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Business and Health Administration Association

Division of MBAA International 2012 Meeting Chicago, Illinois

BHAA President Steve Szydlowski Program Chair Avinandan Mukherjee Proceedings Editor - Scott J. Saccomano

PROCEEDINGS
of the

BUSINESS AND HEALTH ADMINISTRATION ASSOCIATION


CHICAGO, IL March 28-30, 2012
Copyright 2009 Business and Health Administration Association

All rights reserved. No part of these Proceedings may be reproduced, stored in a retrival system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording, or otherwise, without prior permission of the BHAA organization. The BHAA does encourage the author(s) of the enclosed articles to seek publication of their efforts in appropriate journals. All correspondence concerning purchase of these Proceedings or copyright release should be addressed to the Proceedings Editor.

2012 PROCEEDINGS EDITOR Dr. Scott J. Saccomano Herbert H. Lehman College Bronx, NY

Sample Footnote: Please use the following style when referring articles from the Proceedings: Zakari, Nazik M.A. (2009), The Influence of Academic Organizational Climate on Nursing Faculties Commitment in Saudi Arabia, in Business & Health Administration Proceedings, Avinandan Mukherjee, Editor, p. 244.

Business and Health Administration Association Annual Conference 2012

Letter from the BHAA 2012 President

Steve Szydlowski
University of Scranton

Dear Colleagues and Friends, Welcome to the 2012 Business and Health Administration Association (BHAA) academic meeting. This year promises to be another year of high quality, diverse papers and presentations that have been the trademark of conference over the past years. It is with great honor and pleasure to serve as your President for the 2012 BHAA conference and hope you enjoy the academic, networking, and other educational events this week. Thank you again for you continuued support of the BHAA and I look foward to seeing you this week.

Sincerely, Dr. Steve Szydlowski President BHAA 2011/12

Business and Health Administration Association Annual Conference 2012

Letter from the BHAA 2011 Program Chair

Avinandan Mukherjee
Montclair State University

I take great pleasure in extending greetings to all my friends and colleagues attending the 2012 Business and Health Administration Association (BHAA) Conference. As the Program Chair of the 2012 BHAA Conference, I am delighted to welcome you to Chicago. The Business and Health Administration Conference brings together scholars, teachers, students, practitioners, regulators and planners from a variety of business and health related disciplines, such as healthcare administration, pharmaceutical and healthcare marketing, pharmacy, healthcare management, health economics, health policy, medicine, public health, nursing, health informatics, global health, etc. The BHAA is a growing and vibrant organization, under the umbrella of the MBAA International. The 2012 conference has a high quality program and is divided into fifteen distinct specialty tracks chaired by highly qualified and well-known individuals. Several outstanding papers have been submitted by individuals from world-renowned educational institutions and healthcare organizations. I am confident you will find research presentations in this conference useful that will stimulate your thoughts and initiate dialogues and conversations on the state-of-the-art in theory and practice of business and health administration. I hope that your academic and professional pursuits will be enriched by networking and sharing your thoughts and expertise while reflecting on those of others, thus building a BHAA professional community that you will cherish to be a member of. Wish you an enjoyable and productive experience at the conference and have a great time in Chicago! Note: My special thanks to Naz Onel, Doctoral researcher at Montclair State University and Editorial Assistant for the International Journal of Pharmaceutical and Healthcare Marketing , for managing the flow of the manuscripts, communicating with the authors, and providing a professional look to the proceedings. Sincerely Dr. Avinandan Mukherjee Chair BHAA 2011/12
Business and Health Administration Association Annual Conference 2012

Letter from the BHAA 2011 Proceedings Editor

Scott J. Saccomano
Herbert H. Lehman College
Dear BHAA Colleagues: I would like to take this time to welcome you to the BHHA conference. I have been attending this conference now for 10 years and I looked forward to attending and participating in the annual meeting each year due to its intellectually stimulating presentations and activities. BHAA offers everyone an opportunity to meet and work with colleagues from around the globe. It was my pleasure and to serve as your Proceedings Editor for this years meeting. The variety and diversity of this years papers and abstracts continues to underscore the scope, complexity and constant challenges within the healthcare arena. I want express a big thank you to Avinandan Mukherjee whose help in compiling the proceedings was invaluable and greatly appreciated. Chicago holds a special place in my heart, I wish everyone an enjoyable and productive visit to the windy city

Dr. Scott J Saccomano Proceedings Editor - BHAA 2011/12

Business and Health Administration Association Annual Conference 2012

Best Paper Awards


BHAA OVERALL BEST PAPER AWARD Avian and Pandemic Influenza (API) Beyond ControlIt is Prevention! Muhiuddin Haider, Jared Frank

TRACK: HEALTH PROMOTION AND DISEASE PREVENTION Overweight and Obesity and Physical Activity in Healthy People 2010: Where are We Now and where do We Go from Here? Margaret J. Greene TRACK: DISTANCE LEARNING AND ONLINE TEACHING Assessing the Impacts of Anxiety and Gender on Student Attitudes toward Computer Learning Technology in a Saudi Nursing Academic Environment Osama A. Samarkandi

TRACK: HUMAN RESOURCE MANAGEMENT IN HEALTHCARE Strategic Human Resources Solutions for Healthcare Systems in Kenya, Rwanda, and Uganda Neel H. Pathak, Daniel J. West, Jr. Has Gender Equity Improved? An Examination of the Challenges Faced by Professional Women in Leadership Michaeline Skiba, David P. Paul, III

TRACK: PHARMACOECONOMICS AND PHARMACEUTICAL INDUSTRY Price Effects on Prescription Behavior of Physicians Gurumurthy Kalyanaram, Demetrios Vakratsas, Mala Srivastava

TRACK: NATIONAL AND GLOBAL HEALTH POLICY The Impact of the Millennium Development Goals in Argentina, Brazil and Chile Jose D. Alicea-Rivera, Daniel J. West, Jr.
Business and Health Administration Association Annual Conference 2012

TRACK: ETHICAL & LEGAL ISSUES IN HEALTHCARE What are Ethically Acceptable Options in the Protests of Physicians Trade Unions? Eva Grey TRACK: HEALTHCARE EDUCATION Nutritional Provision in the Aurora Area: A Community-Participatory Effort Ileana Brooks, Robert Daugherty

TRACK: GLOBAL HEALTH AND SOCIAL JUSTICE Community Based Interventions against Proteincalorie Malnutrition: Examples from Programme Goat in Sudan, Rwanda and Burundi Milan Schavel, Lucia Paskova, Eva Misikova, Michal Krcmery, Alexandra Mamova, Margareta Kacanyova, Petra Mikulasova, Renata Machalkova, Ivan Duraj, Andrea Bajcarova, George Benca, Jaroslava Sokolova, Nada Kulkova, Vladimir Krcmery, John Mutuku-Muli, Andrej Matel, Ivan Bartosovic

TRACK: HEALTHCARE AND HOSPITAL ADMINISTRATION Vaccination Trends for Public and Private Sectors Suzette Hershman, William B. Stroube

TRACK: HEALTH, WELLNESS AND QUALITY OF LIFE National Culture, Human Development, and Environmental Health: A Cross National Analysis Avinandan Mukherjee, Naz Onel

TRACK: FINANCE AND ACCOUNTING ISSUES IN HEALTHCARE Increased Utilization of Direct Access to Physical Therapy: A Model for Reducing Healthcare Expenditures Adam W. Walker, Zach Frank TRACK: HEALTHCARE REFORM Lack of Access in Healthcare Delivery: A Model for Using Dental Hygienists in a Cost Effective Manner to Help Address the Oral Healthcare Problem Peter G. Fitzpatrick, Susan Duley
Business and Health Administration Association Annual Conference 2012

TRACK: HEALTHCARE MARKETING Perceptions of New Jersey Physicians Regarding Medical Malpractice Insurance and the Impact of these Perceptions on Access to and Delivery of Medical Care in the State David P. Paul, III

TRACK: HEALTHCARE INFORMATICS Computer Physician Order Entry and Clinical Decision Support Systems: Benefits and Concerns Joseph Shaffer, Alberto Coustasse

TRACK: NURSING ADMINISTRATION Job Satisfaction and Retention in Clinical Care Nursing, Contributory Factors, the Effect on Patient Care Quality and an Integrated Solution Ann D. Phillips

Business and Health Administration Association Annual Conference 2012

BUSINESS AND HEALTH ADMINISTRATION ASSOCIATION ABSTRACT AND PAPER PROCEEDINGS


- TABLE OF CONTENTS HEALTH PROMOTION AND DISEASE PREVENTION Consumer Attitudes towards Adoption of DTC Genetic Testing in the U.S.A. Avinandan Mukherjee, Daniel Traum ....................................................................................... 16 A Prototype Design to Deliver Health Care System from Stakeholders In-fights and Save Many Lives Kuriakose Athappilly, Thomas Rienzo, Rajnish Sinha.............................................................. 18 Drinking Water Fluoridation for Dental Health; Controversy and Issues Naz Onel .................................................................................................................................... 21 Use of Allied Health Professionals as Leaders in Wellness and Health Promotion: A Cost Analysis and Guidelines for Implementation Kelsey Maxwell, Zach Frank ..................................................................................................... 32 Overweight and Obesity and Physical Activity in Healthy People 2010: Where Are We Now and Where Do We Go From Here? Margaret J. Greene ..................................................................................................................... 33 DISTANCE LEARNING AND ONLINE TEACHING Strategies for Self Directed Learning in a Virtual Environment Scott J. Saccomano .................................................................................................................... 42 Embarrassing New Information Technology in Teaching Global Health Hengameh Hosseini ................................................................................................................... 43 A Nursing Education Challenge: E-Textbooks Josephine M. DeVito ................................................................................................................. 44 Assessing the Impacts of Anxiety and Gender on Student Attitudes toward Computer Learning Technology in a Saudi Nursing Academic Environment Osama A. Samarkandi ............................................................................................................... 45 HUMAN RESOURCE MANAGEMENT IN HEALTHCARE Compensation as a Construct for Employee Motivation in Healthcare Allen C. Minor .......................................................................................................................... 55 Physician Shortages-How the gaps will be filled Robert J. Spinelli, Kathryn Semcheski ...................................................................................... 59
Business and Health Administration Association Annual Conference 2012

Strategic Human Resources Solutions for Healthcare Systems in Kenya, Rwanda, and Uganda Neel H. Pathak, Daniel J. West, Jr. ............................................................................................ 60 Has Gender Equity Improved? An Examination of the Challenges Faced by Professional Women in Leadership Michaeline Skiba, David P. Paul, III ......................................................................................... 70 PHARMACOECONOMICS AND PHARMACEUTICAL INDUSTRY Challenges in the Management of Pharmaceutical Industry in Kazakhstan Gurumurthy Kalyanaram, Zhansulu Baikenova, Dilbar Gimranova, Alma Alpeissova .................................................................................................................................. 78 Treating Methicillin-Resistant Staphylococcus Aureus with the Drug Vancomycin in a Home Infusion Therapy Setting Joshua L. Webb, Alberto Coustasse, Dennis Emmett................................................................ 85 A Review of Research on Direct-to-Consumer Advertising of Prescription Drugs Yam Limbu, Avinandan Mukherjee .......................................................................................... 92 Price Effects on Prescription Behavior of Physicians Gurumurthy Kalyanaram, Demetrios Vakratsas, Mala Srivastava .......................................... 105 NATIONAL AND GLOBAL HEALTH POLICY International Health Management Education: Phase II Findings, Results and Implications Daniel J. West, Jr., Anthony C. Stanowski, S. Robert Hernandez, Bernardo Ramirez .................................................................................................................................... 110 The Impact of the Millennium Development Goals in Argentina, Brazil and Chile Jose D. Alicea-Rivera, Daniel J. West, Jr. ............................................................................... 112 The Policies and Choices of Abortion Robert D. Fenstermacher, Daniel J. West ................................................................................ 122 Cuban Pharmacy in the Context of its Healthcare System: Transitioning Toward Pharmaceutical Care Practice Alina Martinez Sanchez, J. Warren Salmon ............................................................................ 131 Obesity in school-age children Nashat Zuraikat, Carla J. Baldessaro ....................................................................................... 144 ETHICAL & LEGAL ISSUES IN HEALTHCARE Hospital Indicators Used by CEOs to Determine the Level of Ethical Integration in Their Organizations John J. Newhouse .................................................................................................................... 146
Business and Health Administration Association Annual Conference 2012

The Doctors who Commit Medicare Fraud Vivek Pande, William Maas .................................................................................................... 147 When does a Non-Profit Become a For-Profit Organization? An Analysis of Hybrid Organizational Structure in the Healthcare and Insurance Industry Devlin Aaron Fisher, Christopher J Marquette ........................................................................ 148 What are ethically acceptable options in the protests of physicians trade unions? Eva Grey .................................................................................................................................. 150 HEALTH CARE EDUCATION A Failing Grade for Abstinence Education in Todays Social Climate William K. Willis ..................................................................................................................... 153 Competence Needed in Global Health Management Education Bander Alaqeel ........................................................................................................................ 154 Nutritional Provision in the Aurora Area: A Community-Participatory Effort Ileana Brooks, Robert Daugherty ............................................................................................ 155 Translating Web2.0/3.0 Technology from the Classroom to the Real World of Practice Bernardo Ramirez, Maysoun Dimachkie, Reid Oetjen, Dawn Oetjen .................................... 158 Barriers for Continuing Professional Development for Nurses in Saudi Arabia Ahmad Aboshaiqah.................................................................................................................. 160 Examination of a Health Management Education and Training Grant Kevin C. Flynn, Daniel J. West, Jr. ......................................................................................... 161 GLOBAL HEALTH AND SOCIAL JUSTICE System of Geriatric Care in Slovakia Ivan Bartoovi ........................................................................................................................ 163 A Preliminary Study on Long Term Care in China: The Consumers Perspective Qiu Fang, Deborah Gritzmacher, Ronald Fuqua ..................................................................... 165 Evaluation of the University Education in the Social Work Field of Study and Alumni Program Concept Milan Schavel, Miloslav Hettes ............................................................................................... 166 Expected Fertility, Marriage and Religiosity in Slovakia Jozef Matulnk ......................................................................................................................... 168 Organisation and Management of Antimalnutrition Programmes in Kenya Vladimir Krcmery Dadline Kisundi, Jaroslava Sokolov, Victor Namulanda, Ann Nageudo, Nada Kulkov, Daria Pechov, Mario Janovi, Alexandra Mamov, Petra Stulerova, Anna Porazikova, Sona Revicka, Steve Szydlowsky, Daniel West, Petra Mikolasova ........................................................................................................... 169
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Management of Epidemic Famine in African Horn: Experience from Ethiopia Marian Karvaj, Petra Mikolasova, Gertruda Mikolasova, Kristina Pauerova, Jaroslava Sokolova, Vladimir Krcmery, Steve Szydlowsky, Nada Kulkova........................... 172 Community Based Interventions against Proteincalorie Malnutrition: Examples from Programme Goat in Sudan, Rwanda and Burundi Milan Schavel, Lucia Paskova, Eva Misikova, Michal Krcmery, Alexandra Mamova, Margareta Kacanyova, Petra Mikulasova, Renata Machalkova, Ivan Duraj, Andrea Bajcarova, George Benca, Jaroslava Sokolova, Nada Kulkova, Vladimir Krcmery, John Mutuku-Muli, Andrej Matel, Ivan Bartosovic ................................. 174 Social Service Management for Homeless People in Capital City of Slovakia and Their Surrounding Andrej Matel, Jozef Zuffa, Tibor Roman, Maria Romanova, Jaroslava Polonova, Robert Kovac, Terezia Dudasova, Maria Stepanovska, Peter Kadlecik .................................. 177 HEALTHCARE AND HOSPITAL ADMINISTRATION Customers: Healthcare vs. Traditional M. Scott Stegall, Thomas McIlwain, Peter Fitzpatrick ............................................................ 181 Hospitals and Healthcare Systems The Need to Reduce Errors and Mistakes Robert J. Spinelli...................................................................................................................... 183 Governance Issues in the transition to Accountable Care: A Case Study of Silver Cross Hospital Stephen G. Morrissette............................................................................................................. 184 Essential Differences: Healthcare vs. Business Administration M. Scott Stegall, Thomas McIlwain, Peter Fitzpatrick ............................................................ 185 Vaccination Trends for Public and Private Sectors Suzette Hershman, William B. Stroube ................................................................................... 187 A Comparative Analysis of Healthcare Systems: USA and Sweden Christopher A. Loftus, William B. Stroube ............................................................................. 192 Drug testing in monitoring of patients on chronic opioid treatment Ahmet "Ozzie" Ozturk ............................................................................................................. 196 Avian and Pandemic Influenza (API) Beyond ControlIt is Prevention! Muhiuddin Haider, Jared Frank ............................................................................................... 197 Establishing an Effective and Comprehensive Palliative Care Program in an Acute Hospital Setting Ebony A. Smalls ...................................................................................................................... 210 Physician Behaviors Critical to Accountable Care Organizations (ACO) Leanne Hedberg Carlson, Lisa Wied, Renee Fraser ................................................................ 217
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HEALTH, WELLNESS AND QUALITY OF LIFE Fitness, Health and Productivity Mansour Sharifzadeh ............................................................................................................... 219 Viewpoints on Elective Cosmetic Surgery: An Initial Inquiry into Consumption Practices from a Marketing Perspective Charles Kirk Moore .............................................................................................................. 238 National Culture, Human Development, and Environmental Health: A Cross National Analyses Avinandan Mukherjee, Naz Onel ............................................................................................ 241 Is Elective Cosmetic Surgery a Luxury? Applying Berrys The Idea of Luxury to Elective Cosmetic Surgery Charles Kirk Moore .............................................................................................................. 256 Lifestyle Disease Triad: An empirical comparative assessment of the macro level predictors of Obesity, Diabetes, and Hypertension across the US MSAs Vivek S. Natarajan, Avinandan Mukherjee, Kabir Chandra Sen ............................................. 258 FINANCE AND ACCOUNTING ISSUES IN HEALTHCARE Financial Incentives: Pay for Performance (P4P) and the Effects with the Chronically Ill Patients David Conley, Alberto Coustasse ............................................................................................ 260 Increased Utilization of Direct Access to Physical Therapy: A Model for Reducing Healthcare Expenditures Adam W. Walker, Zach Frank ................................................................................................. 266 The Affordable Care Act: Quality Requirements Despite Medicare Payment Reductions Means Significant Changes for Hospitals Stephanie Hill, Robert J. Spinelli ............................................................................................. 271 Poison Pills in the Pharmaceutical Industry: Effects on Value, Governance, and Strategic Posture Isaac Wanasika ........................................................................................................................ 272 HEALTH CARE REFORM Lack of Access in Healthcare Delivery: A Model for Using Dental Hygienists in a Cost Effective Manner to Help Address the Oral Healthcare Problem Peter G. Fitzpatrick, Susan Duley ............................................................................................ 275 Providing Large-Scale Emergency Medical Care in a Rural Setting: A Model Charles Braun, Jamie Field ...................................................................................................... 286 The Evolution of Urgent Care Centers: Past, Present, and Future Helen Julia, Steven J. Szydlowski ........................................................................................... 287
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HEALTHCARE MARKETING The Prescription Drug Marketing Act of 1987: Consumer Protection or Restraint of Trade? Gene C. Wunder ...................................................................................................................... 289 Perceptions of New Jersey Physicians Regarding Medical Malpractice Insurance and the Impact of these Perceptions on Access to and Delivery of Medical Care in the State David P. Paul, III ..................................................................................................................... 290 Determinants of Patient Satisfaction with Pharmaceutical Services Comparison between Multiple Pharmacy Formats Archana Kumar, John McGinnis, Avinandan Mukherjee........................................................ 298 Strategic Positioning of Big Pharma in Pharmerging Markets Isaac Wanasika ........................................................................................................................ 303 Marketing implications for the Pharmaceutical Industry in Central and Eastern Europe: Generics, Research and Development Steven J. Szydlowski, Robert Babela, Amy M. Szydlowski ................................................... 305 HEALTH CARE INFORMATICS H-1B Foreign Workers in Health IT Industry Stephan Chung, Salvador Esparza, Louis Rubino ................................................................... 307 Benefits and Constraints of Telepsychiatry Utilization in the United States Bruce Stec, Alberto Coustasse ................................................................................................. 309 Computer Physician Order Entry and Clinical Decision Support Systems: Benefits and Concerns Joseph Shaffer, Alberto Coustasse ........................................................................................... 316 Role of Information and Communication Technology (ICT) on Missionary Adaptive Selling Behavior and Salesforce Performance Yam Limbu, C. Jayachandran, Robin T. Peterson ................................................................... 324 NURSING ADMINISTRATION Motivational Factors and Barriers Related to Saudi Arabian Nurses Pursuit of a Bachelors in Nursing Science Degree Majed Alamri ........................................................................................................................... 333 Violence among health care workers: From awareness to Action Nashat Zuraikat ........................................................................................................................ 334 Strategic Planning in Academic Nursing Education: the Road Toward Excellence in Saudi Arabia Adel S. Bashatah, Hanan A. Ezzat Alkorashy ......................................................................... 335
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Evidence-Based Practice Barriers in Saudi Arabia Majed Alamri ........................................................................................................................... 336 Job Satisfaction and Retention in Clinical Care Nursing, Contributory Factors, the Effect on Patient Care Quality and an Integrated Solution Ann D. Phillips ........................................................................................................................ 337

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TRACK HEALTH PROMOTION AND DISEASE PREVENTION

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CONSUMER ATTITUDES TOWARDS ADOPTION OF DTC GENETIC TESTING IN THE U.S.A.


Avinandan Mukherjee, Montclair State University Daniel Traum, Montclair State University

ABSTRACT The individuals ability to obtain adequate diagnosis and treatment in the medical context has become a pressing issue. The traditional approach to the investigation of medical problems, which was solely the job of the physician, has now shifted towards information search by the patient. Furthermore, the emergence of direct to consumer (DTC) genetic testing has begun to change the way that health information can be obtained. Physicians, nurses, pharmacists, insurance companies, and patients, all should be considered in the development and marketing activities of healthcare products. The perspectives of each differ not only based upon their knowledge base, but also through experiences and motivating factors. The objective of this research was to determine the factors that contribute to overall attitudes that are influenced by genetic testing. The two dependent variables utilized are familiarity with genetic testing and whether the respondent has undergone genetic testing in the past. The independent variables were separated in to discreet categories of the following: interpersonal/communications, privacy/regulation, psychological/perceived cost, commitment/patient compliance, and patient education. Data for this research was obtained from the U.S. Department of Health and Human Services, through the Health Information National Trends Survey (HINTS). This is a widely used survey, and quite comprehensive, consisting of responses from over 7,600 individuals. It is administered once every three years, and is adjusted to the changing environment of healthcare. The inherent nature of this research lends itself to some technicalities pertaining to the science behind these tests and the efficacy in the findings provided. Currently, this is still considered a new area of medical research, and much skepticism and critique remains. Some of the major concerns that surround this product are governmental oversight, privacy, and perhaps most importantly, comprehensiveness of the tests. Logistic regression analysis was used principally to determine the relationship between two discreet questions pertaining to genetic testing to a variety of factors. Based upon quantitative data, there is statistical significance between several variables, however far from all that were tested. Taken separately, the first question showed significance in regression to ones ability to take care of their own health, help uncovering uncertainty in ones health, knowledge of cancer risk prior to diagnosis. With regard to the second question exclus ively, significance lies with opportunity to ask questions of ones healthcare provider, concern regarding product quality, difficulty in understanding health or medical topics, and numbers and statistical helpfulness in making health related decisions. Those factors that have significance in regard to both questions include the following: trust of some, but not all sources; healthcare providers providing attention and involving the patient in decision making; maintenance of a healthy weight; little can done to prevent getting cancer; and association of cancer with being a fatal disease. The above factors would be beneficial in development of a successful marketing strategy that could be used by companies who promote DTC genetic tests to the consumer. Those questions that both show significance to the same aspects would likely expected to have greatest appeal to the most consumers. It would likely meet their needs for information and encourage them to use DTC genetic testing in order to better their own health.

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Avinandan Mukherjee Professor and Chair, Department of Marketing Editor International Journal of Pharmaceutical and Healthcare Marketing Montclair State University School of Business Montclair, NJ 07043, USA Phone: (973) 655-5126; Fax: (973) 655-7673 Email: mukherjeeav@mail.montclair.edu

Daniel Traum Undergraduate Student Montclair State University Email: traumd1@mail.montclair.edu

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A PROTOTYPE DESIGN TO DELIVER HEALTH CARE SYSTEM FROM STAKEHOLDERS IN-FIGHTS AND SAVE MANY LIVES
Kuriakose Athappilly, Western Michigan University Thomas Rienzo, Western Michigan University Rajnish Sinha, Western Michigan University

ABSTRACT This paper proposes a design of a prototype which can substantially improve the present day health care system. The authors designed the prototype with three fundamental principles in mind. It must be: a) patient centric, b) IT-integrated deploying the best methodologies available and c) no-tolerant to error-prone human factor. Simply put, the authors believe that the technology is out there but todays health care system is not up to the challenges in its entire spectrum among the providers, the competing stakeholders surrounding the providers and the patients. To design the prototype the authors chose a life threatening situation, something like, as the clock ticks towards the last breath IT must come to rescue enabling physicians to save many lives. The prototype consists of three major architectural components: a) web-enablement, b) integration of several IT layers such as transactional, analytical and decision-making,- much beyond the existing EMR and EHR systems, and c) incorporation AI technologies in particular. To develop and test the prototype, a specific disease needing critical care, in a specific geographical location with a specific health care provider must be chosen. Once the prototype is tested and is proven successful, it can be enhanced by expanding the specificity boundaries. The authors believe the proposed system will significantly impact healthcare by reducing costs and helping physicians provide superior care and above all saving lives which is otherwise almost impossible.

