention. Health services should support the community based interventions to reinforce the knowledge and practices of mother towards the sick children. Knowledge, attitudes, and practice (KAP) studies that evaluate the knowledge of communities regarding disease uncovered marked deficiencies in the level of education given to people at risk of contracting disease. Therefore, health education programmes aimed at improving community participation in control strategies were recommended. A control programme could be achieved successfully if implemented by the village head. The information gathered through these studies could serve as a basis for a quality improvement programme by educating health professionals and the community on disease and its management, to ensure the availability of medications in health facilities, and improve patients’ access to health services.Diarrhea is defined as the passage of three or more loose or watery stools (loose stools take the shape of the container) in a 24-hour period.4Health education is the first component in primary care. It is defined as ‘any combination of learning experiences designed to lead to a situation where people know how to attain health, do what they can individually and collectively to maintain health and seek help when needed.’ Health education aims at changing of behavior and life style.The importance of home management of diarrhea lies in the fact that diarrhea starts at home, and continues at home on return from being seen at a health facility. A lot of fluid is lost in diarrheal stools, and if suitable fluids are given in adequate volumes soon after the onset of diarrhea, dehydration can often be prevented. However, the fluids given must meet certain criteria when given in large volumes. They are easy to prepare, but should be familiar and acceptable to the child, and effective. Specific recommendations such as rice water, soup, yogurt, and oral rehydration salt (ORS) agreed on by the UNICEF are important.Feeding of the child should continue, particularly with plenty of nutritious food, to prevent any decline in growth necessary during and after the episode of diarrhea. Mothers usually prefer traditional methods of managing diarrhea, and only seek medical advice when it fails. Unfortunately, this is usually too late. The child is either already dehydrated or has started to lose weight. Therefore, it is important to notice and identify certain symptoms or signs in order to seek medical advice promptly.Previous studies done in Sudanese villages around Khartoum city showed evidence of the significant role of health education in improving the management of diarrhea at home.–8The efficacy of health education in improving home management of diarrhea has been proved and recommended in some studies in sub-Saharan African countries,10 India,1112This paper has three objectives; first, to assess KAP of mothers on home management of diarrhea; second, to evaluate the effect of educating mothers on health matters to improve health care for children less than five years of age with diarrhea; finally, to improve the competence of mothers in managing diarrhea at home.This is a quasi-experimental study held in Al Maki neighborhood which is located in Greater Wad Medani locality, Gezira State, Central Sudan. The total population of Almaki neighborhood is 11624 of different ethnic backgrounds. The total number of families is 1183. The target group of this study was mothers who had at least one child less than five years of age with diarrhea needing home management. The World Health Organization (WHO) definition of diarrhea which is the passage of three or more loose or watery stools (loose stool being stools that would take the shape of the container) in a 24-hour period was used for the purpose.[Health education was provided by 24 female volunteers, who were members of the Red Crescent, with secondary level of education, selected from the same area. They had previous experience in voluntary work in national immunization drives, a week for the control of diarrhea. The health education sessions were supervised by eight nutritional educators, vaccinators, and teachers from Almaki area. The work was implemented in three phases. In phase one, a baseline survey was conducted with the aim of measuring the KAP of the mothers in managing diarrhea at home. The training of the volunteers took place during this phase. A health education package on the home management of diarrhea was formulated and tested. This dealt with the definition, etiology, assessment of complications, and management of diarrhea.This curriculum was taught in a three-day course of 14 contact hours. The methods used in the training were lectures, group discussion, a video show, role plays, and clinical sessions using mother cards. Participants were evaluated by means of multiple choice questions, group work presentation, and interviews by supervisors. Twelve sessions of focus group discussion were held with mothers and supervisors to determine the implementation of the health education sessions.In phase two, the mothers were divided into 24 groups, five households in each group supervised by one volunteer, and one supervisor having the oversight of three volunteers. Volunteers did one session per week for their groups for four months, meeting in a different home for each session. The supervisor made two visits each to her designated household, and the researcher held a session once every month at the health centre for the mothers, volunteers, and supervisors to consolidate the issues raised in the health education, followed by a meeting to discuss the different reports presented by the volunteers on the progress of work, and resolve any issues or problems.In phase three, the women had no instructions for three months and then were given the postintervention interview. The postintervention survey was conducted using the same preintervention questionnaire, and the mothers’ reports on the preparation of the ORS and the quantity administered.The Statistical Package for Social Sciences (SPSS) software programme was used for data analysis. Frequency distributions were obtained and descriptive statistics was calculated. Also, the Chi-square test was used to test the differences between the pre- and postintervention situation.The majority of fathers (70.9%) were unskilled laborers, 16.4% were workers, and 12.7% were employees. Families with one child less than five years were 45.5% with two children were 37.3%, three children were 11.8%, and only 5.5% had four children.One important determinant affecting the standard of living and social welfare was family income. The children’s environment had a major influence in their well being and survival. According to the multiple indicators survey which was conducted in Central Sudan in 2000, the prevalence rate of diarrhea in children under the age of five years was 27%, while for children less than two years of age it was 39.2%.The household survey conducted in northern Sudan to assess mothers’ KAP toward home management of a child with diarrhea showed that the knowledge of mothers of the three rules of management  showed that 15% of the mothers surveyed knew these three rules.–8The study shows that the significant improvement in the knowledge of the mothers of the three rules of home management after intervention was consistent with the findings of other studies, proving that health education using volunteers is an effective means of improving mothers’ competence in caring for their children at home during episodes of diarrhea. The level of education of the mothers was low, some were illiterate. However, most mothers had two or more children, which indicated that they were only housewives, this means more involvement of mothers in home business, reaching mother at home with somebody who is familiar to them, will let them don’t feel shy to ask about unclear points, all these are assets in receiving the health education messages.Weighing of children is an important means of monitoring the growth of children under the age of five years, and should be done simply by plotting the weight at definite intervals and calculating the rate over specified periods as part of the welfare of children under five years old. To achieWe conclude that health education activities like personal communication, focused group discussion, lectures, and home visits achieved through volunteers produced a significant improvement in mother’s KAP with respect to home care for children under the age of five with diarrheal disease. Finally, we recommend that different approaches used in health education would be an effective strategy for the improvement of mothers’ competence in managing their children at home. Health services should support the community-based interventions to reinforce the activities, raise the referral level, and improve consultation.


