Investigating physician self-referral in public hospitals in South East Nigeria: Insights from stakeholders

Background: Physician self-referral occurs where a full-time paid doctor diverts patients from one hospital to another in which he or she has financial interest.Aim: This study is aimed at investigating the views of service users, physicians and policymakers on physician self-referral practice in public hospitals in Nigeria.Setting: The study was carried out in Enugu urban area of South East Nigeria.Methods: A mix of qualitative and quantitative methods was used to collect information from different categories of stakeholders. Service user views were explored through analysis of four focus group discussions involving 26 participants and 407 questionnaires completed with household members who had recently visited a public hospital and then gone to private hospitals. In-depth interviews were completed with 15 public sector doctors not involved in dual practice and eight key policymakers.Results: Thirty-four of 407 respondents (8.4%) visiting a public hospital were diverted to a private facility associated with the attending public hospital doctor. The research examined age, gender and socio-economic status (SES) as factors that might influence the likelihood of patient diversion. Advice to transfer to a private clinic usually came directly from the doctor involved but might also come from nurses.Conclusion: Physician self-referral in Nigeria could take different forms. It was found that both direct and indirect forms of diversion exist, suggesting that this is an organised practice in which dual-practice doctors and supporting hospital staff members cooperate. The study recommends, among other things, that service users should be adequately protected from any form of diversion to private practice by the public system employee doctors

The impact and outcomes of the implementation of the Wakefield Birth Centre

In today’s western society childbirth takes place mainly in hospital settings and is under the control of doctors (Kirkham, 2003). More recently there have been concerns about increasingly high caesarean section rates (ref), the decreasing number of practising midwives (Ball et al. 2002) and the worryingly small number of women experiencing a natural birth (Page, 2003). Maternity services at The Mid Yorkshire Hospitals NHS Trust provide for a social, cultural and ethnically diverse community and manage 3,600 births per year. Following reconfiguration in February 2002, including the relocation of hospital maternity services, the trust decided to implement some of the Department of Health’s Action Plan and open a standalone Birth Centre in Wakefield. Birth centres are facilities that provide individualised and family centred maternity care, with an emphasis on skilled, sensitive and respectful midwifery care. They provide a relaxed and informal environment where women are encouraged to labour at their own pace. Birth Centres seek to promote physiological childbirth by recognising, respecting and safeguarding normal birth processes. This philosophy enables women and their families to experience a positive start to parenthood (Shallow, 2001, Kirkham, 2003). Midwives are also able to practise “real midwifery” (Kirkham, 2003, p.14). The overall aim of this research was therefore to evaluate the impact and outcomes of the implementation of the Wakefield Birth Centre. The research was funded by the Centre for Health and Social Care Research (CHSCR) at the University of Huddersfield. Ethical advice was sought through School Research and Ethics Panel (SREP) at the university of Huddersfield and ethical approval was granted by the Local Research Ethics Committee (LREC) and the Mid Yorkshire Hospitals NHS Trust Research and Development

Effects of randomization of event sequences in two choice probability learning.

Thesis (M.A.

Students as “development-agents”: How one school in Northern Norway brings students and teachers together to enact school improvement

Acknowledgement I thank Lakselv High School for agreeing to be named and featured in this article. I especially thank Sylvi Josefine Johnsen, Principal of Lakselv High School for her willingness to share insights and experiences as well as providing access to school documentsPeer reviewedPublisher PD

Characterising and modelling time-varying rainfall extremes and their climatic drivers

Extreme climate responses such as floods or droughts pose multi-dimensional hazards to critical infrastructure and the most vulnerable sectors of society; these hazards may increase under climate change. The extreme rainfall events driving these responses may arrive non-uniformly in time, clustering on intra- and inter-annual scales; yet the dependent relationship between events is often ignored. This thesis examines extreme daily rainfall within year clustering to determine whether changes in their temporal pattern are apparent in observational records. It then identifies the key atmospheric variables which drive event frequency and intensity, before testing hypotheses related to clustering. Extreme rainfall regions were developed from the station maxima of a comprehensive new set of 223 daily rainfall observations, spanning the period 1856-2009. The observations are contained within 14 regions which represent the distinctive seasonal clustering, orographic and atmospheric variations in UK extreme rainfall. Significant increases in annual maxima and associated return frequencies over the period 1961-2009 were observed from a Generalized Extreme Value (GEV) analysis. Increases in spring, autumn and winter maxima and their estimated return frequencies were also found. Estimates from summer maxima were variable across the country but indicated an increase in the highest intensity events. Extreme rainfall seasonal clustering and the dependence on sea surface temperatures (SST), air temperature range and the North Atlantic Oscillation (NAO) were represented in flexible GEV and Poisson parameter estimates using Vector Generalized Additive Models. There is a strong negative correlation with air temperature range, reflecting heightened event intensity and probability when the diurnal temperature range is at its lowest. Event frequency is positively correlated with SST for all regions; event magnitude is dependent on either SST or NAO with a north-south divide. While the timing of events has not changed substantially, event probability has increased - resulting in greater within-year clustering. Climate projections indicate increasing SST and decreasing temperature range; this extreme rainfall model corroborates projected increases in event intensity and frequency.EThOS - Electronic Theses Online ServiceNERCSchool of Civil Engineering and GeosciencesGBUnited Kingdo

Le parler des jeunes : nouvelle norme pour le siècle prochain ?

Le recensement de 1991 a indiqué qu’après des années de baisse progressive, le nombre de galloisants se stabilise à 18 % de la population totale. Mais ce chiffre est trompeur car le gallois parlé par la jeune génération se distingue d’une façon importante de celui parlé par les gens plus âgés en ce qui concerne la syntaxe, la morphologie, les domaines linguistiques et le degré de standardisation. Le contact avec l’anglais et le fait que les locuteurs du gallois comme langue seconde se font plus nombreux que ceux qui l’ont comme langue maternelle rend concevable l’idée que le gallois se trouve devant une mutation de ses normes grammaticales et lexicales.The 1991 census indicated that after years of gradual decline, the number of Welsh speakers is stabilising at 18 % of the total population. But this figure is misleading because the Welsh spoken by the younger generation differs in important ways from that spoken by older people in syntax, morphology, language domains and degree of standardisation. Contact with English and the fact that there are more speakers of Welsh as a second language than as a first language makes it conceivable that Welsh is undergoing a change in its grammatical and lexical norms