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Design Model of the Study

Web Application

Page group

Firewall

Workstation WAP Server Web Server - Production Development & Testing

Data Mining/ Business Intelligence Layer

Production Data Mart

Development Data Mart

Extraction/ Transformation

Data Repository

External Data

Internal Data

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REFERENCES Athappilly K. (2006). Kidney Dialysis Analysis Using Symbiotic Data Mining Approach, M SAS Data Mining Conference, Poster presentation, Las Vegas, USA. Athappilly K. (2000). A dynamic web-based knowledge system for prototype development for extended enterprise, The Third International Conference on the Practical Application of Knowledge Management, PAKeM Proceedings 2000, Manchester, UK, pp:11-24. Bates D.W., Leape L.L., Culle D.J., Laird N., Peterson L.A., Teich J.M., et al. (1998). Effect of computerized physician order and team intervention on prevention of serious medication erros, JAMA, 280, 1311-16. Evans RS, Classen DC, Pestotnik SL,et al. (1994). Improving empiric antibiotic selection using computer decision support. Archives of Internal Medicine 154(8):878-84. Frize M., Ennett C.M., Stevenson M., Trigg H.C.E. (2001). Clinical decision-support systems for intensive care units using artificial neural networks. Medical Engineering and Physics, 23(3), 217-225. Frize M., Frasson C. (2000). Decision-support and intelligent tutoring systems in medical education. Clinical and Investigative Medicine, Aug;23(4), 266-269. Frize M, Walker R. (2000). Clinical decision-support systems for intensive care units using case-based reasoning, Medical Engineering and Physics, Nov;22(9), 671-677. Kohn L.T., Corrigan J.M., Donaldson M.S. (1999). Eds. To err is human: building a safer health system. Washington D.C. National Press. Overhage J.M., Tierney W.M., Zhou X.H., McDonald C.J. (1997). A randomized trial of corollary orders, to prevent errors of omission, JAMIA 4, 364-75. Razi, M. and Athappilly, K. (2005). A comparative predictive analysis of Neural Networks (NNs), Nonlinear Regression and Classification and Regression Tree (CART) models. Expert Systems with Applications, Volume 29, Number 1, pp. 65-74.

Dr. Kuriakose Athappilly Department of Business Information Systems Haworth College of Business Western Michigan University, MI USA 269-387-5405 kuriakose.athappilly@wmich.edu Dr. Thomas Rienzo Department of Business Information Systems Haworth College of Business Western Michigan University, MI USA 269-387-5405 Mr. Rajnish Sinha Department of Business Information Systems Haworth College of Business Western Michigan University, MI USA 269-387-5405 Business and Health Administration Association Annual Conference 2012

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DRINKING WATER FLUORIDATION FOR DENTAL HEALTH: CONTROVERSY AND ISSUES


Naz Onel, Montclair State University

ABSTRACT The fluoridation of public drinking water provided by local government agencies is a practice that has been adopted for decades in the U.S and some other countries around the world to prevent tooth decay. Fluoridation of community water is accepted by many to be one of the greatest public health and disease-preventive measures of the last few decades. Supporters of fluoridation see the implementation as effective, easy to deliver, safe, and most importantly, cost efficient. However, opposing views consider water fluoridation to be a form of enforced mass medication and find it to be an unethical practice. Furthermore, some others link fluoridation to enamel fluorosi s and many chronic illnesses that present widely all around the world. This discussion paper examines both sides of the argument in detail with relevant examples. Although the current data on effectiveness and safety of the fluoridation are compelling, future studies are necessary to eliminate controversy and improve public health by adopting only essential actions. This study aims at creating a combined resource and, in this way, highlighting the facts for determining the future direction of the fluoridation practice. Key Words: Water Fluoridation, Public Dental Health, Fluorosis.

INTRODUCTION A form of dental disease, dental caries, understood as a multi-factorial disease which is an end result of a complex interaction between adopted diet, oral bacteria, and the host itself (Keyes, 1960). Dental caries have been linked to various undesirable outcomes such as decreased self-esteem, substantial pain, difficulty eating some kind of foods, reduced ability to sleep, as well as social discomfiture (Slade et al., 2005; Pahel et al., 2007). Although there are available individual treatments for dental caries, because such treatments are usually costly, it typically leads to delayed considerations until the pain level becomes unbearable (Armfield, 2010). It is believed that prevention of tooth decay is possible by increasing fluoride intake, especially during the formation of tooth enamel. Fluoride can help with preventing and, in some cases, reversing tooth decay by rebuilding tooth enamel (CDCP, 1991, 1999) via various topical mechanisms (Featherstone, 1999) (Fig. 1). Therefore, it is generally supported that if the individual keeps the fluoride constantly present in his/her oral environment ( e.g. saliva, enamel surface), the person would be less susceptible to dental caries (Frazao et al., 2011). Enduring this presence, on the other hand, is possible both through topical use, such as toothpaste, mouth rinses, and gels, as well as through increasing general daily use of fluoridated water and salt (Cury and Tenuta, 2008). When all the available systemic fluoridation methods are compared (e.g. fluoride toothpastes, fluoridated water, sugar, milk, salt, soft drinks, and fluoride supplements), however, it is argued that water fluoridation is the only cost-effective, fair, and safe way of providing tooth decay protection to the communities (Ludlow et al., 2007). Therefore, it is the most widely implemented one as a public health intervention strategy (Armfield, 2010). In general, all water sources in nature contain some amount of fluoride. Studies in the early 1940s showed that people with fewer dental cavities lived where drinking-water supplies had a certain amount of naturally occurring-fluoride (approximately 1 ppm). Many different studies over time supported this finding (CDCP, 1991). Following the recommendations of scientists, the department of health and various public health organizations voted for the addition of fluoride to public water supply with the aim of improving public dental health. As a result, beginning with the 1945 Grand Rapids drinking-water fluoridation in Michigan, most of the U.S. population started to receive fluoridated water (NIDCR, 2011). In 1951, fluoridation of water supplies became an official policy in the US (Frazao, 2011). Today, approximately 67 percent of the U.S. population has access to public water supplies that had already been fluoridated (CDPH, 2011) and nearly 60 countries practice the same technique as a dental caries prevention strategy (Frazao, 2011). Business and Health Administration Association Annual Conference 2012

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Processes of the demineralization and re-mineralization

Figure 1. Processes of the demineralization and re-mineralization.Source: Adapted from CDC (2001) Centers for Disease Control and Prevention. CONTROVERSY AND ISSUES Oppositions to water fluoridation Despite considerable evidence regarding the effectiveness of water fluoridation, however, lately various opposing views have emerged (e.g. Armfield, 2010; Gupta et al., 2009; Tenuta and Cury, 2010). Many consider water fluoridation to be a form of enforced mass medication and find it to be an unethical practice (Cohen and Locker, 2002). According to this point of view, the public cannot be forced into receiving any kind of medication without their consent. In addition to this view, Jinadasa et al.(1988) in their article state that high fluoride concentrations (i.e. more than 1.50 ppm) in drinking water can be linked to various adverse health issues. Numerous studies also show that above a certain concentration of fluoride, it is common to see significant increase in the prevalence of dental (enamel) fluorosis (e.g. National Academies, 2006; McDonagh, 2000; NIDCR, 2011; Frazao et al., 2011). When fluoride concentration becomes higher than 1.0 ppm in the water supply, dense areas on the enamel surface of the teeth start to develop visible white color stains (Robinson et al., 2004) (Fig. 2). Frazao, et al. (2011) indicate the importance of amount of fluoridated water consumption when determining the effect of fluoride on tooth enamel. They consider that this effect of fluoride on tooth enamel is dose -dependent. (p4) If the intake becomes too high, severe cases of fluorosis can be seen ( Fig. 3). This theory can also explain why children living in warmer areas have more fluorosis but less caries compared to children from colder areas with same drinking water fluoride level (Frazao, et al., 2011). Exposure to fluoride in high levels can also cause skeletal fluorosis which is an increase in bone density that leads to joint stiffness and pain (Gupta et al., 2001). The condition can severely affect mobility in later stages (called the crippling stage). Fluoridation has been also linked to many chronic Pain-Fatigue Syndromes (e.g. FMSFibromyalgia, CFS Chronic fatigue syndrome), and some other chronic illnesses, which present growing widespread public health concerns (Laylander, 1999). Many studies also confirm the link between induced fractures of the bones in elderly and fluoride intake (e.g. Hedlund and Gallagher, 1989; Bayley et al., 1990; Jacobsen et al., 1992; Danielson et al., 1992; Jacqmin-Gadda et al., 1995). For example, Danielson, et al. (1992) found a small but significant relationship between hip fracture and artificial fluoridation at 1 ppm in Utahs elderly population. Jacobsen, et al. (1992) found a similar result in their study conducted in 129 counties across the U.S. with public water fluoridation and 194 counties without fluoridation. In fluoridated and non-fluoridated counties the hip fracture of the elderly showed different results. The study found a small statistically significant positive relationship between fluoridation and fracture rates.

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Apart from increase in dental fluorosis and fractures, He, et al. (1989) speculates that by crossing bloodbrain barrier and building up in cerebral tissues, fluoride can affect the intelligence even before a child was born. With similar study, Zhao, et al. (1996) suggest that in children, high fluoride intake can lead to low IQ, poor school performance, decreased reading and writing abilities compared to children with normal level of fluoride intake. They indicate that the manifestations occur as a result of influenced calcium currents by fluoride which alters enzyme configuration that eventually affects the brain functions. Similarly, Gupta, et al. (2009) mention fluoride and its harmful neurological effects such as Attention Deficit Disorder (ADD). These important assumptions related to neurological functions, however, are limited to only a few studies. Likewise, the possible relationship between cancer and fluoridated water has been a debate issue by several researchers since the National Toxicology Program s study found the possible link in male rats (Bucher, 1991; Cohn, 1992). Mild dental fluorosis

Figure 2. Mild dental fluorosis occurs when the stains cover between 25% and 50% of the surface (without esthetic or functional significance). Source: Frazao, et al. (2011). Severe dental fluorosis

Figure 3. Severe dental fluorosis caused by well water containing 3.6 mg F/l (with esthetic and functional significance). Source: Frazao, et al. (2011).

The major concerns regarding fluoride use originate from the usage of a combination of methods (Tenuta and Cury, 2010). According to Gupta, et al.(2009), communities ingest fluoride beyond daily permissible limit ( i.e. 1.5 ppm) because of consuming fluoridated drinking water in addition to other forms of fluoride intake, such as medications and tooth pastes. They also consider fluoridated drinking water as the most soluble and toxic form of fluoride. If the consumption is much higher than the permissible limits, it can be extremely toxic (Gupta, et al., 2009). According to Tenuta and Cury (2010), among the individual fluoride delivery methods, fluoridated toothpaste usage should be considered the most important one because it also helps with bio-film removal mechanically in Business and Health Administration Association Annual Conference 2012

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addition to providing fluoride. Therefore, it is accepted by some researchers as an efficient way of controlling caries (Marinho, 2003). In fact, decline in dental caries in many countries has been directly connected to usage of fluoridated toothpaste (Bratthall, 1996; Cury et al., 2004). When fluoridated toothpastes are used in a regular basis, high fluoride values in the biofilm are sustained even 10 hours after brushing the teeth (Tenuta and Cury, 2010). Gupta, et al.(2009) states that by brushing his/her teeth only once, an individual can get about 1.0 to 2.0 mg of fluoride, enough to maintain healthy teeth. Thus, if someone uses fluoride toothpaste regularly, no additional fluoride usage is recommended (Tenuta and Cury, 2010). When an individual gets more amount of fluoride because of extensive additional forms of usage, starting with increased prevalence of fluorosis (Catani et al. 2007), all other related health issues can be seen. Besides, Armfield (2007) points out the growing doubt in terms of fluoridations role in reducing toot h decay. According to him, many opponents of water fluoridation find no significant tooth decay decrease resulting from fluoridated water consumption. He states that about 150 communities in the U.S. and Canada have rejected fluoridation of water since 1990 mainly because of perceived ineffectiveness and potential harm. There are also some countries such as China, Austria, Belgium, Germany, Japan, Denmark, and Switzerland did not accept fluoride addition to their drinking water because of legal reasons and potential risks (Gupta et al., 2009). When we look at studies from Canada, Finland, Germany and Cuba which focus on the dental decay issues of the communities after the discontinuation of fluoridation, interestingly, we see a decreasing amount of dental decay instead of an increasing amount (Kunzel and Fischer, 1997, 2000; Maupome et al., 2001; Kunzel et al., 2000; Seppa et al., 2000). All these aforementioned studies and findings explain why the oppositions perceive the practice as unnecessary and harmful. Supporters of fluoridation Fluoridation of community water is accepted by many to be one of the greatest public health and diseasepreventive measures of the last few decades. Supporters of fluoridation see the implementation as effective, easy to deliver, safe, and most importantly, cost efficient (Horowitz, 1996). Supporters believe that visits to dental health professionals have been reduced with improved dental health, and therefore, have lowered costs to the public. They also believe there is no harm from adding fluoride to drinking water. Because of increasing wide-spread concerns regarding the safety of the usage of fluoride in drinking water, in 1999, the Department of Health commissioned a group of researchers from University of York to examine the effects of the practice in more detail. By examining 735 research studies, the team concluded that water fluoridation and systemic illness showed no evidence of a casual relationship (Cockcroft and Donaldson, 2007). The researchers of the York Team also found that 15% more children without tooth decay reported in the areas received fluoridated water. Furthermore, dental decay in adults has decreased by 27% in those areas. Contrary to the opposing view, supporters of fluoridation believe fluoridated toothpastes cannot be a solution by itself to reduce oral health inequalities in communities because the usage of these products depends solely on individual actions. On the other hand, population based targeted fluoridation schemes such as public drinking water fluoridation offers much greater potential outcomes (Cockcroft and Donaldson, 2007). In their article, Cheng, et al. (2007) mention the significance of water supply fluoridation in reducing the burden of dental disease and its potential to deal with ongoing oral health inequali ties. Furthermore, contrary to the oppositions statement of mass medication (Cohen and Locker, 2002), the Medicines and Healthcare Products Regulatory Agency states that since drinking water (fluoridated or not) is a food, it cannot be categorized as medicine and therefore should not be subject to medication requirements as suggested (Cockcroft and Donaldson, 2007). According to Cockcroft and Donaldson (2007), there is an ethical justification of the practice because of significant benefit to the public health. Since there are ongoing oral health inequalities in different communities, this justification is supported by many authorities, including the U.S. Congress. Consequently, water providers and strategic health authorities can provide necessary fluoride to the communities after broad and open consultations. Morris (1995) argues against the postulate of link between fluoridation of water and cancer risk, and states that fluoridated water consumption can have little or no carcinogenic affect. He and some other scientists (e.g. Mahoney et al., 1991; Freni and Gaylor, 1992) believe that the researchers against this idea have little or no proof to speculate the link. Business and Health Administration Association Annual Conference 2012

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Osteoporosis (i.e. loss of bone density), its related fractures, and their potential connection to fluoridation of community water supplies were examined by various scientists. For instance, Cauley, et al.s (1991) study in Pennsylvania on 1,878 women between the ages of 65 and 93 showed no relation between bone mineral density, history of fracture, and exposure to fluoridated water. A similar study by Cauley, et al. (1991) also showed very similar results. The study on 2076 women with the age of 65 and older in a Pittsburgh clinic showed no statistically significant relationship between wrist, hip or spinal fractures and fluoridation. Demos, et al. (2001) also found no adverse effect of fluoride intake on bone resistance, bone mineral density (BMD) or fracture incidences. A similar conclusion also came from the York studies. The study team found that of the 29 studies examined the relationship between water fluoridation and incidence of bone fracture, only four found a significant effect (Armfield, 2007). All these results oppose the studies mentioned in the previous section. In his 2011 review, George (2011) states that it is inaccurate to link the U. S. Department of Health and Human Services decision to lower the added fluoride level of drinking water to the ineffectiveness of the practice. The reason for the dosage adjustment was to eliminate the potential risk of dental fluorosis in children when the infant formula is prepared with tap water. Also, because there is no confirmed evidence of bone effects or other kinds of detrimental impacts, fluorosis is the only consideration used by the U.S. Health Department to determine future actions. On the other hand, the reason that some municipalities decide to remove fluoride from their drinking water is solely a political decision rather than a scientifically supported one (MacGregor, 2011). Because dental disease is the number one chronic disease among children and adolescents in North America, and optimally fluoridated water is a safe and cost-effective public health benefit, its use is supported by 90 national and international scientific and medical organizations (MacGregor, 2011, p1173). Additionally, many studies conducted by relevant authorities based in the US, UK, and Australia provided adequate amounts of evidence regarding safety and the effectiveness of drinking water fluorid ation in todays modern conditions (CDCP, 1991, 1999; Kumar, 2008). Similar to the York Teams study, Frazao, et al. (2011) mention a broad cross-sectional study from 2003 that shows one third reduction in the rate of dental caries in children and adolescents who live in cities with fluoridated water than those who live without this benefit. After examining various studies in the literature, Frazao, et al. (p3) concludes that water fluoridation is an effective measure for preventing and controlling dental caries in children and adolescents. According to Tenuta and Cury (2010), most studies in the literature show little evidence on the hypothesized link in level of fluorosis and fluoridated water. Moreover, Frazao, et al. (2011) (p4) declares mild dental fluorosis as harmless and without esthetic or functional significance ( Fig. 2). In fact, in some cases where there is an apparent fluorosis, the perceived condition could be seen as improved oral health rather than a problem (Chankanka, 2010). The only issue that was not argued or cited by the oppositions was the cost effectiveness of fluoridation. The reason for this should be the clear advantage of fluoridation of public drinking water in terms of cost savings compared to the costs of disease aversion (i.e. dental cavities) and productivity losses (Griffin et al., 2001). Griffin, et al. (2001) determined annual per person cost savings to be between $15.95 for small size communities to $18.62 for large size communities which shows a clear cost saving for both. Table 1 and 2 illustrate fluoride treatment and disease prevention costs.

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TABLE 1. Weighted per person discounted lifetime cost of carious surface initially occurring at various ages

Source: Griffin et al. (2001)

TABLE 2. Range of estimates for annual per person water fluoridation costs for communities of various sizes

Table 2 shows that large size population gives less annual cost per person. Source: Griffin et al. (2001)

CURRENT STATE OF THE ISSUE AND FUTURE DIRECTION Today, dental caries are accepted to be one of the most common diseases and water fluoridation believed to be the best population-level preventive strategy to this worldwide dental health problem (Armfield, 2007). Since the issue is widespread throughout the world, Armfield (2007) believes the appropriateness and effectiveness of the methodology used to prevent it should consider the population level effect, rather than individual results. This leads us to the necessity of community-wide approaches. Due to the aforementioned effectiveness of the fluoridation in caries prevention, Public Health Services (PHS) recommends fluoride addition to community drinking water (CDCP, 2001). Through adopting a drinking water fluoridation strategy, by the end of 2000, more than 50% population of 38 states and the District of Columbia in the U.S. was receiving fluoridated public drinking water ( Fig. 4). However, since there are ever-increasing levels of exposure to fluoride compounds by the public, such as thru dental products (toothpaste, mouth rinses), medications, tea and beverages (Kiritsy et al., 1996), the public health concern increases rapidly. Thus, recommendations by PHS include setting the highest safe limit to prevent any possible harm, especially enamel Business and Health Administration Association Annual Conference 2012

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fluorosis. Depending on the climate conditions of the given area (warm or cold), the amount of the fluoride addition changes between 0.7 ppm and 1.2 ppm. This range, recommended and maintained by PHS, constitutes the current federal fluoridation guideline adopted since 1962 (CDCP, 2001). In addition to this range, the Environmental Protection Agency (EPA) sets a 4.0 ppm maximum allowable fluoride limit in community drinking water to maintain the safety and quality of drinking water in the U.S. Moreover, the U.S. Food and Drug Administration (FDA) sets standards for the prescription and over-the-counter fluoride products in order to provide safe products to the public. The FDA also sets standards for labeling these fluoride contained products, including bottled water that are marketed in the U.S. In addition to these federal agencies, non-federal agencies develop programs to support a certain amount of fluoride intake as well (e.g. the American Dental Association (ADA)s Seal of Acceptance program) (CDCP, 2001). They also publish studies and make recommendations to the public on acceptable amounts of fluoride dietary intake (Table 3) to maintain the highest safety standards. Percentage of state populations with access to fluoridated water through public water systems

Figure 4. Through adopted drinking water fluoridation strategy, by the end of 2000, more than 50% population of 38 states and the District of Columbia in the U.S. was receiving fluoridated public drinking water. Source: CDC - Centers for Disease Control and Prevention. Recommendations for using fluoride to prevent and control dental caries in the United States (CDCP, 2001).

TABLE 3. Recommended dietary fluoride supplement schedule

Table 3. Joint recommendations by ADA, American Academy of Pediatric Dentistry (AAPD), and the American Academy of Pediatrics (AAP) on fluoride intake. Source: CDCP - Centers for Disease Control and Prevention. Recommendations for using fluoride to prevent and control dental caries in the United States (CDCP, 2001).

Undoubtedly, considering the climate conditions of the regions (Frazao et al., 2011) is an appropriate way of determining the right level of fluoride concentration for communities. However, environmental and social Business and Health Administration Association Annual Conference 2012

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changes we have witnessed since 1962 should also be considered carefully (CDCP, 2001). For instance, today, we see increased usage of air conditioning in hot regions compared to the 1960s. Also inactive life styles are more common nowadays. Furthermore, in some regions, we see shifting climate conditions which all can affect water drinking habits. Thus, constantly evaluating and updating safe and useful levels of fluoride additions can be a crucial strategy for the future. CONCLUSION Balancing the benefits and risks of fluoride use in public drinking water supplies is a continuous challenge. The fact that documenting fluoridation impacts is challenging because of delayed effects (Kumar, 2008), future research on the issue should continue to examine the strategy and try to determine the best acceptable level of fluoride in drinking water to minimize the possible risks related to high fluoride intake. This could be possible by assigning a group of scientists (similar to the York Team) and updating the review of the studies constantly. In addition to monitoring and reviewing the safety of the strategy, continuing discussions of the ethical aspects are also necessary to consider. In the last few decades, it is found that in the countries experiencing caries decline, fluoride usage was adopted in some way (Tenuta and Cury, 2010). The Centers for Disease Control and Prevention claims drinking water fluoridation as: one of the 10 major public health achievements of the 20th century, alongside vaccinations and the control of infectious diseases. (Armfield, 2010) (p656) Thus, it should be accepted that fluoridation of drinking water may be the best and the most necessary option to maintain dental health equalities around the world.

REFERENCES Armfield J.M. (2007). When public action undermines public health: a critical examination of antifluoridationist literature. Aust New Zealand Health Policy, 9(4), p.25. Armfield, J.M. (2010). Community Effectiveness of Public Water Fluoridation in Reducing Children's Dental Disease. Public Health Rep., 125(5), 655664. Bayley T.A., Harrison J.E., Murray T.M., Josse R.G., Sturtridge W., Pritzker K.P., Strauss A., Vieth R., Goodwin S. (1990). Fluoride-induced fractures: relation to osteogenic effect. J Bone Mineral Research, March, 5(1), 217-22. Bratthall D., Hansel-Petersson G., Sundberg H. (1996). Reasons for the caries decline: what do the experts believe? Eur J Oral Sci., 104(4), 416-22. Bucher, J.R., Hejtmancik, M.R., and Toft, J.D. (1991). Results and conclusions of the National Toxicology Programs rodent carcinogenicity studies with sodium fluoride. International Journal of Cancer; 48(5), 73337. Catani, Danilo Bonadia et al. (2007). Relationship between fluoride levels in the public water supply and dental fluorosis. Rev. Sade Pblica, 41(5), 732-39. Cauley J.A., Murphy P.A., Riley T., Black D. (1991). Public Health Bonus of Water Fluoridation: Does Fluoridation Prevent Osteoporosis and Its Related Fractures?,American Journal of Epidemiology, 134, 768, Cauley J.A., Murphy P.A., Riley T.J., Buhari A.M. (1995). Effects of fluoridated drinking water on bone mass and fractures: the study of osteoporotic fractures. J Bone Miner Res, 10 (7), 1076-1086. CDCP (1991). Centers for Disease Control and Prevention. Public Health Service report on fluoride benefits and risks. Journal of the American Medical Association, 266(8), 10611067. CDCP (1999). Centers for Disease Control and Prevention. Achievements in public health, 1900 1999: Fluoridation of drinking water to prevent dental caries. Morbidity and Mortality Weekly Report, 48(41), 933940. Business and Health Administration Association Annual Conference 2012

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CDCP (2001). Centers for Disease Control and Prevention. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR Recomm Rep. 2001;50(RR-14), 142. PMID 11521913. Retrieved from http://cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm on November 19,2011. CDPH.gov (2011). California Department of Public Health. Fluoridation by Public Water Systems. Retrieved from http://www.cdph.ca.gov/certlic/drinkingwater/pages/fluoridation.aspx on November 19, 2011. Chankanka O., Levy S.M., Warren J.J., Chalmers J.M. (2010). A literature review of aesthetic perceptions of dental fluorosis and relationships with psychosocial aspects/oral health-related quality of life. Community Dent Oral Epidemiol, 38(2), 97-109. Cheng K.K., Chalmers I., Sheldon T.A. (2007). Adding fluoride to water supplies. BMJ, 335, 699-702. Cockcroft B. & Donaldson L. (2007). Fluoridation: The Department of Health's view. BMJ, 27;335(7625):840. PMID:17962250. Cohen H. & Locker D. (2002). The Science and Ethics of Water Fluoridation. J Can Dent Assoc., 67(10), 578-80. Cohn P.D. (1992). A Brief Report On The Association Of Drinking Water Fluoridation And The Incidence of Osteosarcoma Among Young Males. New Jersey Department of Health Environ. Health Service: 1- 17. Cury J.A. & Tenuta L.M. (2008). How to maintain a cariostatic fluoride concentration in the oral environment. Adv Dent Res. 20(1), 13-6. DOI:10.1177/154407370802000104. Cury J.A., Tenuta L.M., Ribeiro C.C., Paes Leme A.F. (2004). The importance of fluoride dentifrices to the current dental caries prevalence in Brazil. Braz Dent J. 15(3), 167-74. Danielson C., Lyon J.L., Egger M., Goodenough G.K. (1992). Hip fractures and fluoridation in Utah's elderly population, JAMA, 268(6), 746-748. Demos L.L., Kazda H., Cicuttini F.M., Sinclair M.I., Fairley C.K. (2001). Water fluoridation, osteoporosis, fractures: Recent developments. Aust Dent J., 46(2), 80-7. Featherstone, John D.B. (1999). Prevention and reversal of dental caries: role of low level fluoride. Community Dentistry and Oral Epidemiology, 27(1), 3140. Frazao, P.; Peres, M. and Cury, J. A. (2011). Drinking water quality and fluoride concentration. Rev. Sade Pblica, 45(5), 964-973. Freni S.C. and Gaylor D.W. (1992). International trends in the incidence of bone cancer are not related to drinking water fluoridation. Cancer, 70, 611-8. George C. (2011). Battle renewed over value of fluoridation. CMAJ,183, 531-2. Griffin S.O., Jones K., Tomar S.L. (2001). An economic evaluation of community water fluoridation. J Public Health Dent., 61, 78-86. Gupta S.K., Gupta R.C., Gupta A.B. (2009). Is there a need of extra fluoride in children? Indian Pediatr. 46(9), 7559. Gupta S.K., Khan T.I., Gupta R.C., Gupta A.B., Gupta K.C., Jain P. (2001). Compensatory hyperparathyroidism following high fluoride ingestion a clinico-biochemical correlation. Indian Pediatr., 38, 139-146.