In many countries occupational health care system is in change. Occupational health studies are mainly focused on occupational health substance and content. This study offers new perspectives on municipal OHS and its operations from management perspective.The aim of this study is to analyse how New Public Management (NPM) doctrines are applied in the Finnish occupational health care system (OHS). The main focus is to describe and compare the views of decision-makers' and OH workers within the framework of NPM.The data were collected by semi-structured interviews from 17 municipal decision-makers' and 26 municipal OH workers. Data was analyzed by examining coded data in a theory-driven way according to Hood's doctrine of NPM.The doctrines were not as compatible with the OH personnel view as with the decision-makers' view. Decision-makers and OH personnel highlighted the strict criteria required for operation evaluation. Moreover, decision-makers strongly accentuated professional management in the public sector and the reorganization of public sector units. These were not equally relevant in OH personnel views. In OH personnel views, other doctrines  were not similarly in evidence, only weak evidence was observed when their importance viewed as medium by decision-makers. Neither of the respondents group kept the doctrine of management models of the private sector relevant.The NPM and Hoods doctrine fitted well with OH research. The doctrine brought out view differences and similarities between decision-makers and OH personnel. For example, policymakers highlighted more strongly the structural change by emphasizing professional management compared to OH personnel. The need for reorganization of municipal OH, regardless of different operational preconditions, was obvious for both decision-makers and OH personnel. The adaptation of more clarify management to a municipal context is not trouble-free. The municipality systemic structure, complex operational environment, and reconciliation of political and officer authority set challenges to management of municipalities. The aim of this study is to analyse how New Public Management (NPM) doctrines are applied in the Finnish occupational health care system (OHS). The main focus is to describe and compare the views of municipal decision makers and OH workers within the framework of NPM.The arguments for this study are the following. New public management ideas were adapted in Finnish public administration quite late during the 1990s, introducing decentralisation, simplification of the central administration, stricter control of expenses, public utilities, outsourcing of the services, and renewals to improve the client-oriented operation. These trends still have a strong influence in the Finnish occupation health system. In addition, the content of Finnish occupational health has needed reconsideration based on changes in the working life. For instance, a knowledge-intensive working life with irregular working contracts and increasing skill demands requires a new orientation and new working methods in occupational health. In addition to content development, the structures of OHS are being changed. The division of labour between private and public service providers is changing, the number of private actors has increased, and this has challenged the traditional ways of working for public services providers.Previous OH studies are focused mainly on OH substance and content  e.g -3]. We h. We h3]]The scholarly debate about NPM reforms has increasingly been influenced by what Premfors  labels tDespite early efforts to place the debates on the shift to New Public Management within broader processes of economic and political restructuring - processes that suggest that various trajectories are possible - much of the literature has tended to assume that the shift is inevitable ,19. The So the literature on NPM is now quite wide and includes official exhortations to adopt various elements of NPM, academic considerations of the advantages and disadvantages of NPM, and various texts dealing with specific elements of NPM techniques . Within As earlier stated, binding the NPM discussion to a single perspective is challenging. Table Besides NPM's comprehensive definitions, in the literature NPM is also approached by emphasising the more compact content part of NPM. For instance, van Wart & Bergman , Pollit According to Lane  on goverHowever, Boyne , SandersOn the contrary, several researchers ,41,42,44Public sector entrepreneurship is also an essential part of NPM content ,46. MorrOne way to analyse the NPM concept is to make a list of the principles of NPM. For instance, Kolthoff et al  introducFurthermore, Hays and Kearney  emphasisHood ,35,53 haIn summary, since the 1990s the definition and content of NPM are considered to be broader. The conversation on the role of NPM as a global phenomenon has especially increased. Thus, the definition of NPM is considered to vary between the countries and the public administrative sector. Nevertheless, Hood's doctrines provide a good basis for the investigation and determination of this multiform public management phenomenon. As seen in Table In Finland, all employers are obliged to organise occupational health services for their employees according to the Occupational Health Care Act (2002) to ensure that the preventative contents of the services take into account the needs of the working life and personal characters. Occupational health care can include medical care and other health care services. Occupational health services are planned as a cooperative effort at the workplace by occupational health professionals. Occupational health services can be organised in several ways: in municipal health care centres, in private medical clinics, services may be integrated into the enterprise, or enterprises can collaborate in organising the concerted occupational health services. The occupational health services, which are free of charge for employees, are substituted by the employers by The Social Insurance Institution of Finland. The Social Insurance Institution pays 60% of the costs in compensation to employers that have concluded an agreement with their occupational health service on activities to maintain work ability, follow-up, and early support at the workplace. On the other hand, if the employer has not made this agreement, the compensation for the costs of preventive occupational health care is 50%.In Finland, there are altogether 663 OH units, which have 1.87 million individual clients in 2007 . This isOne-third of OH units are organised by the municipalities with about 600,000 clients. 91 of 663 units are the only provider of OH services in its area. The system of municipal OH ensures the availability of OH services in the whole country. Private units are for-profit organisations located in larger cities, whereas municipal OH units are not-for profit organisations. Their focus of services is also different: private units provide more medical services and municipal units more preventive services. For instance, the coverage of medical services is much larger in private units (89%) than in municipal units (60%) ,61.Management of Finnish health care can be divided into political and operative management. The municipal OHs are steered through national and municipal policy-making processes. Political management consisted of elected policymakers, who are elected for four-year terms. Elected policy makers control the action of municipal OHs, for example, resources and prices through municipal decision-making processes. At the municipal level, municipal managers implement these political decisions in different organisations. By simplifying, municipal managers are leading and organising municipal OH processes as acting as providers of the services, whereas municipal elected policy makers are acting as purchasers of OH services.Management in