Identifying ‘win-win-win’ futures from inequitable value chain trade-offs: A system dynamics approach

Context There is growing recognition that food systems must adapt to become more sustainable and equitable. Consequently, in developing country contexts, there is increasing momentum away from traditional producer-facing value chain upgrades towards efforts to increase both the availability and affordability of nutritious foods at the consumer level. However, such goals must navigate the inherent complexities of agricultural value chains, which involve multiple interactions, feedbacks and unintended consequences, including important but often surprising trade-offs between producers and consumers. Objective and methods Based around the 'Loop' horticultural aggregation scheme of Digital Green in Bihar, India, we develop a system dynamics modelling framework to survey the value chain trade-offs emerging from upgrades that aim to improve the availability of fruits and vegetables in small retail-oriented markets. We model the processes of horticultural production, aggregation, marketing, and retailing – searching for futures that are ‘win-win-win’ for: (i) the availability of fruits and vegetables in small retail markets, (ii) the profits of farmers participating in aggregation, and (iii) the sustainability of the initial scheme for Digital Green as an organisation. We simulate two internal upgrades to aggregation and two upgrades to the wider enabling environment through a series of 5000 Monte Carlo trajectories – designed to explore the plausible future dynamics of the three outcome dimensions relative to the baseline. Results We find that ‘win-win-win’ futures cannot be achieved by internal changes to the aggregation scheme alone, emerging under a narrow range of scenarios that boost supplies to the small retail market whilst simultaneously supporting the financial takeaways of farmers. In contrast, undesirable producer versus consumer trade-offs emerge as unintended consequences of scaling-up aggregation and the introduction of market-based cold storage. Significance This approach furthers ongoing efforts to capture complex value chain processes, outcomes and upgrades within system dynamics modelling frameworks, before scanning the horizon of plausible external scenarios, internal dynamics and unintended trade-offs to identify ‘win-win-win’ futures for all

A framework for identifying and selecting long term adaptation policy directions for deltas

Deltas are precarious environments experiencing significant biophysical, and socio-economic changes with the ebb and flow of seasons (including with floods and drought), with infrastructural developments (such as dikes and polders), with the movement of people, and as a result of climate and environmental variability and change. Decisions are being taken about the future of deltas and about the provision of adaptation investment to enable people and the environment to respond to the changing climate and related changes. The paper presents a framework to identify options for, and trade-offs between, long term adaptation strategies in deltas. Using a three step process, we: (1) identify current policy-led adaptations actions in deltas by conducting literature searches on current observable adaptations, potential transformational adaptations and government policy; (2) develop narratives of future adaptation policy directions that take into account investment cost of adaptation and the extent to which significant policy change/political effort is required; and (3) explore trade-offs that occur within each policy direction using a subjective weighting process developed during a collaborative expert workshop. We conclude that the process of developing policy directions for adaptation can assist policy makers in scoping the spectrum of options that exist, while enabling them to consider their own willingness to make significant policy changes within the delta and to initiate transformative change.</p

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correlates of tobacco quit attempts and cessation in the adult population of India: secondary analysis of the Global Adult Tobacco Survey, 2009-10.

BACKGROUND: Nearly 275 million adults (15 years and above) use tobacco in India, which contributes substantially to potentially preventable morbidity and mortality. There is good evidence from developed country settings that use of tobacco cessation services influences intention to quit, with a higher proportion of attempts being successful in fully quitting. There is little evidence about cessation and quitting behaviour in the Indian context. This study assesses the socio-demographic characteristics and cessation services used by adults i) who attempted to quit smoked and smokeless tobacco and ii) who were successful in quitting. METHODS: The study was a cross-sectional secondary data analysis of the Global Adult Tobacco Survey, India, 2009-10. There were 25,175 ever tobacco users aged 21 years and above included in the study. Bivariate and multivariate logistic regression analysis was done to determine associations between socio-demographic variables and cessation services utilized with attempts to quit tobacco and successful quitting. RESULTS: Of the ever tobacco users, 10,513 (42%) made an attempt to quit tobacco, and of these 4,395 (42%) were successful. Significant associations were demonstrated between male gender, increasing educational attainment and higher asset quintiles for both those who attempted to quit and those who were successful. Younger age groups had higher odds of quit attempts than all except the oldest age group, but also had the lowest odds of successful quitting. Heath care provider advice was positively associated with attempts to quit, but both advice and use of cessation aids were not associated with successful quitting. CONCLUSIONS: This study provides the first national evidence on the relationships between quitting attempts and successful quitting with socio-demographic characteristics, health care provider advice and use of cessation services. The findings of the study have important implications for scaling up tobacco cessation services in India, and indicate a need to re-examine in greater detail the effects of socio-demographic factors, type of tobacco product used and levels of dependency on quitting. Health system factors such as coverage and accessibility of cessation services, type of service, and its duration and follow up also have to be examined in detail to ascertain effects on quitting behavior