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He H., Chen Z.S., Liu X.M. (1989). The influence of fluoride on the human embryo. Chinese Journal of Control of Endemic Diseases 4(3), 136-138. Hedlund L.R., Gallagher J.C. (1989). Increased Incidence of Hip Fracture in Osteoporotic Women Treated with Sodium Fluoride, J. Bone Mineral Res, 4(2), 223-225. Horowitz, H. S. (1996) The Effectiveness of Community Water Fluoridation in the United States, Journal of Public Health Dentistry, 56 (5), 253258, DOI: 10.1111/j.1752-7325.1996.tb02448.x. Jacobsen S.J., Goldberg J., Cooper C., Lockwood S.A. (1992). The association between water fluoridation and hip fracture among white women and men aged 65 years and older. A national ecologic study, Annals of Epidemiology, 2(5), 617-626. Jacqmin-Gadda H., Commenges D., Dartigues J.F., Commenges D., Dartigues J.F. (1995). Fluorine concentration in drinking water and fractures in the elderly [letter]. JAMA, 273(10), 775-6. Jinadasa, K.B.P.N., Weerasooriya, S.W.R. and Dissanayake, C.B. (1988). A rapid method for the defluoridation of fluoride-rich drinking waters at village level. International Journal of Environmental Studies, 31, 305312. Keyes PH. (1960). The infectious and transmissible nature of experimental dental caries. Arch Oral Biol. Mar;1, 304-320. Kiritsy, M.C., Levy, S.M., Warren, J.J. (1996). Assessing fluoride concentrations of juices and juice-flavored drinks. Journal of the American Dental Association, 127; 895-902. Kumar, J.V. (2008). Is Water Fluoridation Still Necessary? Advance in Dental Research, 20 (1), 8-12. Kunzel W. & Fischer T. (1997). Rise and fall of caries prevalence in German towns with different F concentrations in drinking water. Caries Research 31, 166-73. Kunzel W. & Fischer T. (2000). Caries prevalence after cessation of water fluoridation in La Salud, Cuba. Caries Research 34, 20- 5. Knzel W., Fischer T., Lorenz R., Brhmann S. (2000). Decline in caries prevalence after the cessation of water fluoridation in former East Germany. Community Dentistry and Oral Epidemiology, 28(5), 382-389. Laylander, J. A. (1999). A nutrient/toxin interaction theory of the etiology and pathogenesis of chronic pain-fatigue syndromes: Part 1. Journal of Chronic Fatigue Syndrome, 5(1), 67-91. Ludlow M, Luxton G, Mathew T. (2007). Effects of fluoridation of community water supplies for people with chronic kidney disease. Nephrol Dial Transplant. 22(10), 2763-7. MacGregor, R. (2011). Battle renewed over value of fluoridation. CMAJ. 2011 July 12; 183(10): 1173. doi: 10.1503/cmaj.111-2054 PMCID: PMC3134728 Canadian Dental Association, Ottawa, Ont. Mahoney M.C., Nasca P.C. , Burnett W.S., Melius J.M. (1991). Bone cancer incidence rates in New York State : time trends and fluoridated drinking water. Am J Public Health , 81(4), 475-9. Marinho V.C., Higgins J.P., Logan S., Sheiham A. (2003). Topical fluorides (toothpastes, mouthrinses, gels or varnishes) for preventing dental caries in children and adolescents. Cochrane Database Syst Rev CD002782. Maupom G., Clark D.C., Levy S.M., Berkowitz J. (2001). Patterns of dental caries following the cessation of water fluoridation. Community Dentistry and Oral Epidemiology, 29(1), 37-47. Business and Health Administration Association Annual Conference 2012

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McDonagh M.S., Whiting P.F., Wilson P.M., Sutton A.J., Chestnutt I., Cooper J. (2000). Systematic review of water fluoridation. BMJ 321, 855-859. Morris, R.D. (1995). Drinking water and cancer. Environ Health Perspect. 103(8), 225231. National Academies (March, 2006). The National Academy of Sciences. Fluoride in Drinking Water: A Scientific Review of EPAs Standards. Retrieved from <http://dels.nas.edu/reso urces/static-assets/materials-based-onreports/reports-in-brief/fluoride_brief_final.pdf> on November 16, 2011. NIDCR.gov (2011). National Institute of Dental and Craniofacial Research. The Story of Fluoridation. National Institute of Health. Retrieved from http://www.nidcr.nih.gov/oralhealth/topics/fluoride/thestoryoffluoridation.htm on November, 19, 2011. Pahel B.T., Rozier R.G., Slade G.D. (2007). Parental perceptions of childrens oral health: the Early Childhood Oral Health Impact Scale (ECOHIS). Health Qual Life Outcomes;5, 6. Robinson C., Connell S., Kirkham J., Brookes S.J., Shore R.C., Smith A.M. (2004). The effect of fluoride on the developing tooth. Caries Res., 38(3), 268-76. Seppa, L., Karkkaimen, S. and Hausen, H. (2000). Caries trends 1992-98 in two low-fluoride Finnish towns formerly with and without fluoride. Caries Research 34(6), 462-8. Slade G.D., Nuttall N., Sanders A.E., Steele J.G., Allen P.F., Lahti S. (2005). Impacts of oral disorders in the United Kingdom and Australia. Br Dent J, 198, 489-93. Tenuta, L. M. A. & Cury, J. A. (2010). Fluoride: its role in dentistry. Braz. Oral Res. 24(1), 9-17. Zhao L.B., Liang G.H., Zhang D.N., Wu X.R. (1996). Effect of a high fluoride water supply on childrens intelligence. Fluoride, 29, 190-192.

Naz Onel, MBA Ph.D. Student, Environmental Management Earth and Environmental Studies College of Science and Mathematics Doctoral Assistant, Department of Marketing School of Business Montclair State University Montclair, NJ 07043, USA Ph: (973) 655-7037; Fax: (973) 655-7673 Email: onelgarmkhb1@mail.montclair.edu

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USE OF ALLIED HEALTH PROFESSIONALS AS LEADERS IN WELLNESS AND HEALTH PROMOTION: A COST ANALYSIS AND GUIDELINES FOR IMPLEMENTATION
Kelsey Maxwell, Washburn University Zach Frank, Washburn University

ABSTRACT The costs associated with healthcare in this country have become a tremendous economical burden, and yet a number of costly health conditions are preventable. Health promotion has historically been the responsibility of primary care physicians and specialists within the public health sector, yet multiple healthcare providers are qualified to educate patients about prevention and health promotion. The rehabilitation sector employs a high number of qualified individuals including physical therapists (PTs) and physical therapist assistants (PTAs) that are at the forefront of the shift to prevention in terms of healthcare for this country. The economical impact of prevention cannot be overstated and Physical Therapists and Physical Therapist Assistants possess the background that prepares the respective professions to educate and counsel patients in preventive matters. Such efforts can result in reduced overall healthcare expenditures. Research indicates certain healthcare professionals do not feel confident in their abilities or possess the time to discuss promotion and prevention with patients; a strategy that could have a profound impact on reducing costs associated with healthcare today. Compared to primary care physicians and physicians in other areas of healthcare, PTs and PTAs felt qualified to promote prevention through sessions with patients. PTs and PTAs utilize both rehabilitative and preventive measures in the treatment and education of patients. As a result of increased individualized time with the patient in comparison to other professions, PTs and PTAs may be positioned well to have a greater role in prevention of disease and the role it plays in the reduction of healthcare costs. Many physicians feel that in addition to the high caseloads experienced on a day to day basis, they do not have the time or confidence to promote healthy behaviors and individually tailor this promotion to patients in a way that would impact the extremely high healthcare costs. The background of PTs and PTAs, both educationally and clinically, allows these professionals greater opportunity to educate patients about the importance of prevention and good health promotion, and potentially accelerates the reduction of healthcare costs in this country. This paper will analyze the financial impact of using allied health professionals such as PTs and PTAs as the leaders in wellness promotion and disease prevention. It will then identify strategies for successful implementation of such a program.

Kelsey Maxwell Student Physical Therapist Assistant 2920 James, Manhattan, KS, 66502 (785) 341-3240 Kelsey.Maxwell@washburn.edu

Zach Frank PTA Program Director 1700 SW College Ave, Topeka, KS 66621 (785) 670-1406 Zach.Frank@washburn.edu Business and Health Administration Association Annual Conference 2012

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OVERWEIGHT AND OBESITY AND PHYSICAL ACTIVITY IN HEALTHY PEOPLE 2010: WHERE ARE WE NOW AND WHERE DO WE GO FROM HERE?
Margaret J. Greene, Ramapo College of New Jersey

ABSTRACT The United States Department of Health and Human Services (USDHHS) aims to promote health for all citizens. Healthy People 2010 was written ten years ago in 2000, outlining the most significant preventable threats to health as well as establishing national goals to reduce these threats by the end of the decade (USDHHS, U.S. Public Health Service, 2000). Two critical health indicators are overweight and obesity and physical activity which continue to be challenging problems in American society today. This paper examines the efforts taken by the national government and local communities to improve the situation and includes future direction for Healthy People 2020, a guide for public health interventions in the next decade.

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INTRODUCTION In recent years, overweight and obesity have reached epidemic proportions in the United States. Attempting to lower obesity rates is imperative for ensuring the health of citizens because obesity and overweight are major contributors to many preventable conditions and causes of death. Among these are coronary heart disease, type 2 diabetes, cancers, hypertension, dyslipidemia, stroke, liver and gallbladder disease, sleep apnea, respiratory problems, osteoarthritis, and gynecological problems (Centers for Disease Control and Prevention, 2009). In addition to health problems, overweight and obesity create significant economic problems. Direct costs result from prevention, diagnosis, and treatment of obesity-related conditions, and indirect costs include morbidity and mortality costs (CDC, 2009). Morbidity costs are defined as the value of income lost from decreased productivity, restricted activity, absenteeism, and bed days, and mortality costs are the value of future income lost by premature death (CDC, 2009). The total estimated direct and indirect costs resulting from overweight and obesity is estimated to be as high as $147 billion annually, based on data from 2006 (Holden, 2010). Compared to normal weight people, obese people spent $1,429 (42 percent) more for medical care during that year (CDC, 2009). Other studies have shown additional effects of obesity, specifically regarding children. Research has found that obesity and poor nutrition negatively affect school achievement, with severely obese children having lower IQs, poorer school performance, and lower test scores than other children (Hollar et al., 2010). Another important consequence of obesity is its social effects including possible stigmatization, discrimination, and lowered self-esteem (LHI). The effects of overweight and obesity are far-reaching, making apparent its inclusion as one of the ten leading indicators in Healthy People 2010. HEALTH ISSUES Overweight and obesity are determined by body mass index (BMI), which is based on height and weight and usually correlates to the amount of body fat. For adults, overweight is defined as having a BMI between 25 and 29.9, and obesity is defined as having a BMI of 30 or above (CDC, 2010). BMI measurements in children take into account differences between boys and girls in body fat distribution (CDC, 2010). There are many contributing factors as to why people become overweight or obese. The basic underlying cause is an imbalance in energy requirements: people are consuming too many calories and not exercising enough. This has become a serious problem in recent decades due to changing societal and environmental factors. Notably, some Americans have less access to stores and markets that provide healthy, affordable food such as fruits and vegetables, especially in rural, minority and lower-income neighborhoods (CDC, 2010). There has also been an Business and Health Administration Association Annual Conference 2012

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increase in consumption of foods prepared outside the home in the form of fast food, sit-down restaurants, and vending machines (Burton, 2006). This has lead to an increase in obesity rates since away-from-home food is highly palatable, consists of larger portions, and often has a higher energy density, making it frequently higher in calories and fat content (CDC, 2010). All of these factors combine to encourage overeating of often unhealthy foods. Another important societal factor leading to obesity is the fact that less healthy foods and beverages are often easier and cheaper to obtain than healthier options (CDC, 2010). Moreover, there has been an increase in advertising and marketing of foods high in sugar, fat, and salt, making these unhealthy items a highly visible aspect of American culture (CDC, 2010). INTERVENTIONS In conjunction with proper nutrition, physical activity is an important component of maintaining a healthy body weight. Physical activity has many beneficial effects on overall health status. In addition to preventing and controlling obesity, it reduces the risk for many of the diseases associated with obesity, such as diabetes and heart disease (USDHHS, Office of the Surgeon General, 2010). Other effects include building and maintaining healthy bones and lean muscle mass, reducing feelings of depression and anxiety, promoting psychological well being, enhancing independent living for older adults, and improving quality of life for all people (CDC, 2006). The U.S. Surgeon General recommends that adults should do at least 150 minutes of moderate -intensity physical activity per week, and for children and teenagers, the recommendation is for 1 hour of daily physical activity that includes vigorous activities and activities that strengthen their bones (2010). People can fulfill this recommendation through a variety of activities and by making small changes to their lifestyle, such as taking brisk walks and climbing the stairs instead of using the elevator. However, various barriers to physical activity may be encountered. For example, some communities are built in ways that make physical activity difficult or unsafe. Access to parks and recreation centers may be limited, safe routes for walking or biking to school or work may not exist, and daily physical education in school may not occur (CDC, 2010). Excessive television and computer use is another significant barrier, evidenced by the fact that 8-18 year olds spend over seven hours each day using entertainment technology (USDHHS, Office of the Surgeon General, 2010). In addition to contributing to a sedentary lifestyle, the more time children spend watching television, the more likely they are to eat while doing so and the more likely they are to eat the high-calorie foods that are heavily advertised to both adults and children (USDHHS, Office of the Surgeon General, 2010). To achieve an increase in physical activity for Americans, all of these barriers must be overcome. HEALTHY PEOPLE 2010: OBESITY AND NUTRITION Healthy People 2010 is organized into various objectives dealing with obesity and nutrition. These are related to weight status and growth, food and nutrient consumption, and schools, worksites, and nutrition counseling. Healthy People 2010 has set targets for improvement in all areas as follows (USDHHS, USPHS, 2000): Objective Increase the proportion of adults who are at a healthy weight. Reduce the proportion of adults who are obese. Reduce the proportion of children and adolescents who are overweight or obese. Increase the proportion of persons aged 2 years and older who consume at least two daily servings of fruit. Increase the proportion of persons aged 2 years and older who consume at least three daily servings of vegetables, with at least one-third being dark green or orange vegetables. Increase the proportion of persons aged 2 years and older who consume at least six daily servings of grain products, with at least three being whole grains. Increase the proportion of persons aged 2 years and older who consume less than 10 percent of calories from saturated fat. Increase the proportion of persons aged 2 years and older who consume no more than 30 percent of calories from total fat. Increase the proportion of persons aged 2 years and older who consume 2,400 mg or less Business and Health Administration Association Annual Conference 2012 Baseline 42 23 11 28 3 7 36 33 21 Target 60 15 5 75 50 50 75 75 65

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of sodium daily. Increase the proportion of persons aged 2 years and older who meet dietary recommendations for calcium. Increase the proportion of children and adolescents aged 6 to 19 years whose intake of meals and snacks at school contributes to good overall dietary quality. Increase the proportion of worksites that offer nutrition or weight management classes or counseling. Increase the proportion of physician office visits made by patients with a diagnosis of cardiovascular disease, diabetes, or hyperlipidemia that include counseling or education related to diet and nutrition.

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Developmental 55 42 85 75

Healthy People 2010 also established a set of objectives related to physical activity with accompanying targets. These include (USDHHS, USPHS, 2000): Objective Reduce the proportion of adults who engage in no leisure-time physical activity. Increase the proportion of adults who engage regularly, preferably daily, in moderate physical activity for at least 30 minutes per day. Increase the proportion of adults who engage in vigorous physical activity that promotes the development and maintenance of cardio-respiratory fitness 3 or more days per week for 20 or more minutes per occasion. Increase the proportion of adults who perform physical activities that enhance and maintain muscular strength and endurance. Increase the proportion of adults who perform physical activities that enhance and maintain flexibility. Increase the proportion of adolescents who engage in moderate physical activity for at least 30 minutes on 5 or more of the previous 7 days. Increase the proportion of adolescents who engage in vigorous physical activity that promotes cardio-respiratory fitness 3 or more days per week for 20 or more minutes per occasion. Increase the proportion of the Nations public and private schools that require daily physical education for all students. (Middle schools) Increase the proportion of the Nations public and private schools that require daily physical education for all students. (High schools) Increase the proportion of adolescents who participate in daily school physical education. Increase the proportion of adolescents who spend at least 50 percent of school physical education class time being physically active. Increase the proportion of adolescents who view television 2 or fewer hours on a school day. Increase the proportion of the Nations public and private schools that provide access to their physical activity spaces and facilities for all persons outside of normal school hours. Increase the proportion of worksites offering employer-sponsored physical activity and fitness programs. Increase the proportion of trips made by walking. (Adults) Increase the proportion of trips made by walking. (Children to school) Baseline 40 15 23 18 30 27 65 17 2 29 38 57 Target 20 30 30 30 43 35 85 25 5 50 50 75

Developmental 46 17 31 75 25 50

It is apparent that some of these are sizable goals, but with sufficient planning and strategies, substantial progress could hypothetically be reached in the span of ten years. Unfortunately, the majority of these goals have not been achieved due to a wide variety of reasons. An examination of the efforts already implemented show that the United States is headed in the right direction to lessen the obesity epidemic. However, there are still many goals left to be accomplished. Business and Health Administration Association Annual Conference 2012

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An important initiative to improving peoples diets dea ls with providing nutrition information on food packaging. Because away-from-home food consumption has greatly increased in recent years, research has been done to examine the effects of nutrition information in restaurants. Researchers have found that people significantly underestimate levels of calories, fat, and saturated fat in less-healthful restaurant items (Burton, 2006). Moreover, inclusion of nutrition information has a significant influence on peoples product attitudes, purchase intentions, and choices to consume (Burton, 2006). Many restaurants provide nutrition information on company websites or on premises if asked. However, after observing 4,311 consumers in fast food restaurants, a recent study found that only six people, or 0.1%, accessed nutrition information prior to purchasing their food (Roberto, 2009). Having the information available is only useful if people decide to specifically ask for it, so providing nutrition information to all consumers at the point of sale is much more beneficial. When people are aware of what they are eating, they are much more likely to make better choices. In 2006, New York City adopted a law requiring chain restaurants to post calorie information on menu boards (NYC Department of Health and Mental Hygiene, 2006). Laws requiring nutrition information on menus and menu boards have since been adopted in other areas, including Oregon, Philadelphia, and King County, Washington, and many other municipalities are considering similar policies (Stein, 2010). Additionally, the Patient Protection and Affordable Care Act was signed into law March 23, 2010 by President Obama. This law includes a provision creating a uniform standard for nutrition-disclosure for restaurants across the country, requiring restaurant chains with more than 20 locations to post calorie values on menus, menu boards, or drive thru boards and keeping additional nutrition information available upon request. The Food and Drug Administration must now propose specific regulations within one year before changes can take effect (National Restaurant Association, 2010). Now, more people than ever before will be aware of the nutrition information of foods they consume in restaurants, and hopefully this will lead to an increase in healthier choices. FOCUS ON EXERCISE Physical activity can also be improved through government and community initiatives. One significant barrier to getting enough physical activity is living in an environment that is not safe for walking to and from school, work, and other destinations. Research has found that neighborhood physical environments and perceived safety influence adults readiness to encourage childrens physical activityin sports or exercise (Miles, 2008). If the environment does not provide a safe place for physical activity, children and adults will likely spend more time engaging in sedentary activities indoors (USDHHS, USPHS, 2000). There are many ways governments can work to make communities safer and more conducive to physical activity. The following strategies have been recommended by the Surgeon General: Improve access to outdoor recreational facilities, build or enhance infrastructures to support more walking and bicycling, support locating schools within easy walking distance of residential areas, improve access to public transportationand enhance personal and traffic safety in areas where people are or could be physically active (2010). These initiatives require sufficient funding, but some communities have implemented creative, economical strategies to provide safe passages for children between homes and neighborhoods, schools, and after school activities. For example, Lets Move! is a campaign started in February 2010 by First Lady Michelle Obama to end childhood obesity in the United States. One strateg y promoted through this campaign is the walking school bus model, in which adults walk to school with a group of children; many localities across the country have found this to be successful (USDHHS, 2010). Lets Move! promotes many other strategies for parents, schools, and communities to decrease childhood obesity. These include limiting television time, spending family time outdoors being active, increasing physical education time, and creating parks and playgrounds where children can safely play (USDHHS, 2010). Solutions such as these can have a substantial impact on the health of Americas children. FOCUS ON NUTRITION Another component to preventing childhood obesity in schools is promoting good nutrition. One of the CDCs recommended strategies to prevent obesity is that public service venues (e.g. schools) should increase the availability and affordability of healthier food and beverage choices (2010). This goal has been accomplished in many communities, and the results have often been promising. For example, school districts across the country have established nutrition standards that prohibit the sale or serving of foods of minimal nutritional value including soft drinks, candy bars, fried chips, and other high-fat snacks (U.S. Department of Agriculture, CDC, 2005). Other schools have prohibited all beverages besides water, milk, and 100% fruit juice. In addition to prohibiting certain items from menus, some schools have adopted guidelines requiring that only fruits and vegetables can be eaten as Business and Health Administration Association Annual Conference 2012

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snacks in classrooms. Another way school districts are promoting healthier eating is by reevaluating food and beverage contracts with outside vendors. Some districts have chosen to cancel contracts; however, this is not an option for all schools since many have come to rely on the generated revenue. Therefore, districts have attempted to renegotiate with vendors by initiating proposals that include increasing the percentage of healthful items available, improving nutritional quality of beverages available under an existing contract, or charging a lower price for healthier food and beverages (USDA & CDC, 2005). Schools can also adopt marketing techniques to encourage their students to make healthier choices. For example, they should (1) identify and offer healthful products that are appealing and meet student needs, (2) use product placement to make healthful products easy to choose, (3) use promotion strategies so that students know about these products and are motivated to try them, and (4) set their price at a level that encourages students to purchase them (USDA & CDC, 2005). Finally, fundraising activities should support student health. Students can be rewarded by walks with the principal rather than prizes such as a pizza party, and fundraisers should involve selling nutritious foods (e.g. fruit) or non-food items rather than candy (USDA & CDC, 2005). PROGRESS MADE Many school districts across the country have seen improvements in nutrition, wellness education, and physical fitness. For example, in Grand Forks, North Dakota, milk, bottled water, and baby carrots are now sold at extra-curricular school events, which has helped make healthful choices the norm and has also increased fundraising revenue. Additionally, a school-wide classroom snack policy of fruits or vegetables only has been adopted. This policy has generally been well received and is now accepted school practice (USDA & CDC, 2005). In Mercedes, Texas, candy is no longer a fundraiser, soft drinks have been banned, and new options, such as fat-free ice cream bars, yogurt, and string cheese, have been added to the la carte menu. Sales of the new items have been strong, and there has been no significant change in food revenue (USDA & CDC, 2005). In addition to anecdotal evidence in support of these measures, various studies have also been performed. Hollar et. al. (2010) examined the effect of a school-based obesity prevention program that included dietary, educational, and physical activity components on BMI and academic performance among low-income elementary students. Modifications to school menus included more high-fiber items, fewer high-glycemic items, and lower levels of total, saturated, and trans fats. The curricula component consisted of a holistic nutrition and healthy lifestyle management program that sought to teach children, parents, and school sta ff about good nutrition and the benefits of daily physical activity with the goal of improving the health and academic achievement of children in a replicable and sustainable manner. The physical activity component provided increased opportunities for phy sical activity during the school day for students. After two years, 52.1% of students in the experimental condition stayed within normal BMI percentile ranges compared to only 40.7% of those in the control group, and intervention students scored, on average, 10.9-31.7 points higher on the math section of the Florida Comprehensive Achievement Test than students in the control group (Hollar, et. al. 2010). Interventions by schools can have a highly influential effect not only on the physical health of students, but an increase in academic performance may result as well. Although many valuable initiatives have been taken across the country to reduce obesity and increase physical fitness, the most recent round of progress reviews for Healthy People 2010 by the CDC/National Center for Health Statistics has found an overall decline in values for these indicators. Notably, all objectives related to overweight and obesity are moving away from their targets (2008). The proportion of adults whose weight is in the hea lthy range was 32 percent in the period 2003-2006, down from 42 percent in the period 1988-1994. The target for 2010 was 60 percent. Additionally, 33 percent of adults are now obese, compared to only 23 percent in 1988-1994. The target for this measure is 15 percent. Progress for children and adolescents is similarly discouraging: overweight and obesity in children aged 6 to 11 years increased from 11 percent in 1988 1994 to 17 percent in 20032006. In adolescents aged 12 to 19 years, the increase over the same period was from 11 percent to 18 percent. The target for both children and adolescents is 5 percent. Several barriers to preventing obesity have been identified. Away from home foods, which are ready-to-eat items purchased at restaurants, prepared-food counters at grocery stores, and institutional settings such as schools, make it difficult to make healthy choices and limit portion control (USDHHS, 2008). Additionally, encouraging people to maintain behavioral changes for lifelong weight management can be extremely difficult (USDHHS, 2008). States and local communities have the authority to regulate foods and beverages sold in schools, but many localities have not yet taken action (USDHHS, 2008).