health care organisations has traditionally been hierarchical, and this also concerns the management of occupational health care. The management has also been based strongly on professions, especially the medical profession. On the organisational level, management by results and quality management have been the main orientation in management during the last decades. In macro-level management, the provider-purchaser split and client-orientation in management have been the most often-mentioned principles in management. These same principles are similar also in OH management.The functionality of municipal OH units varies a lot. High-quality state-owned OH companies do exist, but many smaller OH units with few overall resources have difficulty ensuring sufficient services for their clients. In the small OH units, there may be only a part-time occupational health (OH) nurse performing the services, and the shortage of OH physicians complicates the pursuits of these units ,61. ThesThe data were collected by semi-structured interviews from 17 municipal decision makers and 26 municipal OH workers from central Finland in January and February 2009. Municipal decision makers consisted of elected policy-makers and permanent municipal managers . A semi-structured interview was based on themes selected beforehand, while there was no clear structure or order in the questions during the interview ,63. ThisThe coding was carried out with the help of the ATLAS/ti program using open coding (ATLAS/ti 5.0). In the present study, data analysis included six phases: (1) transcribing the data into written form, (2) getting a general impression of the data, (3) searching the data for relevant and adequate expressions related to the research aim, (4) using the expressions to form appropriate units, (5) comparing the appropriate units for their similarity and diversity, and (6) creating the final categories: main categories and subcategories. Data was analysed by examining coded data in a theory-driven way according to Hood's doctrines of NPM. Thus, it was observed to what extent the development and change of municipal OH corresponds to NPM content and which extra components are included in the development and change of municipal OH. The results are introduced by Hood's doctrines and with extra components. After analysing the content, doctrines were evaluated by importance (how often the doctrine appears) and variation (unity) between the groups of respondents.Although the data was a case of 12 Finnish OH units, this study represents the situation of OHS in one Finnish province. The collected data were rich and provided the answers sought in this study. This kind of study design corresponds to the study's aim of understanding, not interpreting or generalizing respondents' views. So an added value was to more deeply understand the phenomenon in this special context .Table According to decision makers, there was a clear need for development of accountability and evaluation in occupational health care services. Regional collaboration could be one possible way to arrange uniform quality and a service criteria of "Good occupational health practice" for the entire population of working age.Decision makers thought that OH requirements for levels and the indicator of results should be based on cooperation in OH between municipality and employers. In addition, it is considered important that the indicator of results is based on the needs of municipalities and employers. Cooperation with employers and its development on the whole was a significant challenge from the perspective of both planning and especially OH follow-up and evaluation.Decision makers expected more transparent objective settings to both OH services and the outcome of services. Based on the opinion of decision makers, the focus of OH operation should be more preventative and workplace-oriented. However, the possibility for companies to receive agreements of medical treatment was also regarded as important. Decision makers expected to get information on the effectiveness of OH to support their decision making and promote the welfare of the employees. This, however, requires developments in follow-up and evaluation of operations."I would think that one important target for development would be that we could meet the needs at the working places, as well as possible, the needs of the client firms. After all, that determines the metrics activities." (OH personnel)"If we talk about goals, they are not always clear. Sometimes I also feel that OH is no longer in the workplace. And then the data and report of our workers would be nice to get." (decision makers)OH personnel considered especially corporate client cooperation and workplace-oriented services as a development challenge. Corporate client cooperation was considered as a foundation for accountability. Moreover, the challenges of accountability were emphasised in the OH units' internal operations. Productisation, pricing, marketing, and net budgeting were development challenges.OH personnel saw that quality of operation and quality work produce criteria for service evaluation. Quality work was standardising and strengthening work practices. However, most of the OH personnel thought that the quality of OH needs still improvement. Only a small part of OH personnel thought that the quality of OH is on a good level."Sure, there are things to develop in the quality of our activities, especially the level of quality and monitoring. There is a lot of variation and no uniform working practices." (OH personnel)"The other has a good practices and in cooperation we can certainly improve the quality of health care. Yet the effectiveness of that, yes, it should be assumed from a successful client cooperation." (decision makers)According to decision makers, change in municipal OHS is essential. The unclear role and lack of leadership in OH were considered to be the most significant problems. Regional collaboration was conceived as a possibility for network enabling specialisation and cost-effectiveness. However, regional collaboration was regarded as a possible way to get more responsible, coordinated, and goal-oriented management for future services."It would be more effective cooperating with others, and one would perceive this role better in the occupational health care system and the municipality." (Decision makers)According to decision makers, a more specified management system for OH is required. Especially the OHS detachment from other primary health care was considered problematic. Decision makers thought that OH also has an ambiguous role in the municipal environment. The lack of OH unit management, internal development work of OH units, and lack of resources for these were regarded as the most important challenges for OH units. Decision makers also evaluated their own role in OH management. Decision makers thought that they lack the capability for decisions due to their slight OH knowledge and minor visible role of OH in municipal policymaking processes."There are problems in cooperation. Yes, change is necessary in order to strengthen customership and management. This gives directors an impartial occupational health service and otherwise supports the specialisation." (Decision makers)The management of an OH unit was conceived as a challenge, and this challenge was not recognised in all OH units. Allocation of time between management work and everyday OH activities was seen as problematic. Due to the lack of full-time OH managers, the management reserved more work time than was planned. Management decentralisation in different occupational groups was also problematic in almost all OH units. Especially decentralisation of power complicated OH units' own operation planning."We do not have a real leader. We do everything together or whoever has the time." (OH personnel)"One should find time for leadership. Time goes to basic occupational health activities. The workload of management is always surprising." (OH personnel)"Changes are eagerly anticipated, if only strength could be gained for more professional management. If we would get a real manager, now we are going professional." (OH personnel)Among OH personnel, the required change in management was considered to lead to more active and systematic management. Moreover, the administrative change was thought to clarify the management. On the other hand, structural change was thought to provide both more authority to OH superiors and more responsible and influential management to OH units."Yes, it seems that change and reorganisation is necessary. Occupational health services unit will be able to act more resiliently." (decision makers)The majority of decision makers saw change as a prerequisite for the existence of municipal OHS. According to decision makers, municipal OH requires reorganisation. Reorganisation was considered to include the separation of municipal OH from primary health care in order to create a bigger entity or a public utility. Thus, many advantages were expected: especially security of the OH services in the whole province, cost-effectiveness and its effect on making OH management easier. It was seen that this would also clarify the roles of those people  who are cooperating in municipal OH. Decision makers also appreciated the separation of purchaser-provider from each other in order to clarify their roles. "...and then some; the fact that the removal of basic occupational health care could help us too, the purchaser and the producer could be easily distinguished from each other." (decision makers)Regional collaboration appeared in the context of networking by both allocation of special know-how, resources, and cost-effective operation. The need for disconnecting OH from primary health care strengthened the above-mentioned cooperation. However, decision makers also approached this doctrine through internal development of OH, productisation, and cost-effectiveness.OH personnel did not consider reorganisation of public sector units as important as decision makers. The public utility of OH units was regarded as strengthening and improving municipal OH management efficiency. However, for several OH personnel, structural change was regarded as a threat and the most threatening factors were related to the concern for the OH units' future and to changes in occupational health processes."Sure, this seems to be that public utility is modernity, and this will surely bring efficiency in our operations. New operating models, which are quite welcome, just seems to be the lifeblood." (OH personnel)"The future of occupational health care restructuring, and yes, wondering whether it affects the core of this, and there's always such a combination of stronger roles." (OH personnel)The respondents focused on the cooperation between private and municipal OH in this doctrine. Decision makers perceived cooperation between private and municipal OH mainly by way of functional differences and competition. The functional differences were observed in service supplies and basis for focus. Private OH was considered to be focused on medical treatment and municipal preventative occupational health care. It was recognised that private OH is both gaining ground in metropolitan areas and slowly replacing municipal OH. Regional collaboration was seen as a necessity in municipal OH and structural adjustments. Thus, bigger and (in the operation model point of view) more cost-effective OH units could be created. It was considered that this is the only way to compete against private OH."Is it then just a private alternative to the roles of going crazy, so be regarded as private. After all, those differences in a particular activity, but municipal  should wake up the competition." (decision makers)"It seems that unless the municipality re-organised occupational health care, private power, at least in the growth centres overthrow the municipal health care." (decision makers)Competition inside of municipal OH was not highlighted among OH personnel. Instead, cooperation with private OH units was considered mainly in terms of competition. Private OHS was seen as a threat to municipal OHS. Prejudices were also affiliated against private OH, for instance, as an employer. In contrast to the decision makers, municipal OH personnel did not count competition as a matter that would produce more positive, good quality and cost-effective OH services. Furthermore, in the future, competition against private OH was a concern to OH personnel, and privatisation of Finnish OHS caused some anxiety."It is the private occupational services who are fishing for clients, but the service they provide is quite acceptable. Therefore, it is questionable professional job." (OH personnel)"Of course it  is a clear threat to our municipal services. That is co-illustrated by the competition." (OH personnel)Decision makers approached this doctrine primarily within the OHS multiple change. Better control of expenses and evaluation of resources' requirements were the key factors that were considered to be attainable by implementing structural changes and merging OH units into larger organisations. The lack of resource evaluation was a consequence of unclear cooperation between OHSs and primary health care services and of inadequate collaboration with the corporate client."Of course, also interested in economic issues; seems to be clear that a larger unit would get better control of expenditure and also the size of the resource is more relevant." (decision makers)The effectiveness of OH units was emphasised by decision makers. Effectiveness was considered from the points of view of the public economy and operations. It was thought that this effectiveness could be attainable by producing cost-effectiveness, net-budgeting, and a means test. From the services' point of view, effectiveness was seen above all by means of the OH basis for focus. Decision makers felt that OH services would be more influential if more resources were channelled to preventative work instead of medical treatment. It was stated that by focusing on OH, small resources could also be used to yield quality OH services."If you still come back to effectiveness...after all, since there is a clear link between economic activity and occupational health care, professionals should then consider what is really profitable". (decision makers)Although the great majority of OH personnel saw the structural change as a necessity for ensuring more quality, cost-effective, and multi-professional OH, it was not highlighted in this doctrine. Instead, they considered reasoning of this kind as a threat.Neither the decision makers nor OH personnel stated strongly that more attention should be paid to performance and accomplishments.It was observed that the adaptation of the private sector management models was not essential for municipal OH and its development in both respondents' groups.Two main categories of the NPM in OHS data did not fit the contents of Hood's doctrines. These were: Shared understanding of the challenges in a municipality context and a common goal for action. The respondents didn't share a common understanding of the development challenges. According to decision makers, the changes and challenges of the society came up strongly in the future of OHS. These changes and challenges include, for example, OH's support during in a recession, OH as a support in the change, and challenges of an ageing population. OH personnel did not highlight the change in ambient society as strongly as decision makers. Their talk about the future focused on the OH units' internal matters  and conceivable structural changes.The goal differed between the decision makers and the workers. Decision makers spoke about the meaning of OH and not about the influence of OH. They thought that the