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STRATEGIES FOR THE FUTURE The federal government recognizes these barriers to success, but they have also outlined strategies for the future. Public awareness of overweight and obesity must be increased at the individual and population levels, and communication must be improved to provide the public with recommended actions that can be effective in weight management (USDHHS, 2008). More scientific research needs to be conducted to determine the most effective ways to achieve sustained lifestyle modification so that people will be inspired to make healthy decisions for years to come. Federal nutrition assistance programs should be used to increase the availability of fruits, vegetables, and whole grains and decrease higher-fat dairy products to low-income families. Additionally, school health and physical education programs need more governmental support (USDHHS, 2008). One way the government is beginning to fulfill these promises is through funding by the Centers for Disease Control and Preventions Division of Nutrition, Physical Activity, and Obesity. Currently, 25 states receive funding to help create policies and environmental changes that will improve the health of Americans. The principal target areas include increasing physical activity, increasing fruit and vegetable consumption, decreasing the consumption of sugar sweetened beverages, reducing the consumption of high calorie foods, and decreasing television watching (CDC, 2010). New Jersey is one of the states that have been receiving funding since 2008. The state government created the New Jersey Obesity Action Plan in 2006, which is providing a framework as to how the funds will be spent. One of the objectives that has been developed involves the N.J. Department of Transportation, which will work to promote physical activity by implementing a statewide pedestrian safety campaign, increase funding to the Safe Routes to Schools program which makes it safer and easier for children to walk to school, and create pedestrian and bike paths whenever possible. The Department of Health and Senior Services (DHSS) has created the N.J. Council on Physical Fitness and Sports, which distributes $100,000 grants to communities for policy and environmental change projects. The DHSS is also receiving funding jointly with the Department of Education to promote obesity and tobacco control in schools (CDC, 2010). One of the programs that have been developed since the initial creation of the New Jersey Obesity Action Plan is the Choosing Healthy Life by Making Healthy Choices Program. Lead by the NJ Pediatric Council on Research and Education (PCORE), this campaign encourages children to make healthy choices about nutrition, exercise, and overall well-being. Pediatricians play an important role by providing information and guidelines to parents, and after-school programs promote health by providing 20-30 minutes of physical activity five days a week and teaching children how to make good decisions about food, portion size, and physical activity. After one year of being implemented in schools in Long Branch, NJ, the BMI (Body Mass Index) outcomes for participants showed a 5.7% decrease in children who were overweight/obese, and after two years, there was a 12.7% increase in children who had healthy weight, 8.4% drop in children who were overweight, and a 13.7% drop in children who were obese (NJPCORE, 2009). These are promising results, and researchers hope to expand the program to other school districts. Obesity has had a profound impact in New Jersey. According to Behavioral Risk Factor Surveillance System data from 2007, 38% of adults are considered overweight and another 24% are considered obese (CDC, 2008). Obesity is a significant problem with children as well: New Jersey has the highest reported rate of obesity in the nation for low-income children ages 2-5, and 15% of 9th-12th graders are overweight with an additional 11% being obese (CDC, 2008). A major survey of childhood obesity in the state has not yet been conducted since actions by the NJ Obesity Action Plan have begun; only time will tell if the nationally-funded initiatives are significantly improving the health status of New Jerseys residents compared to this baseline data. HEALTHY PEOPLE 2020 Virtually all of the indicators related to obesity and physical activity have not been met; these goals will continue to be an issue in future years. In fact, they have been included as objectives in Healthy People 2020, which will guide the nations health promotion initiatives for the next ten years (USDHHS, USPHS, 2010). In regards to nutrition and weight status, many of the objectives are the same as in Healthy People 2010, including increasing the proportion of adults who are at a healthy weight, reducing the proportion of adults who are obese, reducing the proportion of children and adolescents who are overweight or obese, and reducing the proportion of adults who engage in no leisure-time physical activity. New objectives include preventing i nappropriate weight gain in youth and adults, increasing the number of states that have state -level policies that incentivize food retail outlets to Business and Health Administration Association Annual Conference 2012

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provide foods that are encouraged by the Dietary Guidelines, and increasing the proportion of Americans who have access to a food retail outlet that sells a variety of foods that are encouraged by the Dietary Guidelines (USDHHS, USPHS, 2010). The objectives related to physical activity have remained similar as well. For example, Healthy People 2020 once again aims to reduce the proportion of adults who engage in no leisure -time physical activity, increase the proportion of trips made by walking, i ncrease the proportion of employed adults who have access to and participate in employer-based exercise facilities and exercise programs, increase the proportion of children and adolescents who do not exceed recommended limits for screen time, and increase the proportion of the nations public and private schools that require daily physical education for all students. However, there are a few new objectives, such as increasing regularly scheduled elementary school recess, increasing legislative policies for the built environment that enhance access to and availability of physical activity opportunities, and increasing the proportion of physician office visits that include counseling or education related to physical activity (USDHHS, USPHS, 2010). With the publication of Healthy People 2020, Americas lawmakers and citizens hopefully have a renewed focus on improving health in the important areas of overweight and obesity and physical activity. Since all of the strategies have been developed, hopefully we will see measurable improvements in the next ten years and into the future. REFERENCES Burton, S., Creyer, E., Kees, J., & Huggins, K. (2006). Attacking the obesity epidemic: The potential health benefits of providing nutrition information in restaurants. American Journal of Public Health. Retrieved from http://ajph.aphapublications.org/cgi/content/full/96/9/1669. Centers for Disease Control and Prevention (2010, August 3). CDC vital signs: Adult Obesity. Retrieved from http://www.cdc.gov/vitalsigns/AdultObesity/index.html. Centers for Disease Control and Prevention (2010, September 30). Overweight and obesity. Retrieved from http://www.cdc.gov/obesity/index.html. Holden, D. (2010, February 9). Fact check: The cost of obesity. Retrieved from http://www.cnn.com/2010/HEALTH/02/09/fact.check.obesity/index.html. Hollar, D., Messiah, S., Lopez-Mitnik, G., Hollar, T., Almon, M., & Agatston, A. (2010). Effect of a two-year obesity prevention intervention on percentile changes in body mass index and academic performance in low-income elementary school children. American Journal of Public Health, 100(4), 646-653. doi:10.2105/AJPH.2009.165746. Miles, R. (2008). Neighborhood disorder, perceived safety, and readiness to encourage use of local playgrounds. American Journal of Preventive Medicine, 34(4), 275-281. National Restaurant Association. (2010). Public policy issue briefs. Retrieved from http://www.restaurant.org/advocacy/issues/issue/?Issue=menulabel. New Jersey Department of Health and Senior Services. (2006). The New Jersey obesity prevention action plan. Retrieved from http://www.state.nj.us/health/fhs/documents/obesity_prevention.pdf. Roberto, C., Agnew, H., & Brownell, K. (2009). An observational study of consumers' accessing of nutrition information in chain restaurants. American Journal of Public Health, 99(5), 820-821. Retrieved from CINAHL database. Stein, J. (2010, February 19). Menus to carry nutrition info starting next year. Los Angeles Times. Retrieved from http://articles.latimes.com/2010/feb/19/health/la-he-0222-restaurants-law-20100218. U.S. Department of Agriculture, & Centers for Disease Control and Prevention (2005). Making it happen: School nutrition success stories. Retrieved from http://www.cdc.gov/HealthyYouth/nutrition/Making-ItHappen/download.htm. Business and Health Administration Association Annual Conference 2012

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U.S. Department of Health and Human Services, Public Health Service (2000). Healthy people 2010. Retrieved from http://www.healthypeople.gov/2010/Document/tableofcontents.htm#tracking. U.S. Department of Health and Human Services, Public Health Service (2006). Healthy people 2010 midcourse review. Retrieved from www.healthypeople.gov/Data/midcourse/. U.S. Department of Health & Human Services, Public Health Service (2008, June 26). Progress review: Physical activity and fitness. Retrieved from http://healthypeople.gov/data/2010prog/focus22/. U.S. Department of Health and Human Services, Public Health Service (2008, April 3). Nutrition and overweight: Progress Review. Retrieved from http://www.healthypeople.gov/Data/2010prog/focus19/2008Focus19.pdf. U.S. Department of Health and Human Services, Public Health Service (2010). Healthy people 2020. Retrieved from http://healthypeople.gov/2020/default.aspx. U.S. Department of Health and Human Services (2009, July 27). Study estimates medical cost of obesity may be as high as $147 billion annually. Retrieved from Centers for Disease Control and Prevention website: http://www.cdc.gov/media/pressrel/2009/r090727.htm. U.S. Department of Health and Human Services (2010). Let's Move! Retrieved from http://www.letsmove.gov/. U.S. Department of Health and Human Services, Office of the Surgeon General (2010, January). The Surgeon Generals vision for a healthy and fit nation. Rockville, MD: U.S. Retrieved at http://www.surgeongeneral.gov/library/obesityvision/obesityvision2010.pdf.

Dr. Margaret J. Greene Ramapo College of New Jersey 505 Ramapo Valley Road, Mahwah, New Jersey 07430 Phone: (201) 684-7206, Fax: (201) 760-2461 E-mail: mgreene1@ramapo.edu

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TRACK DISTANCE LEARNING AND ONLINE TEACHING

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STRATEGIES FOR SELF-DIRECTED LEARNING IN A VIRTUAL ENVIRONMENT


Scott J. Saccomano, Herbert H Lehman College

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ABSTRACT Nursing educators are constantly faced with the challenge of providing students with educational experiences that promote critical thinking and self-directed learning. The goal of such activities is to prepare competent practitioners to deliver nursing care in a variety of settings. Adult learning is most advantageous when individuals are self-directed, identify their own learning goals, and participate in evaluating the learning experiences. Self-directed learning claims to increase students confidence and the capacity for independent learning. Nursing educators are drawn to the self-directed learning model as it has significant implications for professional autonomy, a critical requirement for nursing practice. In order for self-directed learning to be successful, both teachers and learners need to be familiar with the concept and possess the required skills for development of the associated learning strategies. Students must possess a variety of skills, such as self-efficacy and organization, if they are to achieve the required learning objectives. To facilitate student participation in selfdirected learning activities it is crucial to evaluate their purpose for learning. Student attributes for self directed learning: 1. Motivation Why do students choose to participate in academic tasks? 2. Goal Oriented Does the student have the ability to make plans and set goals? 3. Organization - The ability to organize a course of action. 4. Control Do students have the ability to ascribe to achievements? 5. Reflection Students should continuously assess and reevaluate their learning goals. Goals for nurse educators to facilitate self-directed learning: 1. Develop collaborative relationships with students to identify goals and objectives. 2. Identify individual learning styles. 3. Supervise the experience rather than be an information provider. 4. Encourage critical thinking skills. 5. Provider of resources to facilitate learning. It is important with any teaching-learning strategy to assess its congruency with the course of study. The self-directed learning model can enhance the learning experience, improve student performance, and support academic achievement

Scott J. Saccomano Herbert H Lehman College Bronx, New York, 10468

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EMBARRASSING NEW INFORMATION TECHNOLOGY IN TEACHING GLOBAL HEALTH


Hengameh Hosseini, Seton Hall University _____________________________________________________________________________________ ABSTRACT This interdisciplinary global health course, taught from various social science perspectives, is designed to present an overview of salient issues in global health. The course explores the many ramifications of disease, in their social, cultural, economic, political, ethical, physiological, epidemiological, and public health dimensions. A significant portion of the course is devoted to the HIV/AIDS epidemic in the developing world. The author believes the course, which has been taught once before, can be enhanced by the utilization of new media technology (Blackboard, etc.) because todays students, being technology savvy, can attain more information, and can also cause more active engagement of fellow students. Keywords: Health, Global, Interdiciplinary

Hengameh Hosseini, PhD Assistant Professor Master of Healthcare Administration Political Science and Public Affairs 520 Jubilee Hall 400 South Orange South Orange NJ 07079 E-mail: hosseihe@shu.edu Tel: 973-761-9212

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A NURSING EDUCATION CHALLENGE: E-TEXTBOOKS


Josephine M. DeVito, Seton Hall University

ABSTRACT Within the current economic environment, education costs have to be considered in many areas, including tuition and textbooks. Nursing education has undergone many changes as more diverse students enter traditional and accelerated nursing programs. These factors influence the learning experience for students. Traditionally, students learned by buying new or used nursing textbooks. This was the norm, but as textbook prices increased and some students were unable to purchase the required textbooks for a course another option had to be made available. The challenge that nursing education needs to consider is e-textbooks. The most interesting aspect of electronic books is not the devices they can be accessed with, but that they are potentially, a creative technology which provides a new kind of reading experience for the learner. Publishers are beginning to explore visual interfaces that include multimedia and collaborative elements. Pageburst is Elseviers digital textbook solution. Some o f the features of Pageburst are that important concepts can be highlighted, students can make notes, and share notes with other students. It is important that the education of nurses move forward with technology as we move into the 21 st Century and e-textbooks can provide this opportunity. The benefits of incorporating Pageburst into nursing curriculum: 1. Instructors and students can access the entire Elsevier library of Nursing e-textbooks, when the curriculum commits to e-textbooks for its students and at a significant cost savings for the student 2. Pageburst can be accessed on line, offline (on computers or laptops), and mobile (on Apple iPhone, iPod Touch, and iPad devices) 3. Creating folders to organize content 4. Text-to-speech features allows the digital book to be read to the student 5. Students and faculty will have access to Mosbys Nursing Consult at no extra charge: this online reference offers additional resources including books, journals, drugs, clinical updates, images, evidencebased nursing, news, etc. The objectives of this presentation will be to: 1. Understand the role e-textbooks in nursing education 2. Assess the advantages of e-textbooks in nursing education 3. Identify the role of the nurse educator in e-textbook nursing education The outcome of this presentation will be that e-textbooks should be considered a learning strategy for nursing education. It will provide students the opportunity to be motivated and learn at their own pace while developing critical thinking skills.

Josephine M. DeVito Seton Hall University South Orange, New Jersey 07079

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ASSESSING THE IMPACTS OF ANXIETY AND GENDER ON STUDENT ATTITUDES TOWARD COMPUTER LEARNING TECHNOLOGY IN A SAUDI NURSING ACADEMIC ENVIRONMENT
Osama A. Samarkandi, Al-Baha University

ABSTRACT Computer knowledge and skills are becoming essential components technology in nursing education. Saudi nurses must be prepared to utilize these technologies for the advancement of science and nursing practice in local and global communities. Little attention has been directed to students attitudes about computer usage in academic communities in Saudi Arabia. Their attitudes about the use of computers for the enhancement of learning are relatively unknown. Few research studies have been identified that expl icate Saudi Arabian nursing students attitudes toward computer usage for the acquisition of knowledge and skills. Males and females matriculate at King Saud University (KSU), but attend classes in gender-specific groups. This descriptive correlation study will contribute to the body of knowledge related to nursing students attitudes toward computer usage in their baccalaureate education at KSU. The research included all students enrolled in the College of Nursing at KSU in Riyadh, in the summer semester of the academic year 2009-2010. The total number of undergraduate nursing students were 600; 195 were males and 405 were females (KSU, 2008). The findings (n = 335; nm= 133 & nf = 222) suggest that females were more anxious about computer usage (Mean=31.5; 32.7) than males. None of the independent variables explained the variance in the dependent variable, computer usage. Findings did indicate that students had less anxiety if they had access to a computer at home or at school; their anxiety was even less if they had computer exposure at both home and school. Implications of these findings are presented with regard to educating future nurses at KSU for complex roles in health care systems. The study also raises issues about the possibility of planning intervention studies for future research about computer learning, possibly using simulation-based approaches and virtual systems. Issues regarding gender, socioeconomic status, age, learner attitudes, and other variables will need to be systematically investigated. Future studies should assist with the unraveling of traditional cultural issues, including gender-specific roles and expectations for computer usage in nursing and health care delivery.

INTRODUCTION As computer technology becomes a common component in educational institutions, its pedagogical use will continue to gain status and notoriety (Oblinger & Rush, 1997). Core curricula in many colleges and universities now include computer literacy as a basic requirement and for faculty and students. At some institutions, computer literacy is mandatory. Young (1997) listed a number of institutions ( n = 8) that had begun mandatory computer literacy programs for their students. Beginning in the fall of 1998, these institutions required that all of their students either own or have access to a computer. Functionally, computers are used in education for three types of activities: management; instruction and learning; and educational research (Forcier, 1996). The use of computers for management activities includes school and classroom applications in budgeting, accounting, record keeping, printed and electronic communication, and information retrieval. These management activities are essential for nurse leaders who are responsible for planning and implementing health programs in a variety of settings. Budgeting and accounting is activated at the unit level in many hospitals and clinics throughout the world. Nurses are now responsible for nursing care and for financial management. Computer usage is essential in both instances. In addition, use of computers for instruction and learning involves teacher-centered interactions as Business and Health Administration Association Annual Conference 2012

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well as student-centered learning. Teacher-centered instruction provides teachers with greater control in the design, development, and delivery of instructional materials. Student-centered learning gives the individual more freedom to construct activities that would lead to learning, and this method could help the learner to acquire a sense of competence about the acquisition of knowledge and skills. Computers are also used in research, evidence-based practice, statistical analysis, and information retrieval and synthesis. Collectively, these activities contribute to the learning process and help to foster competency among nurses and others (Forcier, 1996; Freedman, 1996; Teo & Lim, 1996). Technology usage is an important component of health care planning and delivery in Saudi Arabia and throughout the Middle East. Its use is expanding at a phenomenal rate. Technology will impact Saudi society in a way that is similar to its influence on other world communities. Specifically, technology will help the Saudis to increase their research efforts at the molecular levels of scientific investigations, such as in genetics. It is an essential tool for conducting epidemiological research and for implementing community-based research in large populations. Computer technology will enable Saudi scientists and clinicians to participate in research on the world stage and reduce costs by utilizing resources for implementing health care that are available in other global communities. Importantly, the use of technology will enable the Saudi people to generate and utilize evidence-based practice approaches to health care, expand research, and generate new knowledge that is specific to the Saudi people. These novel approaches that are available because of technology also have challenges. The Saudi government, like other governments in the world community, will need to give in-depth consideration to technology-related issues such as confidentiality and ethical decision making. Nevertheless, the advantages of technology in Saudi Arabia have been embraced by the society and government. All health care providers are expected to become computer literate and utilize technology in their practice, research, and education and training (McLaughlin et. al, 2008). It is anticipated that teaching and learning at all levels in society will be impacted by innovations that are associated with computer technology. The profound potential that is related to the use of computers will overlap all aspects of human life. Computer technology will also link Saudi Arabia to other Arab countries as well as every country in the global community (Al-Farsi, 2001; Mufti, 2002). These technological advances have assisted the students by enhancing their learning. One practice, however, remains constant. Although King Saud University in Riyadh, the nations capital and largest city, invites males and females to its campus, the religious and cultural practices that dictate that males and females will be educated in different classrooms remains a strong basic value within Saudi culture. Hence, although the KSU male and female students share all resources, they continue to learn in separate classroom environments (KSU, 2008; Saudi Ministry of Higher Education, 2008; Moshaikeh, 1992). COMPUTER USAGE IN NURSING EDUCATION IN SAUDI ARABIA The Saudi Arabian School System adopted a gender-dual education system that is separate and different for males and females. The male education system was established in 1953 by the Ministry of Education, which is responsible for the development of a national educational policy that focuses on Saudi male learners. These institutions are located throughout the nation and are the hallmarks of education for the Saudi male learner (Al-Farsi, 2001). On the other hand, the female educational system was established in 1960 under the Presidency of Girls Education, a government body that was created specifically to handle educational matters for women (Al-Farsi, 2001). Females are required to attend the female gender institutions, and they, too, can matriculate in nursing at the baccalaureate level at the institutions that have been created for them. STATEMENT OF THE PROBLEM The College of Nursing at KSU has been selected as the setting for this research because it is the first and only school of nursing in Saudi Arabia that awards a baccalaureate degree in nursing (BSN) to both sexes (KSU, 2008; Saudi Ministry of Higher Education, 2008). This practice began in 2004. In Saudi Arabia, male and female nursing students in the same educational milieu represent a new and novel approach in nursing education. The future of this policy change (gender-integrated learning) will be evaluated over the next few years (Tumulty, 2001).

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King Saud Universitys College of Nursing now requires that all students successfully complete a computer course (Tech 227). This is a mandatory two-credit-hour class in which students spend 2 hours in the classroom where didactic learning occurs and an additional hour in the learning laboratory where skills are acquired. To accommodate the needs of students, the College of Nursing is equipped with laboratories that house state-of-the-art computer technology (KSU, 2007). Attitudes toward computer use among Saudis have not been systematically studied. Attitudes are consistent opinions that are shaped by experiences, worldviews, cognition, and emotions that determine an individuals opinion about computers, or people, or events (Ajzen & Fishbein, 1975). This perspective suggests that attitudes influence the reactions that people have toward computers, others, and events that occur over time. Furthermore, it suggests that students who are exposed to computers in their academic programs might have some preexisting opinions about the use of computers as an enhancement for the acquisition of knowledge and skills in nursing. RESEARCH QUESTION The research question explored in this study was the following: Does anxiety about computer usage in academic learning vary among males and females at King Saud University College of Nursing? THEORETICAL AND OPERATIONAL DEFINITIONS OF STUDY Computer, Theoretical Definition Computer: An electronic device that is capable of storing, manipulating, and retrieving information as designed through the use of precise mathematical instructions that are guided by software (Merriam-Webster, 2007). An example of software that manages data is Excel, a spreadsheet program. Computer, Operational Definition In this study, a Dell Inspiron computer (electronic device) will be used to manipulate several software programs including Word, Excel, and Statistical Package for the Social Sciences SPSS 18. Attitude, Theoretical Definition Attitude is an enduring view regarding a person, object, or activity that consists of a cognitive element (perceptions and beliefs) and an emotional element (positive or negative feelings). It is also conceptualized as a positive or negative mental state of readiness, learned and organized through experience that influences the individuals response/reaction to people, objects, places, and situations (Ajzen & Fishbein, 1975). Attitudes affect the behaviors of people toward objects, events, and individuals (Scarpa, Smeltzer, & Jasion, 1992). Attitude, Operational Definition Students attitude toward computers is defined as the total score on the four subscales as measured by the Computer Attitudes Scale (CAS): computer anxiety, computer confidence, computer liking, and computer usefulness (Loyd & Gressard, 1985; 1987). Anxiety, Theoretical Definition Computer anxiety is defined as the sense of fear or negative feelings toward computers and a reluctance to learn or manipulate the computer in the academic environment. Computer anxiety involves an array of emotional reactions including fear, apprehension, uneasiness, and distrust of computer technology in general (Loyd & Gressard, 1987). It can also be defined as hesitation or self-doubt in ones own ability to learn about and use computers in the academic environment. This type of anxiety is related to ones sense of self -efficacy about learning and mastering the use of computers (Loyd & Gressard, 1987).