meaning of OH is to enhance work ability and work well-being. They also felt that OH is an employment benefit for employees. To OH personnel, the most significant influential factor is the functionality of OH personnel, for example cooperation in the workplace and preventative work. The client was generally regarded as an influential indicator of OH.The aim of this article was to analyse how New Public Management (NPM) doctrines are applied in the Finnish occupational health care system (OHS). The main focus was to describe and compare municipal decision-makers' and OH workers' points of view within the framework of NPM, especially exploiting Hood's ,35 classInterviewees were informed before an interview about its content and the voluntary nature of their participation. Informal consent was obtained from all interviewees beforehand. Anonymity was assured and the individual interviewees cannot be identified. The role of researcher was neutral during the interview and the themes used were congruent in both groups.However, there are some limitations of this study. The results are context-related to the Finnish occupational health care system and therefore the results have to be interpreted and transferred with care. In addition, the NPM approach was used in this study as a theoretical framework, but this choice can be criticised. Alongside NPM, another trend of ideas that emerged behind the structural and functional changes is the New Governance approach. When observing the current management ideology of the Finnish municipal OHS, the framework provided by NPM to analyse development and change was proven adequate. Still, the operationalisation of NPM on a practice level is somewhat problematic. In this study, Hood's doctrine was used as an attempt in this operationalisation process. Hood's definition provided a good basis to analyse how NPM doctrines are applied to the Finnish occupational health care system. The doctrines revealed the state of Finnish municipal OH, although some new themes emerged to fulfil Hood's framework.The results can be summarised as follows: Among both decision makers and OH personnel, the doctrine of strict criteria required for operation evaluation came up strongly. Moreover, decision makers strongly accentuated the doctrines of professional management in the public sector and the reorganisation of public sector units. These doctrines were not equally relevant in the view of OH personnel (medium importance). Decision makers' thoughts about OH's municipal development was more similar to doctrines than the view of OH personnel. Neither group of respondents felt that the doctrine of private management models was relevant. In the respondents views, there were some relevant main categories not included in Hood's doctrines. Altogether, the NPM and Hood's framework fit well with OH research. The framework brought out both municipal OH's development and need for change as well as differences in the views of decision makers and OH personnel.Based on the NPM framework and the results of this study, some relevant issues can be summarised. Firstly, clear authority for the OH management was seen to clarify the challenging role of OHS related to municipal decision makers, other primary health care, and the employers. However, the adaptation of more clarify management to a municipal context is not trouble-free. The system structure of municipalities, complex environment, and reconciliation of political and managerial authority bring challenges for OH management. In this study, a lack of coherent management appeared on different levels by different actors in their strategic thinking. Municipal managers had a cohesive vision of the development of municipal OH, whereas elected policy-makers approached the development and change more pragmatically, and more variation was observed in their views of change. According this study, we can conclude that future strategy was not clear for OH personnel.Secondly, high professionalism in the personnel generates special demands for the management and development of OH. Administration reform accordant with NPM often highlights the confrontation between professionalism and managerialism. OH personnels' views on development leaned much on professionalism - expertise and education - which are not the issues introduced by decision makers. Instead, decision makers brought out the demands for effectiveness in NPM and features of managerialism. However, professionalism and managerialism/NPM can operate side-by-side. It is essential to find a middle-of-the-road path between self-direction and freedom allowed by professionalism and performance measurement and marketing terms entailed by NPM in the development of municipal OH.Thirdly, the need for reorganisation of municipal OH, regardless of different preconditions, was obvious for both decision makers and OH personnel. More entrepreneurship approach and a clear split between purchaser and provider could be one solution to municipal OH development, as well as a backlash against competition with private OH. According to our results the change of Finnish municipal OH contains a lot of elements that fit with NPM, for example the growth of OH personnel authority, more well-defined responsibilities, and fewer decision-making steps.Fourthly, the NPM framework also brought out differences between the OH personnel's and decision-makers' worlds in terms of OH. This is significant information since the starting point of change and development is different among workers as compared to decision makers. It is essential that the following issues are carefully considered: how these two worlds confront each other, how OH personnel adjust to change, and what is needed for municipal OH to develop. In addition, it's important to think about the position of different decision makers in different kinds of welfare systems. In this study, we found different political and professional views on the trend of OH development. It is important to enhance better communication between elected policy-makers, municipal managers, and OH personnel to achieve a common vision of the development of OH. A prerequisite for this cooperation is elected policy-makers' and municipal managers' knowledge of OH needs and possibilities and vice versa.Fifthly, one aim of this study was to test and develop the New Public Management ideology in the context of OH. For this system-level and country-specific analysis, Hood's doctrine provides a good framework. However, it seems that some new elements could be added to Hood's doctrine and some existing elements were not considered important by the respondents. Especially the common goal for action category could be something which should be reconsidered to fulfil Hood's doctrine or the entire New Public Management ideology.In comparison to other countries, the NPM reform has been only partly implemented in Finnish OHS. Whereas in some other countries the wave of NPM may be in the past, it is still present in Finnish health care. The NPM ideology has been the driver for public sector change. NPM has challenged some of the old-fashioned models of management as seen in Finnish health care. In countries where political decision makers have a role in health care, their role should be considered when implementing management models. In the global context, different countries are in different phases in developing their OHS and NPM. Those countries that are developing their OHS would benefit from research-based information of the NPM.The authors declare that they have no competing interests.HH made substantial contributions to the conception and design of the study, the acquisition of the data and the interpretation of the data. She drafted the final manuscript. JL and SR have been involved in drafting the manuscript and revising it critically for important intellectual content.All authors have read and approved the final manuscript.


This report details the outcome of the 1st Hospital Microbiome Project workshop held on June 7th-8th, 2012 at the University of Chicago, USA. The workshop was arranged to determine the most appropriate sampling strategy and approach to building science measurement to characterize the development of a microbial community within a new hospital pavilion being built at the University of Chicago Medical Center. The workshop made several recommendations and led to the development of a full proposal to the Alfred P. Sloan Foundation as well as to the creation of the Hospital Microbiome Consortium. Hospital-acquired infections  are usually acquired between 48 hours and 4 days after a patient has been admitted to the hospital. Nosocomial infections currently affect 5% of patients admitted to medical facilities in the US, with the total number exceeding 1 million people – 1.7 million hospital acquired infections requiring more than 170 million patient days [Despite considerable interest in developing hospitals with reduced nosocomial infection rates, there has been no systematic analysis of the gradual development of pathogenic reservoirs over the course of the months following the opening of new healthcare facilities. Indeed, there is currently very limited direct evidence as to the source of the infections; if these are airborne then any transmission agent that interacts with the hospital environment could be a potential source of transmission. This is why it is essential to explore the systematic action of populating a hospital to at least qualitatively assess the mode of transmission. The primary hypotheses driving the design of the study are:null-hypothesis is that “the presence of existing diverse microbial communities will have no impact on increased nosocomial pathogen accumulation and persistence in the hospital.” Testing this hypothesis will help to elucidate the interactions between members of microbial communities that influence the development of pathogen populations and potentially act to actively inhibit pathogen populations from colonizing hospital systems.A. “The presence of a ‘beneficial’ or ‘human-benign’ microbiome on surfaces in a hospital ecosystem affects the rate of accumulation and the persistence of hospital acquired infective agents.” The null-hypothesis is that “patients are not the primary source for potential infective agents, instead the transient demographics and occupancy frequency of those demographic groups show complex interrelationships and sporadic disease development events”. Testing this hypothesis will be fundamental to the experimental design, and will focus the human cohort sampling .B. “Nosocomial infections are linked to the occupancy patterns of patients that carry and transmit these infections, and the presence of the potential pathogens increases after patients are admitted to the hospital.” The null-hypothesis is that “locations in the building not associated with patient care demonstrate the highest prevalence of nosocomial infective agents.” Determining the most appropriate locations in which to sample so that this hypothesis can be adequately tested was the focus of the discussions with architects, project managers (including building and component engineers), building crews, custodial and medical staff  on where and when samples should be acquired in the buildingC. “Species associated with nosocomial infections are more prevalent in indoor locations involving patient care”. The The primary driver for the working group was to generate a plan for a spatial and temporal survey of the hospital building and personnel frequenting the building both before and after the start of medical activity. Determining the appropriate strategy to systematically characterize the potential changes in the building microbiota due to the natural evolution of microbial community succession associated with different built environments inside the building will enable the generation of datasets that could have considerable impact upon how hospitals are designed, constructed, and maintained after occupancy. Fundamentally, understanding these processes may impact hospital design, as well as population handling inside the hospitals, even those that are already built. A key aspect will be determining the influence of each human group on the microbial ecology of the building and the potential development of nosocomial reservoirs. Hence, exploring correlations of community profiles with information regarding the abundance and types of people using specific locations will help to determine the relationships between the development of the indoor microbiome in the hospital and the human social interaction with that space.The first day of the workshop comprised the arrival, primary presentation and discussion forum for the meeting. The majority of people attended in person, except John Alverdy , Jessica Green , Rob Knight , and Scott Kelley . These four people attended remotely or periodically via the in-house television communication system. Those attending in person were: Jack Gilbert , Daniel Smith , CPT Benjamin C. Kirkup , Hal Levin , Jeffrey Siegel , Kevin Keegan , Maureen Coleman , Sylvia Garcia-Houchins , Larry Kociolek , Emily Landon , Stephen Weber , Gary An , Julie Segre , and Paula Olsiewski .The meeting started with an introduction and welcome by Jack Gilbert, who provided an overview of the reason for the workshop. The rationale for the workshop was discussed in light of the initial workshop funding provided by the Alfred P. Sloan Foundation (APSF) to explore the potential to capture the microbial community succession in the new hospital pavilion being built in Chicago. It was agreed that, to explore this environment in collaboration with building scientists, microbiologists, ecologists and clinicians both prior to and following the introduction of patients and staff, was an opportunity that could not be wasted. Paula Olsiewski then gave an introduction and welcome on behalf of the APSF, providing a balanced introduction to why APSF was interested in funding projects to explore the indoor environment, and why explicitly they were interested in the opportunity of helping to fund a coordinated analysis of a hospital environment. It was noted that while the impetus of this endeavor had a definite medical application, APSF was not expressly interested in funding medical microbiology research.Daniel Smith then started the meeting with a presentation on the initial vision for a hospital microbiome analysis. This presentation, which can be found on the hospitalmicrobiome.com website, describes the background for doing hospital microbiology research, the layout of the new hospital pavilion, and the need for studying the development of microbial communities in healthcare environments. It also outlined the ideal sampling strategy and a more realistic sampling strategy based on a modest financial funding opportunity. In the ideal model, 6,677 locations from hospital surfaces, air, water, and its occupants would be collected daily over the course of one year for a total of approximately 2.4 million samples. These would include 26 samples from the patient, air, and high-touch surfaces in each of the 240 patient rooms, as well as from hospital staff and surfaces outside the patient rooms, which see the most interactions with human traffic. However, because this level of comprehensiveness would cost $24 million in sample processing and sequencing alone, a smaller scale, more focused plan of action was proposed. Rather than sampling the entire hospital, the alternative plan called for selecting a representative group of 20 patient rooms, and tracking the airborne, waterborne, hostborne, and vectorborne microbial communities that come into contact with these rooms by collecting samples from 187 locations from patients, staff, water, air, and high-touch surface areas weekly for one year. Because collecting microbial samples is relatively inexpensive, and samples can be cryogenically preserved for long periods of time, a cost-saving strategy of this plan was to sample 20 rooms, but select only 8 