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Anxiety, Operational Definition The CAS questionnaire will be used to determine the level of computer anxiety that the students manifest. Specifically, items 1, 5, 9, 13, 17, 21, 25, 29, 33, and 37on the CAS measure will be used to determine computer anxiety levels among the students (Loyd & Gressard, 1987). Computer Confidence, Theoretical Definition Computer confidence is associated with the inherent belief in ones ability to master the use of computers in the academic environment and to use this technology to enhance individual and group learning (Loyd & Gressard, 1987). Computer Confidence, Operational Definition Items on the Computer Attitudes Scale will be used to measure computer confidence. As indicated on the questionnaire, an expression of computer confidence (or lack thereof) may in clude statements like I am sure I could do work with computers, Im not the type to do well with computers, and I could get good grades in computer courses. Questionnaire items 2, 6, 10, 14, l8, 22, 26, 30, 34, and 38 are concerned with computer conf idence on CAS (Loyd & Gressard, 1987). Computer Liking, Theoretical Definition Computer liking is defined as the internal feeling of enjoyment and stimulation, or the desire to learn about, think about, or converse with others about the characteristics and advantages of the computer and its multiple uses (Loyd & Gressard, 1987). Computer Liking, Operational Definition Computer liking will be measured by statements such as I would like to work with computers, or Once I start to work with the computer, I would find it hard to stop, or I dont understand how some people can spend so much time working with computers and seem to enjoy it. Items 3, 7, 11, 15, 19, 23, 27, 31, 35, and 39 on the Computer Attitudes Scale will be used to measure this concept (Loyd & Gressard, 1987). Computer Usefulness, Theoretical Definition Computer usefulness is the extent to which a person believes that using a computer system could/will enhance his or her job performance and improve his/her knowledge and skills (Loyd & Gressard, 1987). Computer Usefulness, Operational Definition Computer usefulness, in this study, will be measured by computing items 4, 8, 12, 16, 20, 24, 28, 32, 36, and 40 on the Computer Attitudes Scale. RESEARCH METHODS Design The study utilized a descriptive correlation design, appropriate for the investigation of the relationships of demographic characteristics (e.g., age, gender, socioeconomic status, previous exposure to computers, years of study at KSU, successful completion of a computer class [Tech 227], and students attitudes toward computer usage at KSU). The independent variables in the study were gender, age, socioeconomic status, academic classification, grade point average, length of previous computer experience before enrolling at KSU, access to computers outside of KSU, number of household members who use the households computer, marital status, geographical region of the nation that is considered to be the students home, and completion of the mandatory computer classes (Tech Business and Health Administration Association Annual Conference 2012

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227). There were four dependent variables that were derived from the subscales on one instrument, the CAS measure. These subscales include computer anxiety, computer confidence, liking of computers, and computer usefulness. Collectively, they were used to describe the nursing students attitudes toward computer use at KSU. Sample The researcher invited all officially enrolled students at the College of Nursing at KSU in Riyadh, Saudi Arabia in the summer semester of the academic year 2009 who met the criteria to participate. Recent (2007-2008) statistical data revealed that there were a total of 63,315 undergraduate students at KSU: 38,092 males and 25,223 females. More specifically, the total number of undergraduate nursing students was 600: 195 males and 405 females (KSU, 2008). From these data, it was hypothesized that the majority of the study sample might be females. The inclusion criteria for participation in the study were: (a) both sexes (males and females), (b) all educational levels at the university (freshman, sophomore, junior, and senior), (c) 18 years of age or older, (d) enrolled as full-time students at KSU, (e) a Saudi citizen, and (f) willingness to participant in this study as evidenced by the signed Informed Consent Form that was completed by each participant before he/she could enter the research study. Other students who did not fit these criteria were not invited to participate in this research study. A clear explanation was provided to the students. See Table 1 for a demographic profile of study participants. Table 1: Demographic Profile of Study Participants Mean-Male Age GPA Family Members Income Computer Experience Anxiety Score Confidence Score Liking Score Usefulness Score Total Score 21.98 3.08 8.24 8,000-9,999 49.86 32.97 31.63 29.28 33.21 127.10 Mean-Female 21.20 3.38 7.78 8,000-9,999 34.73 31.54 30.77 29.61 32.87 124.77 Mean-Total 21.47 3.27 7.95 8,000-9,999 40.15 32.04 31.08 29.49 32.99 125.60 SD-Male 1.98 0.85 3.81 4,877.56 3.79 4.44 4.84 3.82 3.30 13.81 SD-Female 1.72 0.89 2.80 5,067.53 3.53 4.85 4.94 4.20 4.25 15.91 SD-Total 1.84 0.89 3.20 4,977.51 3.69 4.75 4.88 4.07 3.93 15.21

SD=Standard deviation Source: O. A. Samarkandi, Students attitudes toward computers at the College of Nursing at King Saud University (KSU), Table 11, p. 63. Ph.D. Dissertation, Case Western Reserve University, 2011. INSTRUMENTATION Demographic Questionnaire The Demographic Questionnaire was used to collect data about the personal characteristics of the enrolled students in the sample. This questionnaire has 13 items that query the subjects about variables such as age, gender, family income, number of years of previous exposure to computer usage, perceived level of expertise in computer Business and Health Administration Association Annual Conference 2012

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usage, years of matriculation at KSU, marital status, and geographical region of the nation that is considered to be home. The instrument was developed by the researcher and was administered in the Arabic language. Computer Attitude Scale (CAS) The Arabic Version of the Computer Attitude Scale (CAS) was used in this study to describe the students attitudes toward computer usage. The CAS was developed by Loyd and Loyd in 1984 and was modified 1985. It is a four-point Likert-like scale consisting of 40 items distributed among four 10-item subscales that measure computer anxiety, computer confidence, liking of computers, and perceptions of the usefulness of computers. The total CAS score can range from 40-160; higher scores correspond to more positive attitudes about computer usage. Subscales measuring variable constructs included: Computer Anxiety, Computer Usefulness, Computer Liking, and Computer Confidence. This study used the revised version of the CAS by Loyd and Gressard (1987). The CAS has been employed by a diverse group of researchers in numerous global communities, including Israel (Francis et al., 2000), China (Chin, 2001), South Africa (Burger & Blignaut, 2004), and Saudi Arabia (Abanmie, 2002; Alsebail, 2004). Reliability and validity of the instrument have been well-established. The reliability coefficient for the Arabic version is 0.91 for the total scale. Validity has been evaluated by Loyd and Gressard (1987), and the measure was found to be an effective tool for differentiating lea rners attitudes based on varying degrees of computer experiences. Each of the subscales was able to stand alone and produce their own psychometric properties, including validity and reliability. Total instrument Cronbach alphas ranged from .78 in Arabic (Alsebail, 2004), to .89 in English (Burger & Blignaut, 2004), and .95 in English (Loyd & Gressard, 1987), to a high of .95 in Hebrew (Francis, Katz, & Jones, 2000). Subscale alphas ranged from .71 (Computer Liking, Alsebail, 2004, in Arabic) to .95 (Computer Liking, Burger & Blignaut, 2004, in English). Data Collection and Analysis This study was approved by institutional review boards at both the participating university in the U.S. and by King Saud University. Data were collected from students at KSU who volunteered to participate in the study. The researcher emphasized to prospective student participants that the data collection process was confidential and that no one at the school, or any place else, would have information about their responses to the demographic data form and the CSA questionnaire. Students were informed about their rights to refuse to participate in the study or to withdraw from the study at any time during the process of data collection without reprisals or disapproval. They were also told that there were no foreseeable risks associated with participating in this study. SPSS 18 was used to compute and analyze the data. The study sample was described by mean, median, range, standard deviation, and frequency statistics. Missing data were delineated by the numbers 9999. Pie charts and bar graphs were created to visually describe the demographic variables and the distribution of the subscales of students attitudes toward computers. DATA ANALYSIS PLAN FOR THE RESEARCH QUESTION Research Question Does anxiety about computer usage in academic learning vary among males and females at KSU College of Nursing? Data Analysis Plan Summary measures including mean, standard deviations, and variance along with t-tests were used to determine the difference between the two groups (males and females). Results The purpose of this study was to examine the attitudes of baccalaureate-degree seeking student nurses attitudes toward computer usage in the College of Nursing at King Saud University (KSU), Riyadh, Saudi Arabia. Specifically, the study was designed to investigate the influence of gender, age, socioeconomic status, academic classification, grade point average, and mandatory computer classes on students attitudes toward computer usage. Business and Health Administration Association Annual Conference 2012

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The data were collected at KSU during the summer of 2009. All data collection activities were done under the guidance of the researcher and the administrators of KSU. A total of 355 questionnaires were completed (males = 133 and females = 222). Twenty questionnaires were excluded because of missing values (males = 13; females = 7). The actual number of completed and accepted questionnaires was 335 (males = 120 and females = 215). This number reflects more than half of the total student body ( n = 600) during the 2009 summer academic semester at the university. An independent t-test was used to examine the research question. The results of the t-test demonstrated that females were significantly more anxious about computer usage in their academic programs than were their male counterparts (meanf = 31.53 vs. meanm = 32.97). This research helps to support the latter view. However, given the ubiquitous use of computers in health systems and the recent requirement in Saudi Arabia that health records be in electronic format, nurses, regardless of gender, will need to become proficient in computer use. Table 1 depicts the differences in scores between the males and females. Table 2: Mean Anxiety Difference for Gender; Male and Female Standard Error Gender N Mean Mean Anxiety Scores Male Female 120 215 32.967 31.526 4.436 4.854 0.405 0.331

Source: O. A. Samarkandi, Students attitudes toward computers at the College of Nursing at King Saud University (KSU), Table 12, p. 64. Ph.D. Dissertation, Case Western Reserve University, 2011. SUMMARY AND IMPLICATIONS The findings suggest that female students were somewhat more anxious about computer usage than were male students. Gender has been associated with computer anxiety (King et al., 2002), though results have been mixed. Whereas some researchers have reported that male students have lower levels of anxiety (Colley et al., 1994; Okebukola, 1993) than do female students, others posit that females have lower levels of computer anxiety than do males (Loyd et al., 1987; Siann et al., 1990). Still other studies have not reported any gender differences (Colley et al., 1994; Kay, 1992; King et al., 2002). What is clear is that the pervasive presence of technology, for both male and female students and later as clinical practitioners, is quickly becoming a way of life and the use of the computer as a communication device dominates the psyche of both males and females (King et al., 2002). Yet there is another perspective. According to Hass et al. (2002), women have traditionally been considered to be less computer savvy than men primarily because of the linkage between mathematics and computers. This was an early assumption that existed but appears to be changing. This research helps to support the latter view. However, given the ubiquitous use of computers in health systems and the recent requirement in Saudi Arabia that health records be in electronic format, nurses, regardless of gender, will need to become proficient in computer use. The results can also be interpreted through the lens of academic expectations within the context of societal norms and the changing roles of women in academic settings (Henrion, 1997; Otomo, 1998). Perhaps if academic learning is delivered using computers at KSU, female students will become less anxious as their computer knowledge and skills increase. Finally, as demands in health-service-delivery systems for computer-literate nurses increase, nurses will, out of necessity, become more proficient with computers in general as well as in their application for the acquisition of knowledge and skills. According to the findings of this study, males and females can learn through the use of computers even though females in the College of Nursing at KSU are more anxious than their male counterparts. Giving students access to computers in school would also help with their learning and provide an opportunity to increase their usage time and decrease their anxiety. Recommendations for Nursing Education 1. Strengthen and continue to build computer knowledge and skills among the students at KSU School of Nursing,

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2. 3.

Provide opportunities for additional computer-based learning in various segments of the curriculum, Increase public awareness of and support for the use of computer-based learning for advancing nursing knowledge.

Nurses who are expected to use computers during their undergraduate learning experiences would be better prepared to utilize computers in their practice and for their continuing learning needs. Given the growing frequency of the use of computers in educational settings and in practice systems, nurses will be expected to utilize computers for their personal learning and for quality patient care and safety (Kilbridge & Classen, 2008). REFERENCES Abanmie, A. (2002). Attitudes of high school students in Saudi Arabia toward computers (Unpublished doctoral dissertation, Mississippi State University). Ajzen, I., & Fishbein, M. (1975). Belief, attitude, intention, behavior: An introduction to theory and research. Addison Wesley Publishing Company, Inc: Philippines. Al-Farsi, F. (2001). Modernity and tradition: The Saudi equation . Knight Communication Ltd.: UK. Alsebail, A. (2004). The College of Education students attitudes toward computers at King Saud University (Unpublished doctoral dissertation, Ohio University). Burger, A., & Blignaut, P. (2004). A computer literacy course may initially be detrimental to students attitudes towards computers. Proceedings of SAICSIT, 10-14. Chin, K. (2001). Attitudes of Taiwanese nontraditional commercial institute students toward computers (Unpublished doctoral dissertation, University of South Dakota, Vermillion).120 Colley, A. M., Gale, M., & Harris, T. A. (1994). Effects of gender role identity and experience on computer attitudes components. Journal of Educational ComputingResearch. 10(2), 129-137. Forcier, R. C. (1996). The computer as productivity tool in education. Englewood Cliffs, NJ: Prentice-Hall. Francis, L., Katz, Y., & Jones, H. (2000). The reliability and validity of the Hebrew version of the Computer Attitude Scale. Computers & Education, 35, 149-159. Freedman, K., & Liu, M. (1996). The importance of computer experience, learning processes, and communication patterns in multicultural networking. Educational Technology Research and Development, 44(1), 43-59. Hass, A., Tulley, C., & Blair, K. (2002). Mentors versus masters: Womens and girls narratives of (re)negotiation in web-based writing spaces. Computers and Composition, 19, 231-249. Henrion, C. (1997). Women in mathematics: The addition of difference. Indiana University Press. Kay, R. H. (1992a). Gender differences in computer attitudes, literacy, locus of control and commitment. Journal of Research on Computing in Education, 21 (3), 307-316. Kilbridge, P., & Classen, D. (2008). The informatics opportunities at the intersection of patient safety and clinical informatics. Journal of the American Medical Informatics Association, 15(4), 397-407. King, J., Bond, T., & S. Blanford. (2002). An investigation of computer anxiety by gender and grade. Computers in Human Behavior, 18, 69-84. King Saud University (KSU). http://www.ksu.edu.sa.

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Loyd, B. H., & Loyd, D. F. (1985). Reliability and factorial validity of Computer Attitude Scale. Educational Psychological Measurement, 44(2), 501-505. Loyd, B. H., & Gressard, C. P. (1987). Gender and computer experience of teachers as a factors in computer attitudes of middle school students. Journal of Early Adolescence, 7(1), 13-19. McLaughlin, S., Fitch, M., Goyal, D., Hayden, E., Kauh, C., Laack, T., Nowicki, T., Okuda, Y., Palm, K., Pozner, C., Vozenilek, J., Wang, W., Gordon, J., (2008). Simulation in graduate medical education. Academic Emergency Medicine, 15(11), 11171129. Merriam-Webster's medical desk dictionary. (2007). Merriam-Webster's medical desk dictionary (Revised ed.). Merriam-Webster, Incorporated. New York: NY. Moshaikeh, M. (1992). Implementing educational technology in Saudi Arabia. International Journal of Instructional Media, 19(1), 65-70. Mufti, M. (2002). A case from a community and hospital-based long-term care facilities in Saudi Arabia. Annals of Saudi Medicine, 22(5-6), 336-338. Oblinger, D. G., & Rush, S. C. (Eds.). (1997). The learning revolution: The challenge of information technology in academy. Boston, MA: Anker. Okebukola, P. A. (1993). The gender factor in computer anxiety and interest among some Australian high school students. Educational Research, 35(2), 181-189. Otomo, Y. (1998). The relationship of computer anxiety, mathematics anxiety, test anxiety, gender and demographic characteristics among community college students. Dissertation Abstracts International, 59(6A), 957A. Saudi Ministry of Higher Education (MOHE). http://www.mohe.gov.sa. Scarpa, R., Smeltzer, S. C., & Jasion, B. (1992). Attitudes of nurses toward computerization: A replication. Computers in Nursing, 10, 72-80. Siann, G, Macleod, H., Glissov, P., Durnel, A. (1990). The effect of computer use on gender differences in attitudes to computers. Computers in Education, 14, 183-191. Statistical Package for the Social Sciences for Windows, Rel. 18.0.1. [Computer software]. Chicago, IL: SPSS Inc. Teo, T. S. H., & Lim, V. K. G. (1996). Factors influencing personal computer usage: The gender gap. Women in Management Review, 11, 18-26. Tumulty, G. (2001). Professional development of nursing in Saudi Arabia. Journal of Nursing Scholarship, 33(3), 285-290. Young, J. (1997). Invasion of laptops: More colleges adopt mandatory computing programs. Chronicle of Higher Education, 44(15), 433-475. Osama A. Samarkandi BSc, BSN, RN, MSN, Ph.D Department of Nursing Faculty of Applied Medical Science Director, International Collaboration Office Al-Baha University Al-Baha, Saudi Arabia osamarkandi@hotmail.com

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TRACK HUMAN RESOURCE MANAGEMENT IN HEALTHCARE

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COMPENSATION AS A CONSTRUCT FOR EMPLOYEE MOTIVATION IN HEALTHCARE


Allen C. Minor, Misericordia University

ABSTRACT There is no difference between performance of those employees receiving a salary as compensation for services and those employees receiving compensation based on output by the specific employee, (Null), or alternatively, incentive compensation results in increased employee productivity. This issue has been debated historically and the debate continues. This paper reviews the issue from a historical perspective and includes contemporary research and concludes with implications for further research.

Employee motivation has been debated since the inception of management as a discipline. The Chinese bureaucracy 1000 B.C. developed a theory of management based on rewards and Punishments as a way to manage productivity. Confucius, in the period 552 B.C. through 479 B.C. advocated that employee productivity could be managed by improving morale (Wren, p. 14). In 35 A.D., the Egyptians used wage incentives to motivate workers (Lee, p. 42). In a study completed by Mercer, incentive compensation plans increased morale and increased productivity for those plans including all employees but not for firms offering incentive pay programs to only high-ranking managers (Wall Street Journal). Whitney argues that because of prejudices on the part of executives, wage and salary programs are poorly designed and, in most companies, are not true pay-for-performance programs. Evans argues that governmental regulations in unions demanding rewards based on seniority have eroded the pay-forperformance compensation programs (Evans, p. 726). Short-term incentive plans, however, are gaining popularity in the health care industry (Hospitals). Cash incentives have increased 5% to 10% in 2008 (Evans). Bonus payments are an (integral part of compensation) in healthcare. (Healthcare Facility Management) as bonuses will increase quality of healthcare and reduce costs (Armstrong). There are no consistent policies or body of theory regarding incentive compensation programs followed and practiced by organizations. It is clear, however, that incentive compensation programs are effective in increasing productivity if properly designed for the situation or goal to be accomplished. (Haman). One such method of incentive compensation is payment based on the profitability of the organization. Charles Babbage On the Economy of Machinery and Manufacturer indicated the mode of payment could be so arranged that every person employed should drive advantage from the success of the whole; that the profits of each individual should advance as the factory itself produces profit, without the necessity of making any change in wages (Wren, p. 61). This was seen as a way to develop a synergy between the employee goals and the company goals from an economic point of view. Whitney maintains that good performance deserves a higher pay, and therefore poor performance should result in lower pay. If an organizations profits were reduced, compensation should also be reduced. Because this is taboo in Americas culture, such plans will not work (Whit ney p. 36). He argues that a bonus system would be a more effective way of rewarding high performers with a reduction in this program should the performance not be achieved. Whitney also argues that management rewards are based on power, compensation and prestige opposed to technical excellence and therefore such plans may not provide the appropriate incentives for executives to achieve the goals of the organization. If compensation is based upon individual performance, cooperation among team members may be inhibited, whereas if compensation is based on team objectives, individuals may not work as diligently and may lean on other team members. Bonus systems are a way to achieve both team and individual performance based on appropriate measures and evaluations. However, if profitability drops and bonuses are not given, this may result in turnover or a feeling of mistrust on the part of the employee. This works successfully in the Japanese system, however, they have a concept of lifetime employment (Whitney, Part II, p. 47). Because there is not a direct relationship between individual employee Business and Health Administration Association Annual Conference 2012

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performance and compensation, the typical employee is unable to see a relationship between merit increases and his/her level of performance and therefore may not provide the incentive to increase productivity (Evans). Another system of rewarding employees for performance is the merit system. This is a system whereby employees are evaluated based on their merit each year and given an increase based thereon. However, the typical employee is unable to see a relationship between the merit increase and his/her level of performance in most cases. Based on a study of certain Fortune 500 companies that contributed approximately 40% of the Gross National Product in the United States in 1968, job performance is not the primary determinate of wage and salary progression for non-supervisor employees. This is true even though 93# of the firms claims that they subscribe to the merit reward philosophy by advancing wage and salaries on the basis of job performance (Evans, p. 730). Therefore, it appears that those companies, although of the opinion that incentive wage and salary programs influence employees to produce more, do not implement such programs in such a way as to increase productivity. Studies have indicated that there is no significant link between paid performance and common merit pay programs (Markham, p. 172). One system of rewarding employees is to reward departments based on departmental productivity opposed to rewarding employees based on the organizations profits. Henry R. Towne thought that profit sharing was inappropriate because it did not reward individuals for their efforts. He proposed a method of payment that would reward work units or departments for their efforts and to split productivity gains by departments; 50% to the employer and 50% to the workers (Wren, p. 91). Incentive compensation advocated by Towne was based on the thinking of See who promoted paying higher wages to attract better workers (Wren, p. 87). Edward Atkinson, anAmerican economist, suggested that the cheapest labor is the best paid labor (Wren, p. 90) because more productivity will result and therefore unit cost will be lower leading to the concept that higher wages led to more productivity and therefore lower unit cost. The individual performance incentives of compensation plans are the most attractive. Frederick Taylor suggested that the piece-rage system had failed because standards were poorly set and employers would game the system by cutting rates when productivity increased. This caused inefficiency and gaming of the system by the employees. Taylor developed his differential piece-rate incentive plan system at Midvale Steel (Wren, p. 106) based on time studies and set a rate where the standard for each element was determined b the time study. This rate moved job performance from guess work and tradition to a more rational basis. The principle of the differential rate worked two ways: it forced those who did not meet the standard or receive a low rate of pay and greatly rewarded those who did attain the standard (Wren, . 109). Taylor strongly opposed paying individuals based on averages of the group and therefore opposed union attempts to set quotas. He advocated that higher paid workers would be more productive and therefore lower unit cost and suggested that workers be paid from 30% to 100% accor ding to the nature of the work which he does, beyond the average of his class (Wren, p. 110). Gantt, a disciple of Taylor, also advocated incentive compensation as a way to increase employee performance. Gantt devised his task work with a bonus system that paid the worker a bonus of $.50 per day if he did all the work assigned for a particular day (Wren, p. 134). He modified this plan to increase productivity by increasing wages for employees for completing a job below the standard as an incentive to increase productivity. In addition, foremen would receive a bonus if the workers performed better the standard providing an incentive for the foremen to teach the workers to be more productive. Harrington Emerson installed an individual reward system in the Burlington Railroad Company. In two years, output increased by 57%, average pay increased by 14% and the cost decreased by 36% (Wren, p. 148). Physicians are highly motivated by compensation plans (Helman, Hemenway). Physicians concerns should be primarily for the patients well being, however, physicians do appear to respond to economic stimuli occasioned by their contractual obligations to third party insurers (Helman, p. 86). Health Maintenance Organizations (HMO) have been designed as a way to reduce health care costs by paying Physicians and other health care providers based on the number of enrollees in a plan as opposed to the number or quantity of services provided to patients. Therefore, physicians, in such a plan, are paid for not rendering services. One study showed that physicians on a salary based payment showed a reduction in hospital days of 13.1% and those on a capitation basis, i.e. paid for the subscribers in the program, also showed a reduction in hospital days (Helman, p.88). The study also showed there was a higher use of primary outpatient visits that are less expensive than inpatient care for HMO physicians. Bonuses were not found to be significant in terms of productivity. Distribution of bonuses of Business and Health Administration Association Annual Conference 2012

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may lack effect because such incentives delay any reward. Physicians, like anyone else, respond to economic stimuli that are immediate rather than delayed (Helman, p. 91). The Affordable Care Act has created Accountable Care Organizations. Organizations can apply for this program providing financial incentives to reduce health care cost through wellness programs for Medicare /Healthcare government. Also the JCAHO has provided financial incentives to reduce cost through core measures sets. In a study of physician financial incentives in a for-profit care center, it was determined that substantial monetary incentives based on individual performance may reduce a group of physicians to increase the intensity of their practice, even though not all of them benefit from the incentives (Hemenway, p. 1059). Therefore, it is clear that individual incentive compensation plans, if properly designed, do result in increased productivity. There are other factors that influence employee productivity in addition to compensation. (Whitney) Williams hypothesized that motivation for employees was based on their feelings rather than their thoughts (Wren, p. 167). He said that a persons social standing is determined by his job. He indicated that beyond a certain point, the increased wages are quite likely to lessen as to increased effort (Wren, p. 168). Thus, salary is a negative motivator. Over-payment will not necessarily increase productivity but under-payment will cause decreased productivity, soldiering and turnover. Continuing this socialistic viewpoint, Henry DeMan viewed that work itself was a motivator and it was managements job to remove the hindrances such inequitable wage systems that prevent workers from finding joy in work (Wren, p. 172). Winn looked at incentive to increase sales opposed to incentives to increase net income. He hypothesized that because of personal self interest factors, managers tend to increase sales opposed to increase compensation based on incentives. In other words, executive salaries appear to be more closely correlated with the scale of operations of a firm than and with their profitability (Winn). Taylor and Gantt concepts of compensation based on individual performance including accurate and fair standards is worth further research and study. Implications for further research Current research on compensation plans is sketchy and in many cases flawed. There are many factors that affect employees motivation including political, social and economic. An attempt to isolate economic factors is difficult and the research therefore is not conclusive as to whether incentive compensation programs positively or negatively affect employee productivity. Managers have developed principals of wage and salary administration based on inadequate research and individual bias indicating that the academic community has not provided appropriate guidance for the practitioner in this area. This area is right for research and should include not only the economic factors but the social factors as barriers to implementing the programs to positively motivate employees. It is clear that unless American companies and American industry respond appropriately to a threat of international competition, it will not remain as a predominate economic power.

REFERENCES Armstrong et.al. (2009). Realigning U.S. Health Care Incentives To Better Serve Patients and Taxpayers. Health CEOs for Health Reform. Evans (1970). Pay for Performance: Fact or Fable. Personnel Journal, 49 (9). Evans (2008). We just dont see a Slowdown. Modern Healthcare, 38(30). Freundt (1990). Merit Increases for Top Executives to Average 5.2% in 1990. Hospitals. Hanman, K., Newman (2008). The Effect of Disseminating Relative Performance Feedback in Tournament and Individual Performance Compensation Plans. The Accounting Review, 83(4). Healthcare Facility Management (2009). 22 (7). Bonus Pay No Longer an Afterthought. Business and Health Administration Association Annual Conference 2012

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Accountable Care Organizations: Improving Care Coordination for People with Medicare. Retrieved from http://www.healthcare.gov (March 31, 2011). Hemenway, K., & Cashman, P. B. (1990). Physicians Response to Financial Incentives. New England Journal of Medicine. Hillman, P., & Kerstein (1989). How do Financial Incentives Affect Physicians Clinical Decisions and Financial Performance of Health Maintenance Organizations. New England Journal of Medicine. Hospitals (1990). Merit Increase of Top Executives to Average 5.2% in 1990 . JCAHO (2010). Core Measure Sets. Markham (1988), Pay for Performance Dilemma Revisited: Empirical Example of the Importance of Group Effects. Journal of Applied Psychology, 73(2). Whitney (1988), Pay Concepts for the 1990s Part I, Compensation and Benefits Review, 20 (2). Whitney (1988). Pay Concepts for the 1990s Part II. Compensation and Benefits Review, 20 (3). Winn, S. (1988). Compensation-Based (DIS) Incentives for Revenue-Maximizing Behavior: A test of the Revised Baumol Hypothesis. The Review of Economics and Statistics, 70 (1). Wisdom, D. (1989), Compensation Management In Practice Compensation and Benefits, 21(4) . Wren, D. (1987). Evolution of Management Thought. John Wiley and Sons: New York, NY. Wall Street Journal (1992). Retrieved from http:// www.wallstreetjournal.com.