for downstream processing and analysis based on rooms appearing to have high vs low rates of human-microbial interactions, as measured by diagnoses of hospital acquired infections. This sampling regimen, in conjunction with building science measurements (described below) and standard research expenses, was estimated to require approximately $300,000 in funding.The timeline for this project was driven by the projected opening date for the new hospital pavilion – January 31st, 2013. Clinical cleanings designed to improve the level of cleanliness from construction site to hospital-grade will be completed by October 19th 2012. To attain a baseline measurement of variation in microbial community structure among the different elements in this project, the proposed timeline calls for beginning sampling of the new hospital pavilion and its future staff on January 1st, 2013. At that time, the future staff will be sampled in the current working location in order to observe changes in their microflora resulting from beginning work at the new hospital pavilion, and to acquire a “microbial fingerprint” of each staff member to be used in determining source contaminants of the new hospital pavilion. Observing the hospital surfaces, water, and air prior to the admission of patients is necessary for determining the rate at which microbial communities of the building change in the absence of human occupants. This rate can then be compared to rates of change for the occupied building on surfaces where patient microflora is postulated to be a driving factor of community change.Several algorithms were put forward as useful tools for identifying patterns in community succession. SourceTracker  detects The presentation prompted considerable discussion on two different fronts, led by two of the specific consortium partners, namely the building scientists and the clinicians. Here we breakdown some of the key findings from these discussions:Legionella spp. infections. This led to agreement regarding the need to explore the water supply for the development of microbial communities and specific pathogens. In addition, the plumbing for the water system in the hospital was identified as a key concern, especially regarding the potential for ‘dead-ends’ in the water system on patient ward levels, which could act as potential pathogen breeding grounds. The issue of recording surface materials and cleaning schedules was also raised, and the need to determine the paint-types used on each surface. The need to record and measure the airflow and filtration system for both pressure, CO2 and microbial/viral community structure was also highlighted; the HVAC system in the hospital was discussed at length and it was agreed that the building schematics would be made available to explore the system in more detail. It was highlighted that ventilation systems, when new, are generally quite clean, but can rapidly become full of lint, dust and microorganisms that can cause significant hospital environmental contamination. The total building design was also taken into consideration including the use of ‘shell-floors’ on the lower part of the building, which were designed to remain empty for storage and potential expansion. These floors are enclosed but could act as potential reservoirs of microbial contaminants to the rest of the hospital. It was, however, decided that the risk of such infection was relatively minor, and these empty floors would not be considered for further analysis.Hal Levin and Jeffrey Siegel represented the building science community at the workshop and provided extremely valuable input into the considerations regarding architectural design, building infrastructure and the need for appropriate measurements to define the specific aspects of the built environment that could have an impact on the microbial community diversity and structure. Sylvia Garcia-Houchins from the infection and control and immunity group at the University of Chicago Hospital was also extremely interested in building issues and highlighted the need to understand the key elements of pathogen reservoir development in the building. A lengthy discussion ensued regarding the water supplies and cooling towers as potential reservoirs of A particular point of concern in the proposed sampling methodology was the weekly sampling frequency. Though some patients reside in the same room for months, many other are admitted for only 1-3 days, potentially leaving behind their microflora without a biological record of its source. Further discussion suggested that hourly sampling may be necessary to comprehensively track fluctuations in microbial populations, though such fine resolution may be unnecessary for accomplishing the stated research objectives. Therefore to better balance comprehensiveness against replication within the target budget, the proposed methodology was amended to sample 2 rooms on a daily basis and the remaining 18 rooms on a weekly basis.The selection of organisms to be monitored was another point of interest. The amplicon library strategy suggested in the presentation describes the presence of prokaryotic, eukaryotic, and fungal microorganisms by a 151 base pair segment of their genes encoding the small rRNA subunit. As a result, species-level identifications would be inconsistent , culturi2 concentrations used to estimate the percentage of recycled air.Emily Landon brought to the group’s attention the possibility of tapping into the new hospital pavilion’s RFID system to track the movement of staff and visitors among the patient rooms. These data would allow microbial source tracking to be independently substantiated. For instance, data derived from rRNA amplicon libraries indicating that bacteria in room B originate from room A may be confirmed with RFID data showing that hospital staff regularly walk directly from room A to room B. The RFID system could also double as a monitor of room occupancy, which is a crucial metric for the building science calculations (described below) for computing the rate at which microorganisms are introduced into the environment through human respiration, as well as COThe importance of recording the behaviors and habits of hospital staff was also raised. Hand-washing is perhaps the single most effective measure in preventing hospital-acquired infections. Glove use was mentioned as having limited utility in preventing cross-contamination due to the fact that when reaching into a glove box for a pair of disposable glove, the skin contacts the outer layers of many hospital exam gloves, rendering them contaminated. Glove boxes were therefore posited as a relevant sampling location for this project. For these reasons, patient care can strongly impact the likelihood of transmission of infectious agents. Tracking, or asking staff to self-report, their degree of caution in limiting the spread of bacteria may be useful for quantifying hospital staff as vectors of bacterial communities.Following the afternoon discussions, the group broke for dinner.The second day of the workshop was predominated by a visit to the hospital building site to view the locations we had discussed in the afternoon of Day 1. Elizabeth Lockwood, the program manager, provided the group with a detailed tour of the building, starting with the cooling towers and air intake systems on the roof, and then working down through the building examining each of the floors. To provide an interesting ‘first-look’ at the hospital microbiome, Jack Gilbert and Daniel Smith worked with the group to sample the shoes of randomly chosen members of the team both before and after the tour, the floors, water supply, walls, taps, handles, control panels and equipment in the patient rooms, nurse stations, and corridors of the hospital during the tour. These samples have been DNA extracted, 16S rRNA amplified and sequenced, and the results published on the hospital microbiome website . The touIt was agreed that another meeting be held in early 2013 during the first phase of the expected APSF funded research project to explore the evolution of the consortium, and the research agenda.