Allen C. Minor Assistant Professor Misericordia University 301 Lake Street Dallas, PA 18612 aminor@misericordia.edu

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PHYSICIAN SHORTAGES HOW THE GAPS WILL BE FILLED


Robert J. Spinelli, University of Scranton Kathryn Semcheski, University of Scranton _____________________________________________________________________________________________ ABSTRACT The United States population is aging just as quickly as the physicians. A challenge in the medical field today is keeping up with the physician shortages and trying to decipher how to fill the gaps. With the worsening conditions of the economy and job sectors, not many aspiring medical students can afford the cost of medical school. As many physicians are looking to retire, one must as the question of who will fill the voids? A career as a primary care physician is not as enticing to the younger population as is the career path of orthopedic surgeons. This presentation will discuss why we are encountering a physician shortage, what factors play a role in the decisions made by medical students to specialize and how medical professional are going to fix the physician shortage issue. _____________________________________________________________________________________________

Robert J. Spinelli, DBA Assistant Professor Department of Health Administration and Human Resources The University of Scranton 423 McGurrin Hall, Scranton, PA 18510 spinellir2@scranton.edu Kathryn Semcheski, MHA Student The University of Scranton Scranton, PA 18510

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STRATEGIC HUMAN RESOURCES SOLUTIONS FOR HEALTHCARE SYSTEMS IN KENYA, RWANDA, AND UGANDA
Neel H. Pathak, University of Scranton Daniel J. West, Jr., University of Scranton

ABSTRACT Health systems in Kenya, Rwanda, and Uganda are compared and contrasted on various economic, political and health delivery parameters. Comparisons reveal common factors contributing to an ineffective healthcare system. This article explores the human resources problems along with the health status and services for specific countries. Situational analysis on health status and service delivery is presented via a thorough examination of country specific National Health Sector Strategic Plans (NHSSP). Strategic solutions based on improving the Human Resources for Health (HRH) for all the three countries are explained. Also, World Health Organizations (WHO) Millennium Development Goals (MDG) are examined.

INTRODUCTION A well-functioning health system encompasses the core components of a healthcare triad; access, affordability and quality. The healthcare delivery system varies from country to country. The systems balanced response to population needs and demands require maintaining a reliable healthcare network across the country. Detailed importance on country context, history, geography, health status and services is analyzed via comparing and contrasting of different systems of care. Facts about the country population, characteristics, economy, government, health status, health finances and human resources are tabulated. The revelations in this paper highlight some similar problems for the aforementioned countries at a systems level. One significant factor that is present in all three countries is a shortage of the healthcare workforce. Thus, a collective strategic solution based on human resources would help to address the challenges and pave the way for an improved healthcare system. The United Nations (UN) MDGs are eight goals which all UN member states have agreed to achieve by the year 2015.It commits the world leaders to combat poverty, hunger, diseases, illiteracy, environmental degradation and discrimination against women. This research paper examines the MDGs and suggests solutions on a HRH perspective twined with NHSSP plans which may help the country progress towards their specific MDGs. 1. 2. 3. 4. 5. 6. 7. Eradicate extreme poverty and hunger Promote gender equality and empower woman Reduce child mortality Improve maternal health Combat HIV/AIDS, malaria and other diseases Ensure environmental sustainability Develop global partnership for development

COUNTRY OVERVIEW Kenya is located in the eastern part of Africa. It borders the Indian Ocean between Somalia and Tanzania. Kenyas total area comprises of 580,367 square kilometers. The size of Kenya is more than twice the size of Nevada. Nairobi is the Capital of Kenya. Around 85% of the total Kenyan population is literate. Table 1 gives a Business and Health Administration Association Annual Conference 2012

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brief outline on countrys geographic location, population, age characteristics, language, and religion. Also, the political map of Africa is portrayed in the Appendix. Table 1: Country Population and Characteristics Country Kenya Geography East Africa Population 41,070,934 % Urban-22 % Rural-78 11,370,425 % Urban-19 % Rural-81 Age Structure 0-14 years- 42.2% 15-64 years- 55.1% 65 years and over- 2.7% 0-14 years- 42.9% 15-64 years- 54.7% 65 years and over- 2.4% Language English Kiswahili Religions Protestants-45% Roman Catholic- 33% Others-22% Roman Catholic- 56.5% Protestant- 26% Others- 17.5%

Rwanda

Central Africa

Uganda

East Africa

34,612,250 % Urban-13 % Rural-87

0-14 years- 49.9% 15-64 years- 48.1% 65 years and over- 2%

Kinyarwanda French English Kiswahili (Swahili) English Ganda (Luganda)

Roman Catholic-41.9% Protestant- 42% Others- 16.1%

Source: Central Intelligence Agency, 2011 Rwanda is located in the central part of Africa. It lies to the east of the Democratic Republic of Congo. Rwandas total area comprises of 26,338 square kilometers. The size of Rwanda is slightly smaller than Maryland. Kigali is the capital of Rwanda. Around 50% of the Rwandan population is literate. Table 2 describes the country specific economic situation based on factors of Gross Domestic Product (GDP), population below poverty line and industrial production growth rate. Table 2: Country Economy

Country

GDP Per Capita

Population Below Poverty Line 50% (2000 est.) 60% (2001 est.) 35% (2001 est.)

Industrial Production Growth Rate 4% (2010 est.) 7.5% (2010 est.) 6% (2010 est.)

Kenya Rwanda Uganda

$1,600 (2010 est.) $1,100 (2010 est.) $1,200 (2010 est.)

Source: Central Intelligence Agency, 2011 Uganda is a part of East Africa. It lies to the west of Kenya. Ugandas total area comprises of 241,038 square kilometers. The size of Uganda is slightly smaller than Oregon. Kampala is the capital of Uganda. Around 67% of the total Ugandan population is literate. Table 3 portrays the government types, components and forms implemented in Kenya, Rwanda, and Uganda.

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Table 3: Country Government Country Kenya Type Republic Components 7 Provinces Forms Executive Branch: Chief of State: President Mwai KIBAKI Legislative Branch: Unicameral National Assembly/Parliament Judicial Branch: Court of Appeal, High Court Executive Branch: Chief of State: President Paul KAGAME Legislative Branch: Bicameral Parliament consists of Senate and Chamber of Deputies Judicial Branch: Supreme Court, High Courts of the Republic, Provincial Courts Executive Branch: Chief of State: President Yoweri MUSEVENI Legislative Branch: unicameral National Assembly Judicial Branch: Court of Appeal, High Court COMPARATIVE HEALTH SYSTEMS Kenya The healthcare system of Kenya is comprised of the public sector, the private sector, Non-Governmental Organizations (NGOs) and Faith Based Organizations (FBOs). The public sector includes the Ministry of Health (MOH) and quasi-governmental organizations. The public sector is comprised of national referral hospitals, provincial general hospital, district hospitals, health centers, and dispensaries. According to the Ministry of Health statistics (May 2011) on number of healthcare facilities, Kenya has a total of 471 hospitals, 847 health centers, 3910 dispensaries, 182 nursing and maternity homes, 1987 medical clinics and 180 standalone private clinics and NGOs. Different levels of care are distributed in these ranges of facilities. National referral hospitals provide the highest quality of care services. Moi Teaching and Referral Hospital and Kenyatta National Hospital serve as the national hospitals in Kenya. The public sector provides more than 50% of all the healthcare services. Overall, healthcare delivery in Kenya is provided by a network of more than 7,500 facilities. The total number of hospital beds in Kenya including the public and the private sector is around 48,000. The private sector owns about 40% percent of the total hospital beds in Kenya. The Government of Kenya (GOK) funds the MOH and its affiliated organizations. The National Health Insurance Fund (NHIF) is a quasi-governmental organization under the MOH. NHIFs core function is to provide medical insurance to all its members. The NHIF membership is open to all Kenyans who are above 18 years of age and have a monthly income of more than Ksh 1,000. NHIF has contracted hospitals under three categories (A, B, and C) each having a different system of reimbursement. Private insurance companies include AAR and Jubilee insurance. They usually cover outpatient charges, not included in the NHIF. Health personnel are directly affected by the nature of health systems. Kenyan Health Sector follows a tiered structure. Exercising such a tiered structure leads to unequal distribution of human resources for health (HRH). Top medical facilities may have more staffing than the district hospitals which might be the first contact for the patient. Along with the tiered system; brain drain, economic stagnation, poor remuneration and migration are also contributing factors to the workforce shortage. The establishment of private practices has exacerbated the workforce shortage in government organizations. All these factors have created an unstable healthcare market. The effect of brain drain causes workers to leave and settle in a well-established setting. Poor remuneration also is a major reason why healthcare workforce succumbs to brain drain. Migration of these workers from the place where they are needed the most to other

Rwanda

Republic

4 Provinces

Uganda

Republic

80 Districts

Source: Central Intelligence Agency, 2011

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developed areas creates instability both in the healthcare sector and the economic sector. A case in point for migration is noted by the fact that the number of physicians from Kenya working abroad was 2,733 in 2002. The Government of Kenya recognized the aforementioned problems and declared the shortage of HRH to be a major challenge and took measures to address the problems. HRH mapping was undertaken in all healthcare delivery sites and understaffed areas were designated. There are only 4,506 physicians and 37,113 nurses in Kenya. (WHO statistics, 2006)The attrition rate for total number of health workers (all cadres involved) was not different based on the healthcare facility type. The highest attrition rate was for pharmacists, followed by doctors, nurses and lab staff. Table 4 gives an overview of the health status in the three countries based on Infant Mortality Rate, Life Expectancy at Birth, Prevalence of HIV/AIDS, and Prevalence of Tuberculosis (TB). Table 4: Health Status Infant Mortality Rate (per 1,000 live births) 52.29 deaths 64.04 deaths 62.47 deaths Life Expectancy at Birth 59.48 years 58.02 years 53.24 years HIV/AIDS Prevalence (adults, 15-49) 6.7% 5.1% 4.1% TB Prevalence (per 100,000 population) 888 660 646

Country

Kenya Rwanda Uganda

Source: Central Intelligence Agency, 2011 and WHO Country Health System Factsheet, 2006 Rwanda Health services in Rwanda are channeled through a variety of settings. They include public sector, government assisted health facilities (GAHF), private sector, and traditional healers. The public sector is furthermore categorized into three levels namely the central level, the intermediate level and the district level. Each level has a predefined technical and administrative objective. Such objectives are known as the minimum package of activities. Butare Teaching Hospital and the Teaching hospital in Kigali are national referral hospitals. GAHF constitute about 40% of the primary and secondary health facilities. They are usually run by religious groups and not for profit organizations. These facilities are integrated into the public health system. There are about 538 health care facilities providing basic services and qualified staff for the people of Rwanda. Of the 389 health centers, around 380 are partly or fully governmental. The provider type from the total number of facilities includes around 36% public hospitals, 30% private clinics and hospitals and other 34% include health centers, and dispensaries. There are a total of 568 physicians, 69751 nurses and midwives, and 2371 management and support staff in Rwanda according to the HRH factsheet by African Health Workforce Laboratory (AHWO), 2010. Mutual health insurance groups in Rwanda are developed to increase access and decrease the financial burden of the population. They are autonomous organizations managed by their members. The health insurance groups function on national, district, and sector level. The Government of Rwanda has promoted mechanisms such as La Rwandese d Assurance Maladies (RAMA), and Military Medical Insurance (MMI) which offer subsidized insurance rates to help the people of Rwanda. A recent article in New York Times; A Poor Nation, with a Health Plan, revealed that 92% of the Rwandan population is insured with a fee of $2 per year. The coverage includes basic health care services. The services include maternity care, treatment of most common causes of death such as diarrhea, malaria, and infections. Also, most health centers have medicines that are on the WHO list of essential medicines. Some health centers also include diagnostic facilities of blood and urine analysis. This low cost insurance is possible because of the funding they receive from foreign countries under the humanitarian aid programs. The MOH receives its funding from the Ministry of Finance and Economic Planning. An imbalance between the provision of services and financial resources always existed. The genocide affected Rwanda from a Business and Health Administration Association Annual Conference 2012

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social, economic and a human resources standpoint. The health care delivery system is still suffering its effects. There is a nationwide shortage of the healthcare workforce to respond the needs of health facilities clinically and managerially. There are a total of 401 physicians and 3593 nurses working across Rwanda. WHO statistics, 2006) Table 5 depicts the financing mechanisms used in the three countries based on %GDP spending, GDP per capita, government spending and private spending. Table 5: Health Financing Country Kenya Rwanda Uganda % GDP Spending 4.3 3.7 7.3 GDP-Per Capita(USD) $1600 $1100 $1300 Government Spending (%) 38.7 43.5 30.4 Private Spending (%) 61.3 56.5 69.6

Source: Central Intelligence Agency, 2011 and WHO Country Health System Factsheet, 2006 Uganda Healthcare in Uganda is provided by a mix of the public sector, private sector including private health practitioners, traditional medicine practitioners, and community health workers. Ugandan health system is divided in village health teams/ community medicine distributors, Health Center II, Health Center III, Health Center IV and Hospitals. Different kinds of hospitals are general hospitals, regional referral hospitals and national referral hospitals. Butabika Hospital and the Mulago Hospital serve as the national hospitals in Uganda. The government has faced a lot of challenges incorporating the National Health Insurance (NHI) program. It is still working towards its full implementation. Similar to Rwandan healthcare system, a minimum package of services is designed for health centers. This package is known as the Uganda Minimum Healthcare Package (UNMHCP). Some of the private insurance companies include Microcare and East African underwriters. The Uganda Catholic Medical Bureau, Uganda Moslem Medical Bureau and Uganda Protestant Medical Bureau coordinate and act as umbrella organizations for the private facilities in Uganda. Healthcare in Uganda is delivered via a network of around 2545 facilities. The facilities consist of 2 national hospitals, 10 regional referral hospitals, 101 general hospitals and 2432 HC II, III and IV centers. HRH in Uganda consist of 3361 doctors, 664 nurses and midwives, and around 100 management and support staff. Ugandan healthcare system faces a shortage of the healthcare workforce. There are only 2,209 physicians and 16,221 nurses working across Uganda. It is prone to the areas that have poor infrastructure and amenities. Inadequate funding for training human resources for health is of paramount concern. Training outputs do not match the service requirements. Poor remuneration and work environment also have an impact on the low retention. A survey based on 3 hospitals in Uganda in 2006 including 139 participants concluded that 70% of the nurses would like to work outside Uganda. Those 70% of the nurses had structured plans to work either in the US (59%) or the UK (49%). One fourth of the respondents stated they would like to work in other countries of Africa. This is a major problem which in turn creates the other aforementioned problems for healthcare workforce in Uganda. Table 6 illustrates the human resources situation in the three countries based on the factors of physician density, nurses and midwives density, and health management and support staff.

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Table 6: Human Resources Nurses and Midwives Density/1000 1.14 0.43 0.62 Health Management and Support Staff/ 1000 0.055 0.167 0.243

Country Kenya Rwanda Uganda

Physician Density/1000 0.139 0.047 0.083

Source: WHO Country Health System Factsheet, 2006 SITUATIONAL ANALYSIS FROM A HUMAN RESOURCE STANDPOINT Health workers are identified as the soul of the healthcare systems. The shortage of healthcare workers across Africa is one of the most serious limitations to the achievement of health and development goals. Africa has the highest burden of diseases per population but has the lowest number of health workers per population. Despite higher maternal and infant mortality rates, Africa produces the lowest number of basic health workers. The World Health Organization (WHO) in its World Health Report, 2006 (WHR) depicted a shortage of 1.5 million workers in Africa. The WHR also recommended a minimum worker density threshold of 2.3 workers (doctors and nurses) per 1,000 population to achieve the United Nations Millennium Development Goals. Kenya, Uganda, and Rwanda are distant in reaching those standards. The pull of better salaries in developed countries, and the push of poor working conditions in Africa drive thousands of jobs abroad. Several factors contribute to the workforce shortage specific to Kenya, Uganda, and Rwanda. They include the tiered structure of health care delivery, underproduction, internal mal-distribution and brain drain. Ultimately, the countrys economic and health service delivery systems are affected. Such factors call for immediate actions on HRH perspectives. Strategies on HRH perspectives should be structured and implemented in countrys National Health Sector Strategic Plans. SOLUTIONS Strategic Solutions Strategic Solution 1: Identifying Workforce Challenges Preparing the health workforce to work towards attainment of health objectives is one of the most important challenges faced by these health systems. The WHR recommended that the skill mix should include the number of people trained, the degree to which they reflect the socio-cultural characteristics and the levels of competency for practice. Maintaining a reasonable balance in terms of number, diversity and competencies would be central to the success of HRH in Africa. Figure 1 illustrates the various factors influencing workforce compensation and outlines possible solutions.

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Drivers influencing workforce compensation


Health Needs Health Systems Market and Economy

Challenges
Number Diversity Maldistribution Homogenecity Competencies Missing Ineffective

Possible Actions
Increase class size for clinicians and administrators Shorten training time Redistribution New Institutions Accreditation Certification

Adapted from the WHR, 2006 Figure 3.1 Figure 1: Workforce compensation challenges and possible solutions Strategic Solution 2: Identify the Mechanism of Generating and Recruiting Workforce The WHR depicts a pipeline approach to understand the process of generating and recru iting healthcare workers. This approach is executed via three phases. Phase 1 concentrates on the educational institutions. Phase 2 concentrates on the graduates and categorization of workforce. Phase 3 is concerned with the recruitment and retention of workforce. These three phases are illustrated in Figure 2.

Phase1

Pool of eligibles Selection Accreditation Training institutes


Graduates Potential Workers Categorization Licensing

Phase 2

Phase 3

Recruitment Retention Redistribution

Adapted from WHR, 2006 Figure 3.2 Figure 2: The Pipe line approach for generating and recruiting healthcare workforce

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Strategic Solution 3: Strengthening the Internal Education System and Policies Educational institutions for health service providers and management staff are one of the key constituents in maintaining a balanced workforce. Factors such as governance, educational services and sustainability happen to be the components of such institutions. Figure 3 illustrates detailed analysis of those factors.

Governance

Manage the number and quality of institutions Adequate financing


Orient curriculum towards professional competencies Quality staff Comprehensive training sites Revise Policies Continuous evaluation of health workforce production

Educational Services

Sustainability

Adapted from WHR, 2006, Table 3.1 Figure 3: Importance of Educational Institutions

CONCLUSION Kenya, Rwanda, and Uganda are grappling with the reforming healthcare systems. Provisions to assure an adequate and competent workforce should be considered. Workforce planning and assessment is a challenging task as there is no single entity in charge of it. Population based estimation, needs based assessment and training output estimation should be given emphasis in the national healthcare strategic plans. The saying, Plan Tomorrows Workforce Today is appropriate for these countries. Strategic solutions if implemented will boost the likelihood to develop and improve the struggling workforce in Kenya, Uganda and Rwanda.

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APPENDIX Political Map of Africa

Source: http://www.ilike2learn.com/ilike2learn/Continent%20Maps/Africa%20Political%20Large.gif

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REFERENCES HRH profiles - Africa Health Workforce Observatory (n.d.). Welcome to AHWO Website - Africa Health Workforce Observatory. Retrieved July 2011 from http://www.hrh-observatory.afro.who.int/en/hrh-country-profiles/profile-bycountry.html. Human Resources for Health (n.d.). Retrieved July 2011from http://www.human-resources-health.com/. WHO The World Health Report 2006 - working together for health (n.d.). Retrieved July 2011 from http://www.who.int/whr/2006/en/. Drager, S., Gedik, G., & Poz, M.R.D. (2006). Health workforce issues and the Global Fund to fight AIDS, Tuberculosis and Malaria: an analytical review. Human Resource Health, 4(23). Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1564037/. Academy for Educational Develoment. (2003, February). The Health Sector Human Resource Crisis in Africa. Retrieved from http://www.healthgap.org/camp/hcw_docs/USAID_healthsector_africa.pdf. The JLI Africa Working Group: The Challenge of HRH in Africa . (September, 2006). The Health Workforce in Africa: Challenges and Prospects. Retrieved from http://www.who.int/hrh/documents/HRH_Africa_JLIreport.pdf. Global Health Workforce Alliance. (May, 2008). Statement on the occasion of International Nurses. Retrieved from http://www.who.int/workforcealliance/news/IND/en/index.html. Zikusooka, C.M., Kyomuhang, R.L., Orem, J.N., & Tumwine, M.N. (October, 2009). Will private health insurance schemes subscriptions continue after the introduction of National Health Insurance in Uganda? Africa Health Science, 9(S2). Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2877293/. Central Intelligence Agency. (2011). The World Fact Book. Retrieved from https://www.cia.gov/library/publications/the-world-factbook/. Keriga, L., & Bujra, A. (March, 2009). Social Policy, Development and Governance in Kenya. Retrieved from http://www.dpmf.org/dpmf/downloads/Health%20Report.pdf. Muga, R., Kizito, P., Mbayah, M., & Gakuruh, T. (2004). Overview of the Health System in Kenya. Retrieved from http://www.measuredhs.com/pubs/pdf/SPA8/02Chapter2.pdf. World Health Organization . (May, 2010). Key components of a well-functioning health system. Retrieved from http://www.who.int/healthsystems/EN_HSSkeycomponents.pdf.

Neel H. Pathak University of Scranton 516 North Irving Avenue Apartment 1 Scranton PA 18510 U.S.A Pathakn2@scranton.edu Daniel J. West, Jr. Professor Chairman, Department of Health Administration and Human Resources University of Scranton daniel.west@scranton.edu

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HAS GENDER EQUITY IMPROVED? AN EXAMINATION OF THE CHALLENGES FACED BY PROFESSIONAL WOMEN IN LEADERSHIP
Michaeline Skiba, Monmouth University, West Long Branch, New Jersey David P. Paul, III, Monmouth University, West Long Branch, New Jersey _____________________________________________________________________________________________ ABSTRACT Four years ago, one of these authors wrote a research paper on the glass ceiling that examined how a select group of business employees/managers view issues regarding pay equity and promotional opportunities for female business professionals. Although information was collected from a small sample, results indicated that the importance of mentors, knowledge acquisition, and the need for work-life balance were dimensions that appeared to strengthen the upward mobility of female professional workers in the United States (Skiba, Mosca and Smith, 2007). This paper will look at contemporary developments and some of the social and political phenomena that have affected the status of women engaged in certain types of professional work in the United States. In addition, this paper will examine how well female healthcare professionals have fared to date, and provide recommendations for future improvements. _____________________________________________________________________________________________ BACKGROUND In 2000, women were paid an average of 79.7 cents for every dollar paid to men. The average earnings for women (workers and non-workers) were $16,554, compared with $35,942 for men (workers and non-workers) (US General Accounting Office, 2003). Three years later, the Economic Policy Institute (2003) reported that the ratio of womens median wage to mens median wage reached 81.3%. By 2005, the Bureau of Labor Statistics (BLS) found that women held half of all management, professional, and related occupations in 2004, and from 1979 to 2004, womens earnings as compared with mens salaries increased by 18% - from 62 to 80 percent (BLS, 2005). Another research study (Jones, 2005) indicated that the larger the organization, the more significant the gap between male and female executive directors. This finding was evident in the Equal Employment Opportunity Commissions (EEOCs) first sexual discrimination case against a Wall Street firm, Morgan Stanley, in which the company was found to systematically deny women promotions and raises (Kelly and DeBaise, 2004). The case was settled out of court with a $54 million settlement. Similarly, in early February of 2007, the Ninth Circuit court affirmed class certification in the sex discrimination case of Wal-Mart Stores, the worlds largest retailer. Although it was settled in Wal-Marts favor, this case was the largest civil rights class action (with over 1.5 million plaintiffs) ever certified against a private employer. While these cases involve large employers, gender equity issues continue to occur within other and perhaps less prominent employment sectors, and the remainder of this paper will examine why they warrant serious attention from employers and long before they are brought to court. WHERE WE ARE TODAY Early in 2009, one of President Obamas first pieces of legislation was the Lilly Ledbetter Fair Pay Act. In a protracted battle, including a Supreme Court decision that rejected the initial lawsuit against Goodyear, Ms. Ledbetter spearheaded the bill that relaxed the statute of limitations related to the 180 day window during which an alleged unlawful employment practice must be filed by a complainant. According to Representative George Miller, Democrat of California, the Supreme Court decided to commit legal jujitsu to satisfy a narrow ideological agendaunder the Ledbetter ruling, employers can escape responsibility for pay discrimination if they keep it hidden for the first 180 days (Pear, 2009, p. 2). Not surprisingly , governmental bipartisanship fueled arguments over this legislation, but a focal point of this case and others like it is this: many women do not realize that they are paid less than men until years after the discrimination begins, and a salary is one of the best kept secrets in any work organization. Business and Health Administration Association Annual Conference 2012

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In spite of more widespread implementation of company policies and greater employee awareness of gender bias issues, discriminatory practices have increased. Since 2000, the total number of charges fil ed with the EEOC has increased 25.1% to 999,922 in 2010 (Greenwald, 2011, p. 1). Ironically, it is the raised consciousness of aggrieved employees that may have exacerbated this increase. For example, in mid-2010, Novartis A.G., a large Swiss pharmaceutical firm, settled a class action of the unfair treatment of 5,600 female sales representatives for $175 million. In early 2011, a senior manager at Toshiba Corporation sought $100 million from a U.S. unit of this Japanese firm for gender bias against women in pay and promotions. In terms of satisfaction with overall pay, a Kenexa Corporation survey reported that a third of men thought they were underpaid while 43% of women felt they were an indicator that may support past studies that show women tend to get paid less for the same work (Light, 2011). In comparable studies done at Hay Group, only one in five companies invites employees to give feedback on pay programs (Light, 2011), an action that could alleviate the perception of unfairness and, subsequently, quell the filing of lawsuits. Another factor that has fueled discrimination cases is the bundling of grievances under the category of gender discrimination. These grievances include more men who allege sexual harassment, and maternity leave complaints (under the Family and Medical Leave Act) that are classified under gender discrimination. These are important developments; however, the remainder of this paper will focus on the pay and promotional status of women engaged in professional work and later, women employed in healthcare management. CORPORATE STRUCTURAL CHANGES IN THE LEGAL PROFESSION The challenges women face regarding pay and promotional opportunities cut across all types of industries. While some employment sectors have demonstrated gender awareness and pay/promotional equity, others remain stagnant. This next section focuses on the results of a particular profession the legal profession via the Report of the Fifth Annual National Survey on Retention and Promotion of Women in Law Firms, a comprehensive study conducted jointly by the National Association of Women Lawyers (NAWL) and the NAWL Foundation. Published in October of 2010, this report tracked the professional progress of women in the nations 200 largest law firms and provided a comparative view of male and female lawyers at all levels of private practice. Throughout 2009 and 2010 (and probably due to the economic recession), both men and women were terminated across the associate and partner levels of these firms. However, the substantial majority of part-time lawyers who were cut were women. The authors of the study attribute this finding to the changing structure of the firms: Not so many years ago, the typical law firm had a very simple structure. A junior lawyer entered a firm as an associate and, after perhaps half a dozen years of satisfactory, full-time training and experience, was invited to become a partner in the firm. Partners were the owners of the firm and shared in the overall profits or losses of the firms annual operations. Partner terminations were rare. The career path for a fledgling lawyer was straightforward towards a well-understood goal. Today, in sharp contrast, the typical large law firm is a byzantine structure where the career path for a new lawyer is anything but clear. A law firm will still have associates and partners, but now these basic categories have nuanced stratifications that did not exist a generation ago. A lawyer working in a large law firm may be a contract attorney, staff attorney, associate, counsel, nonequity partner, or equity partner. Lawyers in any of these roles may work part-time (Scharf & and Flom, 2010, pp. 5-6). This report provides a detailed explanation of all of the aforementioned levels; however, an important finding was the proportion of women who are equity partners: close to 15%, a proportion that has been constant across the five years during which the authors have collected data. In addition, the authors point to the growing gender diversity in other leadership populations in the legal community. For example, the number of female general counsels among the Fortune 500 companies has been growing and is larger at 19% - than the proportion of female equity partners in large firms (MCCAs 2010 Survey of Fortune 500 Women General Counsel, 2010, in Scharf and Flom, 2010). Furthermore, the National Association of Women Judges reported that 26% of state court judges in the U.S. are women (U.S. State Court Statistics, 2008, in Scharf and Flom, 2010).

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In a review of this report, a writer for the American Bar Association Journal commented that women are underrepresented in the highest ranks of legal leadership because there are few women on the highest governing committee, and few women are top law firm rainmakers (Weiss, 2010). While this report did not indicate how structural changes within the sampled firms have affected both women and men, it certainly underscores how the use of outsourced, temporary, and permanent temporary positions have negatively affected womens progress, and how the top-tiers regardless of restructuring continue to show few gains. WOMEN IN HEALTHCARE MANAGEMENT Over a decade ago, an Institute of Medicine (IOM) report entitled Crossing the Quality Chasm proposed an agenda intended to improve both healthcare finance and delivery systems to a level where safe, effective, patientcentered, timely, efficient, and equitable care is would be routine (Institute of Medicine, 2001), and part of that agenda included the recruitment, selection and hiring of intellectual talent. According to researchers in that same timeframe, salaries were part of the recruitment problem because for at least a generation, the market has set salaries in healthcare management lower than private commerce but higher than government (Warden, and Griffith , 2001, p. 230) and although women have been entering healthcare management in substan tial numbers since 1975, they still do not participate appropriately in senior management (Warden and Griffith, 2001, p. 231). Similarly and again, over a decade ago, the American College of Healthcare Executives (ACHE) surveyed 1,108 of its affiliates and found that female healthcare executives earned an average of 19% less than their male counterparts; there were significantly more males than females in CEO and upper-level positions; and while both groups reported that opportunity existed to ascend the organizational hierarchy, only about 11% of female healthcare executives, compared with 25% of male healthcare executives, have achieved CEO positions (Weil and Mattis, 2001). In an examination of this ACHE report, one researcher identified four reasons for these disparities: (1) men and women are perceived to have different management skills; (2) there are differences in types of education and work experience; (3) there are differences in responses to work and family demands; and (4) career aspirations vary (Gathers, 2003). While these reasons appear valid, the rationales behind them are questionable, at best. For example, in terms of education and work experience and in data gleaned in the ACHE report there were more men than women with specialized training in health administration, and men were more likely than women to begin their career in general management, financial services management, or clinical services vs. women, who were more likely to begin in nursing management or planning and marketing (Weill and Mattis, 2001). In a review of the book entitled Rx for the Nursing Shortage: A Guidebook written by Shaffner and Beymer, Palkon noted that one reason for the shortage cited by the books authors is that women have numerous other opportunities. Palkon explained: For example, the authors note that in the 1997 -1998 period 48% of the bachelor degrees in business, 38.6% of the masters degrees in business, 28.9% of the masters degrees in computer and information science, 38.2% of the degrees in dentistry, 41.6% of the degrees in medicine and 44.4% of the law degrees went to women, respectively (Palkon, 2003, p. 36). It appears clear that women continue to pursue a host of professional choices and, therefore, nursing will continue to have significant challenges from other professions as a career choice for women. An earlier study of 210 MBA graduates who also were employed in healthcare administrative positions was intended to study how organizational and individual variables differ between male and female health administrators. While several variables such as the provision of financial and nonfinancial benefits, access to training programs, success factors, demographics, and motivating factors underlying career choices were analyzed, the most striking findings occurred in the analysis of the factors that dealt with salary level and professional advancement. In their initial post-MBA positions, mens and womens starting salaries were not significantly different. However, 26% of the women remained in clinical positions compared to only 8% of the men. According to the researchers, this lag in womens changing from clinical to nonclinical positions contributes to delayed career development and mobility and, consequently, a slower rate of increase in salary than their male counterparts (Walsh and Borkowski , 1995, p. 266). Recommendations from these researchers included the identification of opportunities for interaction with executives from healthcare employment settings, and the need for future research on how organizational environments promote or deter mentoring relationships. Finally, a very recent examination of the status of women in the public health profession was conducted at the leading public health agency within the U.S.: the Centers for Disease Control and Prevention (CDC). Business and Health Administration Association Annual Conference 2012

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Specifically, the study explored gender-related differences in promotional rates. During the study period of 2002 through 2006, both gender groups showed improvements in educational attainment, and w omens progress actually surpassed that of men. In addition, the actual pay grades of both men and women increased steadily with time. However, the gender gap in average GSR grade, although narrowing with time, persisted, and the percentage of women attaining GSR 15+ positions in 2006 was 5.6% and less than that of men, at 13.9% (Chan and Crawford, 2010). The researchers question whether women now encounter barriers in securing top posts in the agency. GLIMMERS OF PROGRESS During and after the recent Great Recession, unemployment fell for both sexes, but labor force participation (the percentage of working age employed people) also dropped. Interestingly, the labor force participation rate fell more among men than women. While the explanations for these phenomena are complex and require analysis beyond the scope of this paper, one reason why more women continue to be employed may be because they merely earn less than their male counterparts in so many comparable positions. This may be something to carefully examine during the economic recovery of the U.S. As mentioned earlier, Wal-Mart was under intense scrutiny for alleged unfair policies including discrimination against women. Several years ago, Wal-Mart tried to revitalize its corporate image in the eyes of customers and investors through increased marketing efforts, a more proactive corporate affairs department, and a restructured investor relations group (Troy, 2006). Earlier the previous year (Morris, 2005), Wal-Mart made changes to its compensation structure and required that new hires with the same experience receive the same starting pay, regardless of what they were paid in the past. Perhaps due to this effort, historys largest class action lawsuit was settled in Wal-Marts favor. Wal-Mart contended that the alleged victims, who worked in 170 job classifications across 3,400 stores, had too little in common to qualify for a single class action suit (Bravin and Zimmerman, 2011). Not surprisingly, labor rights and civil rights groups are enraged over this decision since a large class action is one of the few and effective tools against deep-seated discriminatory practice. Perhaps more importantly, Wal-Marts efforts do not seem to reflect the root issue of promotional opportunities for f emale managers. In the healthcare arena, progress has slowly improved over time, although most studies cited here and elsewhere point to problems with promotions, regardless of educational attainments and motivational characteristics. Modern Healthcares recent list of the top 25 women in healthcare, 40% of which hold key positions at hospitals or health systems, is optimistic news. The brief biographies of these leaders demonstrate very wide differences in demographics and experience. Debra Cafaro, the chairperson and CEO of Ventas, one of the leading healthcare real estate investment trusts, was an expert in real estate law and finance. Nancy Schlichting was a deeply experienced hospital administrator whose female mentor persuaded her to apply for her own position as president and CEO of Henry Ford Health System. Maureen Bisognano was a nurse who transitioned into hospital administration, assumed increasingly more responsible roles, and recently was appointed as president and CEO at the Institute for Healthcare Improvement (Vesely, 2011). The one commonality that these authors could discern from this list is the presence of mentors who either groomed their protgs or alerted them to unique advancement opportunities. CONCLUSIONS AND RECOMMENDATIONS Apart from ones political or social viewpoint, it appears clear that women are vital to the economic growth of the U.S. According to a recent McKinsey report, Unlocking the full potential of women in the US economy , the biggest barrier is entrenched mindsets and behaviors at companies and among women themselves two of the biggest culprits in preventing women from advancingfrom middle manager to senior manager (Barsh and Yee, 2011, p. 1). The report goes on to state that women who have reached middle management or senior management stages have shown increased interest in leadership roles; however, perceptions from senior executives indicate that certain jobs shouldnt be available to women, and their tendency is to reward men for their potential and women only for their performance. How can these mindsets be changed? One answer is found in the Institute of Management & Administration (IOMA) Report on Salary Surveys, which urges women to learn how to be more aggressive in salary negotiations. Cited in this report, a number of organizations offer seminars that teach women how to negotiate compensation and promotions as early as the high school and community college levels (Anonymous, 2011). Business and Health Administration Association Annual Conference 2012

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While American women continue to challenge the glass ceiling, gender inequities are wreaking havoc on a global scale as well. The World Economic Forums 2011 Gender Gap Index stated that a nations prosperity correlates with the level of parity between women and men across a number of dimensions that include education, health, economic opportunity, and political empowerment. In terms of progress in the U.S., the WEF stated that GDP could increase by as much as nine percent by putting more women in leadership positions in business and government. Other countries may fare worse. In the Asia-Pacific region, countries are losing between $42 billion and $46 billion a year by restricting womens access to the workforce (Hausmann et al., 2011). Employers must recognize and learn how to maximize the productivity and potential of women, a large and growing segment of the professional workforce. Some forward-thinking countries already are taking action in this regard. Earlier this year, the Association of British Insurers announced that it will begin reporting the number of women on FTSE boards after Lord Davies was commissioned by the government to investigate why so few women make it to the top of corporations in Britain. His report will urge shareholders and recruitment organizations to do more to push boards to change (Ahmed, 2011). Another area of interest is the Middle East specifically, the Gulf Cooperation Council (GCC) countries of Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the UAE. Strategy & Business recently interviewed a small yet significant group of women who are making rapid progress in these six countries all of which were ranked below 100 (among 134 countries) for gender equality by the WEF. The eight women who were interviewed offered their recommendations for creating institutions that will allow more women to grow and succeed: Constant improvement. A refusal to accept the status quo, in themselves, their organization, or their region. This manifests itself in unending evaluation and improvement. Studied discomfort. A willingness to go outside their comfort zone, professionally and personally, particularly when taking on new challenges that would benefit their organization. Quiet confidence. A certainty in their own abilities and recognition that when they are inevitably called upon to substantiate the value of their work, they will be prepared (Aguirre, Cavanaugh and Sabbagh, 2011).

The authors of these interviews emphasize that there is an institutional shift underway in womens economic participation in these countries. Hopefully, other countries with a shorter history of gender inequities will learn that the expansion of opportunities can lead to greater social and economic progress.

REFERENCES Aguirre, D., Cavanaugh, M.M., & Sabbagh, K. (2011). The Future of Women Leaders in the Middle East. Strategy & Business. Retrieved November 2011 from http://www.strategy-business.com/article/ 11209?rssid=all_updates&gko=dc8bf&utm_sour. Ahmed, K. (2011). Shareholders to Force Progress on FTSE Women. The Telegraph. Retrieved February 2011 from http://www.telegraph.co.uk/finance/markets/ftse100/8335700/Shareholders-to-force-program.. Anonymous (2011). How Women Can Contribute More to the US Economy. McKinsey Quarterly. Retrieved April 2011 from https://www.mckinseyquarterly.com/article_print.aspx?L2=18&L2=31&ar=2784. Anonymous (2011). Studies Examine Whys, What-to-do About Gender Pay Gaps. IOMAs Report on Salary Surveys. Institute of Management & Administration, 18(4), 9-10. Barsh, J. and Yee, L. (2011), Unlocking the Full Potential of Women in the US Economy . McKinsey Quarterly. Retrieved November 2011 from http://www.mckinsey.com/client_service/organization/latest_thinking/ unlocking_the_full_potential.aspx. Bravin, J. and Zimmerman, A. (2011). Court Weighs Bias Claim. The Wall Street Journal. Retrieved March 2011 from http://online.wsj.com/article/SB10001424052748704471904576230764121359864.html? Business and Health Administration Association Annual Conference 2012

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Bureau of Labor Statistics (2005). Women in the Labor Force: A Databook. Washington, DC: United States Department of Labor. Retrieved May 2007 from http://www.bls.gov/cps/wlf-databook2005.htm. Chen, Z., Roy, K., and Crawford, C.A. (2010). Examining the Role of Gender in Career Advancement at the Centers for Disease Control and Prevention. American Journal of Public Health, 100(3), 426-434. Gathers, D. (2003). Diversity Management: An Imperative for Healthcare Organizations. Hospital Topics, 81(3), 14-20. Greenwald, J. (2011). Gender Bias Claims Not Slowing Down; Employer Policies Help, but Rising Awareness Fuels Complaints. Business Insurance, 45(8), l. Hausmann, R., Tyson, L.D., Bekhouse, Y., & Zahidi, S, (2011), The Global Gender Gap Index 2011, World Economic Forum. Retrieved November 2011 from http://reports.weforum.org/global-gender-gap-2011. Institute of Medicine (2001). Committee on Quality. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press. Jones, J. (2005). Top Executives Expect Raises, Women Leaders Pay Lags Behind Men. The NPT 2005 Salary Survey, February 1, 2005. Retrieved July 2007 from http://www.nptimes.com/Feb05/sr1.html. Kelly, K., & DeBaise, C. (2004). Morgan Stanley Is Focus of Trial on Gender Bias. The New York Times, July 6, 2004. Light, J. (2011). Women, Northeasterners Would Like More Pay. The Wall Street Journal. Retrieved November 2011 from http://online.wsj.com/article/ SB10001424052748704843404576250851086189820.html?KEYWORDS=joe+light#articleTabs=article. Morris, B. (2005). How Corporate America Is Betraying Women. Fortune, 151(1), 68. Palkon, D.S. (2003). Rx for the Nursing Shortage: A Guidebook. Hospital Topics, 81(1), 36-37. Pear, R. (2009). Congress Relaxes Rules on Suits Over Pay Inequity. The New York Times. Retrieved January 2009 from http://www.nytimes.com/2009/01/28/us/politics/28rights.html?_r=1&emc=eta1&pagewant...Accessed . Scharf, S., & Flom, B.M. (2010). Report of the Fifth Annual National Survey on Retention and Promotion of Women in Law Firms. The NAWL Foundation and the National Association of Women Lawyers. Skiba, M., Mosca, J., & Smith, D. (2007). Revisiting the Glass Ceiling: Pay Equity & Promotional Opportunities Among U.S. Female Business Professionals. The 7th Global Conference on Business & Economics. Proceedings publication presented in October, 2007 in Rome, Italy. Troy, M. (2006). War of Words Continuing Over Wal-Marts Salaries, Benefits. DSN Retailing Today. New York: Jan. 23, 45(2), 4. U.S. General Accounting Office (2003). In 2004 Wow! Quick Facts: Women and Diversity, 11. Washington, DC: 2004 Diversity Best Practices/Business Womens Network. Vesely, R. (April, 2011). Taking it to the next level. Modern Healthcare, 41(16), 6-31. Walsh, A., & Borkowski, S.C. (Summer, 1995). Gender differences in factors affecting health care administration career development. Journal of Healthcare Management, 40(2), 263-269. Warden, G.L., & Griffith, J.R. (2001). Ensuring Management Excellence in the Healthcare System. Journal of Healthcare Management, 46(4), 228-237.

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Weiss, D.C. (2010). Have Law Firm Structural Changes Created a Pink Ghetto? Study Raises the Question. American Bar Association Journal. Retrieved November 2010 from http://www.abajournal.com/news/article/have_law_firm_changes_created_a_pink_ghetto.

Michaeline Skiba Department of Marketing and International Business Leon Hess Business School Monmouth University West Long Branch, New Jersey mskiba@monmouth.edu

David P. Paul, III Department of Marketing and International Business Leon Hess Business School Monmouth University West Long Branch, New Jersey dpaul@monmouth.edu

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TRACK PHARMACOECONOMICS AND PHARMACEUTICAL INDUSTRY

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CHALLENGES IN THE MANAGEMENT OF PHARMACEUTICAL INDUSTRY IN KAZAKHSTAN


Zhansulu Baikenova, KIMEP, Kazakhstan Dilbar Gimranova, KIMEP, Kazakhstan Alma Alpeissova, KIMEP, Kazakhstan Gurumurthy Kalyanaram, Narsee Monjee Institute of Management Studies

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ABSTRACT Over the last few years counterfeiting of medicines has become a serious challenge in developing high quality National Health Service in the Kazakhstan. Effective management measures in pharmaceutical industry are considered key instruments in resolving this problem. The goal of this paper is to provide a critical review of the studies that have focused on the evaluation of different anti-counterfeiting activities of pharmaceutical companies and the government bodies in Kazakhstan and in other developing countries. As a country in transition, Kazakhstan has implemented several steps to address this issue. However, there is much more to be done in this area.

INTRODUCTION Realizing that effective management of pharmaceutical industry is a key to address the issue of counterfeiting products suggests that proper management systems are to be introduced. Among all consumer goods the medicines are the most strictly regulated products because of their potential adverse impact on a patients health. Further, there are important issues related to protection of intellectual property rights (trade mark, patent, regulatory data protection). The challenge is difficulty in identifying counterfeited medicine. Therefore counterfeiting of medicines should be treated as seriously as the effective treatment of AIDS, cancer, heart attack, child mortality etc. This paper presents an overview of counterfeiting of medicines: the nature of counterfeiting and the methods that have been employed to prevent such counterfeiting. Finally, we also present an analysis of the situation in Kazakhstan. The paper also considers the issues to be addressed in order to develop effective management system in solving the problem of counterfeited medicine in Kazakhstan. Accordingly, the main goals of this paper are: To discuss the growth of counterfeit medicines business in Kazakhstan; To understand whether the pharmaceutical companies should interfere the activities of regulatory bodies to protect patients from fake medicines; To explore the pharmaceutical industry regulation effectiveness in Kazakhstan.

This study is based on the in-depth interviews conducted with government officials, and focus groups with heads of pharmaceutical companies operating in Kazakhstan. AN OVERVIEW OF COUNTERFEITING IN PHARMACEUTICAL DRUGS Counterfeiting is not specific to any industry but it affects at least 90% of them: the music, software, and luxury goods industries, automobile industry, fast moving consumer goods industry, and toys, pharmaceutical industry, etc. Counterfeiting and product piracy constitute a serious and ever growing problem against legally run businesses and owners of intellectual property rights. According to the International Chamber of Commerce, counterfeiting and piracy are growing exponentially in terms of volume, sophistication, range of goods, and countries affected - this has significant negative economic and social impact for governments, consumers and businesses (International Chamber of Commerce, 2005). However, in spite of the fact that counterfeiting is general Business and Health Administration Association Annual Conference 2012

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problem, most seriously this problem affects and harms everything that directly relate to human-being. And one of the most seriously affected industries is pharmaceutical industry. According to definition, counterfeiting of medicine is characterized as a medicine, which deliberately and fraudulently mislabeled with respect to identity and/or source. Counterfeiting can apply to both brand and generic products (WHO Programmes and Projects). The subject of medicines counterfeiting can be different. For example, pharmaceutical products contain the active substances that have therapeutic effects, and can be counterfeited. Or the finished product itself pharmaceutical medicine in form of tablets, drugs, capsules, oral drops and solutions for injections is subject of counterfeiting most commonly. Also such thing as the fake packaging of medicine is also an example of counterfeiting, for instance, when counterfeiters re-date labeling of expired genuine products for prolonging shelflife, and product (even if genuine inside) becoming dangerous for health. Counterfeit producers can manufacture both branded and generic products and fake drugs may include products with the correct active substances or with the wrong substances, without active substances, with insufficient active ingredients or with fake packaging. Research conducted by UK, Swedish and American researchers shows that 90% of counterfeit drugs are sold on the Internet and that the global sale of counterfeit drugs was $75 billion in 2010 year (ScienceDaily, 2010). All countries, companies, official bodies attempt to solve this problem but growth in this sphere can still be observed. Why is it still popular to produce and sell counterfeiting of medicine? The possible reasons include the following: high cost of producing medicine, being R&D expenses a large proportion of it with long time gap between developing a product and placing it on the shelf. Moreover, before the product launch it should pass the approval of regulatory bodies, for example, in United States only 0.01 to 0.02% of the tested (i.e. 1 out of 5000 to 10000) compounds receives regulatory approval (OECD, 2007). The pharmaceutical industry uses tools of intellectual property rights (trade marks, patents for invention of compound and method of manufacture), market exclusivity rights to justify the expenses spent on researches. That is why the industry barriers are easier to overcome for the well established pharmaceutical companies while for the new entrants they remain high by suggesting gaining low margins within the long time period. Finally, beyond the abovementioned factors, there are more to be analyzed such as increasing life expectancy, standards of living in developing countries that may lead to tendency of producing counterfeiting products. However, not all the medicines are subject to counterfeiting, the most counterfeited drugs are the bestselling drugs so called "blockbuster medicine" which is defined as being one which achieves annual revenues of over US$ 1 billion at global level" (FIW Innsbruck Symposium on Innovation and Competition Law, 2009). The most affected to counterfeiting products are modern pharmaceutical medicines of wide range of therapeutic classes, including drugs for treatment of erectile dysfunction, heart diseases, cancer, hormones, antibiotics, anti-histamines, vitamins and many others. Distribution of counterfeits vary from country to country, depending on the economic situation, for example, in developed countries such as US, EU, Canada, Australia, Japan, New Zealand the statistics is low (less than 1 %) versus some developing countries where the level is estimated as 10-30% (WHO Media Centre , 2006). Another trend is the diversification of products depending on country, for instance, in developed countries the modern anti-cancer drugs, cholesterol-lowering & anti-hypertension drugs are mostly counterfeited, whereas in developing countries the most commonly counterfeited drugs include the basic medicines against infection, i.e. antibiotics, anti-malarials, anti-retrovirals and anti-tuberculosis (OECD, 2007). ANALYSIS OF KAZAKHSTAN PHARMACEUTICAL INDUSTRY The pharmaceutical industry growth in Kazakhstan is positively correlated with its economic growth.

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Table 1: Kazakhstan economic indicators 2006 GDP growth, % (annual change) GDP per capita Industrial production, % (annual change) Unemployment, end of period Inflation, end of period Pharmaceutical industry market size 7.8% 7.3% 6.6% 6.6% 5.8% 7.2% 5.0% 2.1% 1.5% 10% 10.7% 2007 8.9% 2008 3.3% 2009 1.2% 2010 7%

$ 5 262

6 757

8 398

6 710

9 100

9.5%

8.4%

18.8%

6.2%

7.8% KZT179.3bn (US$1.22bn) 20% annual growth

There are other factors have also contributed to the sustained growth of pharmaceutical industry in Kazakhstan: introduction of a unique healthcare system which started in January 2010, increase of the budget for guaranteed volume of Health Medicare (GOBMP), announcement of President N. Nazarbaev to increase the local production to 50% before 2014, plans to build the new manufacturing pharmaceutical sites with total investments of about $200 mln. USD. Government provides lower taxes, cheaper registration, cancellation of registration of pharmaceutical substances, benefits for land purchases for the building of new sites, monopoly preferences for state tender purchases. However, local pharmaceutical producers dont always meet international manufacturing requirements, such as Good Manufacturing Practice (GMP) standards. The pharmaceutical industry in Kazakhstan has the following strengths: relatively low cost registration procedures, ongoing healthcare reforms, and overall attractiveness of the industr y due to the countys political stability, well-established financial sector coupled with the absence of VAT for pharmaceuticals. Foreign investors might be attracted by the development of private insurance system, opportunities for generic companies as original drug producers are usually opening the way for generics by inclusion of the drug into formulary system. The major disadvantages of entering the pharmaceutical industry include the following: non-avoidable parallel import from Russian Federation due to the Customs Union Agreement, low level of pharmaceutical inspection due to lack of resources, and weak protection of intellectual property rights. There is also a threat of monopolization of distribution of medicines by creating the state unique opera tor SK Pharmacia. Business Monitor International (BMI) highlights that pharmaceutical market of Kazakhstan scores 43 for market risk due to prolonged registration process, low respect of IP laws, and 74 in country risk category related to corruption. This ranking is done for the Central Asian and Easter European markets. Regulatory bodies in Kazakhstan are the Committee of control of medical and pharmaceutical activity and National Center of expertise of medicines, both bodies directly report to the Ministry of Healthcare. Under the system of unique healthcare started in January 2010, the local regulators developed a National system with the list of Business and Health Administration Association Annual Conference 2012

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the medicines recommended to use for treatment of certain diseases, which is implemented by the National Formulary Committee. The National Center of Expertise on the basis of European Pharmacopoeia elaborated and issued the local State Pharmacopoeia which is the document regulating the standards of quality of medicines under which the drugs can be given the marketing authorization. In the framework of joining the WTO, the country is gradually revising the regulations especially in Intellectual Property rights area, but this process is done by the government very carefully in order to protect the local producers and provide the way for easy entrance of generics due to the willingness of state not to lose the access to cheaper generic and local medicines. According to experts who represent the Center of patent-rights consulting of National Institute of intellectual property, the country should protect the interest of local manufacturers and generic producers in order to provide an access to cheap generics. Their concern is about Regulatory data protection rule (TRIPS agreement) which allows to originator companies to extend the exclusivity rights to 5 years, and she proposes to the government to use flexibilities such as parallel import and forced licensing (Baimbetova, 2010). Total pharmaceutical market in Kazakhstan is: KZT179.3bln (US$1.22bln) in 2010 KZT209.6bln (US$1.46bln) in 2011; +16.9% in local currency terms and +19.9% in US dollar terms (Forecast up from Q3.2011 due to improved macroeconomic factors) and among the total approximately 10 -12 % is counterfeit medicines (Business Monitor International, 2011). The local pharmaceutical industry represents approximately 10% of total turnover in country, whereas almost 90% of medicines are imported, mostly from European countries. EFFECTIVE MANAGEMENT APPROACH TO SOLVE THE PROBLEM OF COUNTERFEITING OF MEDICINE IN KAZAKHSTAN According to the Code of the Republic of Kazakhstan No.199-N ZRK About Health of population and healthcare system signed by President of the Republic of Kazakhstan on 18 September 2009, it is prohibited to import, store, distribute, sell and use the counterfeit medicine on the territory of the Republic of Kazakhstan, and the officials of authorized body should withdraw the discovered counterfeit medicines and take measures for their destruction. According to WHO data the level of counterfeiting in CIS countries is between 10 and 20 % that means at least 10% of the drugs sold in Kazakhstan are counterfeited. Due to its geographical location between the East and the West, Kazakhstan has been used as a transit route for counterfeit drugs originating from China, India and other South East Asian countries. Some counterfeits may also originate in Russia and Ukraine. In the last three years, the number of fake products on the Kazakhstani market has increased, according to a US Pharmacopeia Drug Quality and Information Programme study (Business Monitor International, 2010). However, the pharmaceutical & medical society continues to keep silence. Counterfeiting is not being properly addressed in Kazakhstan. So far the initiatives include proposals by the Association of representative offices of foreign pharmaceutical companies that suggest stricter punishment for manufacture and sell counterfeits, the creation of analytical centres intended to detect the fake medicine promptly and increase of co-operation and information exchange between drug-makers and state quality control departments. As one of the measures the labelling of drugs in the local state Kazakh language was proposed which can serve as a barrier for fake medicines originating from Russian Federation. But all the measures did not result in improvement of situation with counterfeiting in Kazakhstan. The big pharmaceutical companies still face an issue with counterfeiting; cases are discovered after the advertising campaign on TV and promotional actions conducted by Marketing & Sales team of pharmaceutical company. From practical point of view when companies discover the single cases of counterfeits, according to corporate procedures they send the sample for investigation to manufacturing site or headquarter. Usual practice in Kazakhstan that companys report the confirmed findings by submission of claim to Committee of Pharmaceutical control of Ministry of Health of the Republic of Kazakhstan with provision of samples and indicating the infringer-drugstore. The aim of such claim is to find the final producer of fake medicine and investigate the supply chain (Figure 1).