The past decade has seen remarkable progress in increasing access to antiretroviral therapy in resource-limited settings. Early concerns about the cost and complexity of treatment were overcome thanks to the efforts of a global coalition of health providers, activists, academics, and people living with HIV/AIDS, who argued that every effort must be made to ensure access to essential care when millions of lives depended on it. The high cost of treatment was reduced through advocacy to promote access to generic drugs; care provision was simplified through a public health approach to treatment provision; the lack of human resources was overcome through task-shifting to support the provision of care by non-physicians; and access was expanded through the development of models of care that could work at the primary care level. The challenge for the next decade is to further increase access to treatment and support sustained care for those on treatment, while at the same time ensuring that the package of care is continuously improved such that all patients can benefit from the latest improvements in drug development, clinical science, and public health. Since 2001, the international effort to scale up antiretroviral therapy (ART) in the developing world has been one of the most important programmes in global health .Despite these concerns, treatment programmes began to deliver ART at scale, and in less than a decade, more than five million people were successfully started on treatment. This remarkable progress was supported by a global coalition of doctors, patients, civil society actors, governments, and non-governmental organizations, who refused to accept that millions of people could be consigned to an early death from a disease that in developed countries had been transformed into a chronic, manageable condition.This article provides an overview of the main policy and delivery challenges to the provision of effective ART in resource-limited settings, before outlining some of the future challenges for the coming years.The early reluctance to support ART for developing countries was driven by both public health caution and treatment cost. The fact that antiretroviral medicines were priced beyond the reach of most people who needed them in Africa had long been an international concern: at the International AIDS Conference in Stockholm in 1988 there was debate about how to ensure people in the developing world could access the treatment of that time - zidovudine monotherapy - which was marketed at a price of US$8000 per year . Triple Civil society groups, and in particular people living with HIV/AIDS, were crucial to breaking the deadlock. Patient groups in Thailand, Brazil, South Africa, India, Kenya, Uganda, and other high-burden countries formed alliances with health providers, non-governmental organizations, and health groups in developed countries to argue the case that the cost of treatment was too high . ActivisIn 2002, a landmark legal case was to change the landscape. In South Africa, home to the largest number of people living with HIV/AIDS, the government fought (and arguably won) a court case against a consortium of 39 pharmaceutical companies over a law that would allow the government to source more affordable antiretrovirals from neighbouring countries [Thailand and Brazil also played a critical part. Both countries established public capacity to produce medicines at a fraction of the price demanded by multinational pharmaceutical companies. These two countries played a leadership role by challenging the international monopolies of antiretroviral drugs and producing generic versions for a fraction of the price of the patented equivalents .Widespread access to affordable antiretrovirals became feasible after the announcement by an Indian generics manufacturer in early 2001 that triple therapy could be manufactured for less than a dollar a day. This established a dynamic of global market competition that in 10 years has brought down the price of standard triple therapy from $US 10,000 per patient/year to almost $US50 . Today, As programmes began to enrol increasing numbers of patients, it became clear that the lack of qualified health personnel, particularly in Africa, would prove to be a major bottleneck in increasing access to treatment . WhereasA simplified treatment paradigm was required in resource-limited settings, entailing a shift from a specialized medical approach to a public health approach, in which the majority of clinical tasks would be undertaken by lower health cadres such as nurses. Given the vast numbers of lives being lost to HIV/AIDS every day, task-shifting strategies were initially employed outside of a formal evidence base. Rather than waiting for randomized trial data to show that nurses could perform as well as doctors in the prescribing of antiretrovirals, operational research was conducted to assess the effectiveness of such a strategy at the same time as it was being rolled out as national policy. Countries such as Lesotho , South AThe delivery of ART at the primary care level required a regimen that is easy to store, simple to take, and could be administered by lesser-trained health cadres via standardized guidelines. The development of fixed-dose combination ART was one answer to these requirements. World Health Organization (WHO) guidelines for antiretroviral therapy in resource-limited settings, first issued in 2001, recommended a regimen of nevirapine, stavudine, and lamivudine, as the preferred option . This reTask shifting and simplification strategies have been essential for supporting equitable access to care. Across sub-Saharan Africa, doctors are in short supply and for the most part are located in hospitals in cities: rural parts of South Africa for example have 14 times fewer doctors than the national average, whereas over half of Mozambique's doctors are working in the capital city, Maputo [Because distance to health services is associated with poorer adherence  and highAs the number of people on treatment continues to grow, there will be a need to go even further in the decentralization of care and develop models of chronic disease care outside of the formal health system. Studies from Uganda , Kenya  and MozaIn the initial years of ART provision, HIV/AIDS was considered a humanitarian emergency, requiring a simple, rapid emergency response to reduce mortality as quickly as possible . In orde3 or earlier) results in significant survival gains [3 [3, especially in patients with other co-morbidities, aged over 50, or with organ dysfunction [Data from European cohorts indicate that starting ART earlier . However, treating earlier increases the number of people eligible for treatment, and donors and countries are still reluctant to support this policy shift.In line with this evidence, WHO revised its treatment guidelines for resource-limited settings at the end of 2009, recommending a move towards initiation at 350 cells/mm3  , availability as a fixed-dose combination, good early tolerability, and its safety for use in pregnant women . HoweverTen years ago, global inaction against HIV/AIDS was labelled as a crime against humanity . A growiAs coverage of antiretroviral therapy increased, so the broader benefits of ART became apparent. In Malawi, adult mortality within the general population fell by a third as ART access increased , and simEnrolment and retention in care is an important challenge. In order to ensure sustained delivery of ART to increasing numbers and realize the potential preventive benefits of widespread treatment coverage, efforts are needed to reinforce the treatment cascade all along the pathway from HIV testing to early initiation to lifelong adherence to treatment. Recent reports indicate substantial rates of attrition at each step along the care pathway . An impoDespite these major advances, there is a sense that many of the important lessons of the past decade are being forgotten. In 2010, the high cost of treatment was again cited as a reason to accept sub-optimal care. The latest WHO guidelines recommend replacing older drugs long-abandoned in high-income countries with more durable and less toxic alternatives, but because these newer drugs are more expensive, developing countries are reluctant to make the change . Just asIn 2005, the international community committed to a goal of achieving universal access to antiretroviral therapy by 2010. Not only have we failed to achieve that goal, but also the sustainability of gains made to date is under threat from multiple sides. Clinics are reporting major stock ruptures of antiretrovirals due in part to insufficiencies in Global Fund financing . InternaA decade ago, those in the international community who did not support the scale up of ART in Africa could argue that it was untested. In 2011, it is now clear that treating HIV/AIDS on a large scale is entirely possible. Improving the basic package of care can limit side-effects and delay the need for patients to switch to more expensive second or even third-line regimens, whereas treating earlier will potentially yield massive public health benefits in terms of reduced transmission of HIV and other diseases.The challenge for the next decade is to increase access to treatment and support sustained care for those on treatment, while at the same time ensuring that the package of care is continuously improved such that all patients - whether they happen to be born in the developed world or the developing world - can benefit from the latest improvements in drug development, clinical science, and public health.The authors declare that they have no competing interests.NF conceived of the study and wrote the first draft. All authors contributed to subsequent drafts. All authors have read and approved the final manuscript.