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Step 1. Company confirms counterfeiting

Step 2. Claim to the Committee of Pharmaceutical control of the Ministry of Healthcare

Step 3. Investigation of Supply Chain with the aim to detect a fake producer

Step 4. If counterfeiting is confirmed, the case is considered by the Court

Figure 1: Steps in detection of counterfeiting medicines in Kazakhstan

However, steps 3 and 4 (Figure 1) are not always effective due to the difficulty of finding the evidence of counterfeiting as fake producers take needed measures to overcome the inspection by removing all fake products from their stores. On the other hand detection of counterfeiting is not desirable even by legal pharmaceutical companies as they avoid being associated with counterfeit in order not to damage their brand loyalty. There is a need to strengthen cooperation between regulatory authorities and pharmaceutical product manufacturers, to provide better publicity for counterfeiting events, to improve the interaction with customs bodies. Just after the collapse of the USSR, in the beginning of 1990s, the medicines in Kazakhstan as well as in most of the CIS countries were sold at food and cloth markets (bazaars). During this period the storage conditions of medicines were not followed and the share of counterfeited medicines was very high due to the absolute absence of control from state bodies and authorities. In 1994, the CIS countries came to common understanding that it is a time to harmonize the legislation on medicines circulation. The Intergovernmental Commission on standardizing, registration and quality control of medicines, medical devices and medical technique of countries-participants of CIS was established in 1995. There were plans to build the information centre which would collect the data about all medicines registered in CIS, discovered adverse drug events (side effects), defected batches and discovered counterfeited medicines. The Committee of Health and Zdrav/Reform Program of the Ministry of Education, Culture and Health of the Republic of Kazakhstan elaborated and issued the list of essential (vitally necessary) medicines in 1995. It has helped to purchase the medicines in a centralized manner from reliable known manufacturers and distributors. The state enterprise "Dari-Darmek" was established in 1997. Its goals included the regulation of import/export of medicines, registration of imported drugs, certification of imported batches and other normative-legal relations. The main responsibilities of "Dari-Darmek" was the execution of practical activities in healthcare for provision of safety, efficacy and quality of medicines, conducting the regulatory measures in pharmaceutical area and certification of medicines according to the state system of certification of medicines, and pharmaceutical inspection. However, since 2000 the inspection activities were not permitted to execute by state enterprises, that's why there was necessity to have a special body within the Ministry of Health responsible for circulation of medicines. Therefore, since 2002 the Committee of Pharmaceutical control of the Ministry of Healthcare of the Republic of Kazakhstan has started to follow the implementation of all the regulating activities. Today this body has its affiliates in all regions of the country. Some positive measures were taken by the Committee of Pharmaceutical control: the notion of counterfeited medicines was included in the "Law on Drugs" of the Republic of Kazakhstan that was enforced on 13.01.2004 and Business and Health Administration Association Annual Conference 2012

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introduction of administrative liability for the manufacture, distribution, storage, sale of fake medicines with specified fine. The main source of fake medicines in Kazakhstan is Russian Federation. Experts of pharmaceutical industry in Russian Federation state that most of fake medicines are produced by those companies which are legitimately producing their own legal products. It happens due to the high profitability of counterfeited medicine manufacturing, many players in distribution chain, and lack of legislation for distribution of counterfeited medicines. The legal gaps include the facts that the samples cannot be considered as material evidences and should be destroyed at once after the seizure and absence of evidences causes the reason for refuse of criminal case, and the lack of the specific laboratories where the product can be confirmed as fake or genuine (Rozkov, 2009). A lot of wholesalers and retail market players make it difficult to find the counterfeited medicine source of distribution. As practice shows, the fake medicines main distributors are illegal "one-day-firms", which cannot be easily found. The republican state enterprise "Dari-Darmek" was reorganized to the "National Centre of Expertise of Medicines, Medical devices and Medical Techniques of the Ministry of Health of the Republic of Kazakhstan in 2004. This organization is authorized to register all the medicines and monitor the adverse drug reactions (side effects), which also is one of the tools for discovering the counterfeited medicines. However, despite of the trainings conducted by the National Center for doctors in different regions of Kazakhstan, the activity on reporting the side effects of medicines is still very low. Moreover, patients rarely complain to authorities about the doubtful drug pack on counterfeiting. The National Centre conducts the laboratorial expertise of medicines and prepares the official report discovered by pharmaceutical inspection. However, the director of analytical department of Vi-ORTIS Group Consulting, Aliya Svanova, states that the Committee of Pharmaceutical Control of the Ministry of Healthcare is not able to control the activities of all drugstores because of insufficiency of inspection. This low control situation leads to appearance of big quantity of fake medicines and drugs with expired shelf-life. Determination of effective tools to exterminate the counterfeiting of medicine form the market requires the involvement of all parties in the healthcare and pharmaceutical supply chain system, with specific responsibility of manufacturers, all delivery chain stakeholders, consumers and healthcare professionals as well as regulatory bodies for development of legal evolution to criminalize the responsibility for delivery of fake medicines in all countries worldwide.

REFERENCES

Baimbetova, O. (2010). The Availability of Medicines within the Context of WTO Entrance. Kazakhstanskii Pharmacevticheskii Vestnik, 2, p.342. Counterfeit Internet Drugs Pose Significant Risks and Discourage Vital Health Checks (Jan 20,2010). ScienceDaily. Retrieved from http://www.sciencedaily.com/releases/2010/01/100120085348.htm. Counterfeit Medicines: The Silent Epidemic (February 15, 2006). WHO Media Centre. Retrieved from http://www.who.int/mediacentre/news/releases/2006/pr09/en/index.html. General Information on Counterfeit Medicines. WHO Programmes http://www.who.int/medicines/services/counterfeit/overview/en/index.html. and Projects. Retrieved from

International Chamber of Commerce ( September, 2005). Current and Emerging Intellectual Property Issues for Business, Sixth edition. Retrieved from www.iccwbo.org/iproadmap. Kazakhstan Pharmaceuticals and Healthcare Report (2011). Business Monitor International, Q4. Kazakhstan Pharmaceuticals and Healthcare Report (2009). Business Monitor International, Q4.

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Rozkov, R. (March, 2009). The means for strengthening of panic. Money, 10, p.715. The economic impact of counterfeiting and piracy: Executive summary (2007). OECD. Retrieved from http://www.oecd.org/dataoecd/13/12/38707619.pdf The ECs Pharmaceutical Sector Inquiry Preliminary Report: Wading Into The Thicket of The Antitrust/Intellectual Property Law Overlap (February, 2009). FIWInnsbruck Symposium on Innovation and Competition Law. Retrieved from http://www.ftc.gov/speeches/rosch/090226innsbruck.pdf.

Zhansulu Baikenova ,Professor KIMEP, Kazakhstan Abay Ave. 2, Executive Education Center 050000, Almaty, Kazakhstan

Dilbar Gimranova, General Director KIMEP, Kazakhstan Abay Ave. 2, Executive Education Center 050000, Almaty, Kazakhstan

Alma Alpeissova KIMEP, Kazakhstan Abay Ave. 2, Executive Education Center 050000, Almaty, Kazakhstan

Dr. Gurumurthy Kalyanaram Inaugural University Dean for Research NMIMS University Mumbai, India and President, GK Associates kalyan@alum.mit.edu

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TREATING METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS WITH THE DRUG VANCOMYCIN IN A HOME INFUSION THERAPY SETTING
Joshua L. Webb, Marshall University Alberto Coustasse-Henke, Marshall University Dennis Emmett, Marshall University

ABSTRACT The basic purpose of this paper is to examine the effects the home infusion therapy has on the cost, duration of, and effectiveness of treatment between those individuals under 60 and those 60 and over. The results show that those 60 and over had a slightly higher cost/day. The older age group had slightly smaller treatment duration, then the younger group. The number of adverse effects was small. The results suggest that home infusion therapy appears to be a viable alternative to hospitalization.

INTRODUCTION The risk of being exposed to nosomical infections and/or antibiotic resistant organisms such as Methicillin-Resistant Staphylococcus Aureus (MRSA) has experienced a dramatic increase over the past decade (CDC, 2010; Guilbeau & Fordham, 2010; Klein, Smith, & Laxminarayan, 2007; Klevens, 2007; Capitano, Leshem, Nightingale, Nicolau, 2003). It has been estimated that in the U.S. in 2005, there were 94,360 individuals infected with MRSA; the most recent comprehensive study of the infection (CDC, 2010; Klevens, 2007). MRSA has been easily classified as endemic and even an epidemic in many U.S. hospitals and long-term care facilities, with an increase of MRSA related hospitalizations of 62% between 1999 and 2005 (Crum, et al.; Klein, et al., 2007). What was once confined primarily to intensive care units and acute care hospitals, MRSA has emerged as a major public health problem that only prolongs hospitalization and increases morbidity (Guilbeau & Fordham, 2010; Klein, et al., 2007; Klevens, 2007; Capitano, et al., 2003). Antibiotic choice Susceptibility testing is necessary to determine the treatment regimen (Wilcox, 2008). Treatment of the infection is biased to a variety of factors: severity of the infection, area and association of the infection, risk of bacteraemia, whether it is CA-MRSA or MA-MRSA; just to name a few (Wilcox, 2008). Resistance of Staphylococcus aureus to vancomycin has been particularly rare in the medical community; and therefore, vancomycin has been extensively used to treat these types of infections specifically MRSA (Barclay, 2008; Wilcox, 2008; WMHS, 2006). Home infusion therapy MRSA has by and large been treated in an in-patient setting (Wilcox, 2008). However, due to an increased recognition that it is safe for patients with MRSA to be treated at home, treatment provided through Home Infusion Therapy (HIT) has emerged (GAO, 2010; Wilcox, 2008). HIT is the administration of medication intravenously in the patients home as an alternative to receiving the same treatment in a hospital, inpatient setting (NHIA, 2011; Williams, 2011). This method of treatment has been proven to be an effective, efficient, and safe alternative to in-patient therapy, and is generally provided through a HIT pharmacy in collaboration with the physician, home health nurse, and dietitian (if applicable) to administer Business and Health Administration Association Annual Conference 2012

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the therapy plan (Williams, 2011). The infusion therapy is typically performed through the injection of liquid medicines directly into the vein; either through a catheter or needle (National Home Infusion Association, 2011). Purpose of research The purpose of this research was to analyze the treatment of MRSA with the drug vancomycin in a HIT setting. The research focused on the differences between two patient groups; patients < 60 years of age and patients 60 years of age, as well as patients being treated for a secondary diagnosis and those being treated only for MRSA, both being analyzed with regard to clinical outcomes and costs associated with the therapy. METHODOLOGY Research hypothesis The research hypothesis was that patients in the older age group ( 60) would experience a higher mean cost per day for the therapy, longer therapy duration, with lower positive clinical outcomes than that of the younger age group. Research settings This retrospective quantitative case study was performed in a Mid West Home Infusion Pharmacy that provided the infusion services. Sample population and description Data of patients being treated for MRSA with the drug vancomycin in a home infusion setting between 2007 and 2010 were obtained with 60 cases used for this study. Only cases involving the treatment of MRSA using the drug vancomycin were used due to the relevance of the research. All insurance and payer types were allowed to avoid limitations on comparisons between the differences in reimbursement by Medicare, Medicaid, Commercial, Workers Compensation, and Private Pay. Data collection and instruments Patient age, gender, diagnosis, insurance provider, treatment duration, treatment method, costs, reimbursements, and clinical outcome(s) were provided in the data acquired from the Home Infusion Pharmacy. The cases were measured in age categories cases of patients 60 years and older, patients younger than 60 years, and by total population. The categories were then analyzed by the total mean cost-per-day for therapy regiments, the mean cost by insurance payer type, treatment duration, adverse events, and positive clinical outcomes. Adverse events were defined as events that complicated the completion of therapy regiments or events that resulted in the unsuccessful completion of therapy regiments. Positive clinical outcomes were defined as cases that completed the therapy regiments without any adverse events and resulted in the successful treatment of the infection. Treatment Costs were measured in Cost-Per-Day; this included cost of the drug, supplies, equipment rentals, and nursing services if required. Dependent and independent variables The study analyzed each therapy case in < 60 years of age group and a 60 years of age group to better understand the differences in both clinical outcomes and financial implications with Medicare eligibility and reimbursement being a major factor. In addition, the study analyzed the difference between patients being treated with a secondary diagnosis and patients being treated solely for MRSA. The dependent variables were: the patients age group, and whether or not he/she was being treated for a secondary diagnosis. The independent variables were: Bacteremia, Carbunkle, Cellulitius, E.Coli, Epidural Abscess, Infected Pacemaker, Osteomyelit, Post Operation Infections, Pseudomonas Infection, Septic Joint, Urinary Tract Infection, and No Secondary Diagnosis.

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Ethical considerations Secondary, non-identifiable data was provided by a Mid-West Home Infusion Pharmacy, thus an IRB was not required in conducting this research. RESULTS Basic analysis Basic frequencies and percentages were performed on all the data. The two groups, Age 60 and Age< 60, were used. The frequencies and percentage were performed for both groups combined. Due to the small sample size, other statistical analysis did not provide any significant results. Gender and age data A total of 60 patient cases that underwent IV infusion therapy in a HIT setting were analyzed for the treatment of MRSA with the drug vancomycin; this included therapy in an older age group (60 years and older) and in a younger age group (Less than 60 years). There were 26 cases (43.3%) of patients aged 60 years or older and 34 cases (56.7%) of patients younger than 60 years of age. The overall mean age was 56.1 (range 8-90). Of those aged 60 years and older, the mean age was 71.5 (range 60-90), and of those aged younger than 60 years, the mean age was 44.3 (range 8-57). Of the 60 patient cases, 33 (55%) were male and 27 (45%) were female. Of those aged 60 years and older (N=26), 16 were male and 10 were female. Of those aged less than 60 years of age (N=34), 17 were male and 17 were female. Diagnosis data A total of 1,529 therapy days of IV infusion therapy in a HIT setting between January 1, 2007 and December 31, 2010, were reviewed. Thirty-four patients (57%) were being treated for a second diagnosis in addition to MRSA, while 26 cases (43%) were being treated solely for MRSA with no secondary diagnosis. Eleven different secondary diagnoses were found, with the flowing being the most prevelant: Cellulitis, 7 (12%); Osteomyelitis, 7 (12%); Bacteremia, 5 (8%). Eleven cases (18.3%) were reported to be hospital acquired MRSA infections with 49 cases (81.7%) not reported as hospital acquired MRSA (Table 1). Table 1: Secondary Diagnosis of 60 Patients Receiving 1,529 Therapy Days of Home IV Vancomycin Aged 60 (N=26) Secondary Diagnosis Bacteremia Carbunkle Cellulitius E.Coli Epidural Abscess Infected Pacemaker Osteomyelit Post Operation Infections Pseudomonas Infection Septic Joint Urinary Tract Infection No Secondary Diagnosis 2 (7.5) 0 (0) 1 (4) 0 (0) 1 (4) 1 (4) 5 (19) 2 (7.5) 1 (4) 1 (4) 1 (4) 11 (42) Aged < 60 (N=34) Cases, N (%) 3 (9) 1 (3) 6 (17) 1 (3) 1 (3) 0 (0) 2 (6) 0 (0) 2 (6) 1 (3) 2 (6) 15 (44) 5 (8) 1 (2) 7 (12) 1 (2) 2 (3) 1 (2) 7 (12) 2 (3) 3 (5) 2 (3) 3 (5) 26 (43) Total (N=60)

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Treatment duration and clinical outcomes The mean treatment duration of the total sample population (N=60) was 25.5 days; this included patients from both age groups. Further, this included patients being treated for MRSA alone, as well as the patients being treated for MRSA with a secondary diagnosis. Patients in the 60 years and older age group (N=26) presented a total mean treatment duration of 25.9 days. When this age group was divided into those being treated for MRSA alone and those being treated for a secondary diagnosis, the MRSA patients without a secondary diagnosis (N=11) provided a treatment duration mean of 21.5 days. Patients with a secondary diagnosis (N=15) had a mean treatment duration of 29.1 days. The age group younger than 60 years of age (N=34) produced a mean treatment duration of 25.1 days. When dividing the younger age group between MRSA patients without a secondary diagnosis (N=15) and patients with a secondary diagnosis (N=19) saw mean treatment durations of 19.1 days and 30.9 days respectively (Table 2).

Table 2: Treatment Duration of 60 Patients Receiving 1,529 Therapy Days of Home IV Vancomycin

Aged 60 (N=26)

Aged < 60 (N=34) Mean Treatment Duration, N (days) 15 (19.1) 19 (30.9) 34 (25.1)

Total (N=60)

MRSA Secondary Diagnosis Total

11 (21.5) 15 (29.1) 26 (25.9)

26 (19.4) 34 (30.1) 60 (25.5)

The total sample population (N=60) experienced five adverse event cases (8%) with 55 cases (92%) having no complications and successfully completing the therapy regiment. These adverse events included: Infected Peripherally Inserted Central Catheter (PICC) Line, Hospitalization, and Non-Compliance of treatment plan. Further, the case in which the PICC Line was infected was still able to complete the treatment regiment; leaving only three cases not completing the treatment. When analyzing the difference between the older age group and the younger age group, the 60 and older age group (N=26) experienced two adverse events (8%) leaving the remaining 24 patients (92%) without complications and successfully completing treatment. The younger age group, younger than 60 years of age (N=34), experienced similar results having three adverse events (9%) with 31 cases (91%) successfully completing treatment without complications (Table 3). Table 3: Adverse Events of 60 Patients Receiving 1,529 Therapy Days of Home IV Vancomycin Aged 60 (N=26) Aged < 60 (N=34) Adverse Events, N (%) Infected PICC Line Hospitalized Non-Comply No Adverse Events 1 (4) 1 (4) 0 (0) 24 (92) 1 (3) 1 (3) 1 (3) 31 (91) 2 (3) 2 (3) 1 (2) 55 (92) Total (N=60)

Treatment costs The total population sample (N=60) cost per day mean was $114.14. Mean costs of patients being treated for MRSA alone and patients being treated for MRSA with a secondary diagnosis was $123.97 per day and $106.63 per day respectively. Patients aged 60 years or older saw a mean cost of 112.28 per day while the younger age Business and Health Administration Association Annual Conference 2012

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group saw a mean cost per day of $115.75. Patients in the 60 years and older age group being treated for MRSA alone had a mean cost per day of $122.98. Patients in this same age group being treated for MRSA with a second diagnosis saw a reduced mean cost per day of $88.07. The younger age group saw increased costs per day with the patients in this age group being treated for MRSA alone and patients being treated for MRSA with a secondary diagnosis saw mean costs of $115.01 and $121.28 respectively (Table 4). Table 4: Mean Cost Per Day of 60 Patients Receiving 1,529 Therapy Days of Home IV Vancomycin Aged 60 (N=26) Gender MRSA Only Secondary Diagnosis Total 122.98 88.07 112.28 Aged < 60 (N=34) Average Cost Per Day (S) 115.01 121.28 115.75 123.97 106.63 114.14 Total (N=60)

Patients with Commercial Insurance (N=18) experienced the highest mean cost per day of $148.41. Medicare Patients (N=19) and Medicaid Patients (N=19) produced cost per day means of $128.69 and $108.65 respectively. Workers Compensation Patients (N=2) produced a mean cost per day of $125.27, while the Private Pay Patients (N=2) experienced the lowest with a mean cost per day of $85.08. When breaking these measures down by age group, the older age group saw mean costs of the Commercial, Medicare, Medicaid, and Private Pay of $110.05, $128.69, $28.44, and $78.00 respectively. The younger age group experienced mean costs of Commercial, Medicaid, Workers Compensation and Private Pay of $163.06, $66.51, $125.27, and $78.41 respectively (Table 5).

Table 5: Cost by Insurance Type of 60 Patients Receiving 1,529 Therapy Days of Home IV Vancomycin Aged 60 (N=26) Aged < 60 (N=34) Mean Cost Per Day by Insurance Type, N (S) Commercial Medicare Medicaid Workers Compensation Private Pay 4 (110.05) 19 (128.69) 2 (28.44) 0 (0) 1 (78.0) 14 (163.06) 0 (0) 17 (66.51) 2 (125.27) 1 (78.41) 18 (148.41) 19 (128.69) 19 (62.51) 2 (125.27) 2 (78.20) Total (N=60)

DISCUSSION Cost-per-day analysis Patients in the 60 years or older age group saw a slightly lower cost than patients in the younger age group; which could be credited to the fact that 19 of the groups 26 patients (73%) were Medicare patients, whereas 18 of the younger groups 34 patients (52%) were Commercial Insurance holders. The difference in reimbursements between the two payer groups was $19.72 per day. Additionally, the four cases of Commercial Insurance holders in the older age group saw a reimbursement rate of $53.01 per day less than the Commercial Insurance holders in the younger age group.

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One interesting finding in this sample population was that of the cost-per-day difference in the older age group when comparing the patients being treatment for MRSA alone versus those in the group being treated for MRSA and a secondary diagnosis. Patients in the older age group actually saw a lower cost-per-day when being treated for a secondary diagnosis than those in the group being treated only for MRSA. Although there was no evidence contained in the data to support this theory, perhaps the cause of this reduced rate in those with a secondary diagnosis was that the pharmacy only provided the drugs to these patients; without the costs of supplies, skilled nursing, etc. The younger age group did see increased costs per day when being treated for a secondary diagnosis in addition to the treatment of MRSA. Clinical outcome analysis As previously mentioned, this research yielded a 92% positive clinical outcome with only five adverse events. Both age groups saw identical treatment durations when compared to one another; including total age group samples, patients being treated for only MRSA, and patients being treated for MRSA and a secondary diagnosis. Both age groups saw increased duration of treatments in the patients being treated with a secondary diagnosis, which would be expected. With regard to the percentage of the age groups having a secondary diagnosis, the older age group only saw a two percent increase than that of the younger group having a secondary diagnosis. Therefore, the patients age did not factor into this element; at least not in this study. Limitations of research Limitations were imposed on this research which included: dependency of accurate secondary data from Home Infusion Pharmacy; Sample size of research population; and the lack of detailed cost associations with treatment from the Home Infusion Pharmacy data. The sample size was extremely small. More data is available and that data may provide statistically significant result

REFERENCES Barclay, L. (2008). Vancomycin Treatment Again MRSA May Fail When MICs Are Lower Than Current Breakpoints. Antimicrob Agent Chemother. 52(9), 33153320. Capitano, B., Leshem, O., Nightingale, C. H., & Nicolau, D. P. (2003). Cost Effect of Managing MethicillinResistant Staphylococcus Aureus in a Long-Term Care Facility. Journal of the American Geriatrics Society, 51(1), 10-16. Center for Disease Control and Prevention [CDC]. (2010). Invasive MRSA Statistics. Retrieved March 3, 2011, from http://www.cdc.gov/MRSA/library/index.html Crum, N.F., Lee, R.U., Thornton, S.A., Stine, O.C., Wallace M.R., & Barrozo, C., et al. (2007). Fifteen-Year Study of the Changing Epidemiology of Methicillin-Resistant Staphylococcus aureus. The American Journal of Medicine, 119(11), 943-951. Guilbeau, J., & Fordham, P. (2010). Evidence-based management and treatment of outpatient community-associated MRSA. Journal for Nurse Practitioners, 6(2), 140-145. Klein, E., Smith, D. L., & Laxminarayan, R. (2007). Hospitalizations and Deaths Caused by Methicillin-Resistant Staphylococcus aureus, United States, 1999-2005. Emerging Infectious Diseases, 13(12), p.1840. Klevens, R. (2007). Invasive Methicillin-Resistant Staphylococcus aureus Infections in theUnited States. JAMA: Journal of the American Medical Association, 298(15), 1763-1771. Business and Health Administration Association Annual Conference 2012

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National Home Infusion Association (NHIA). (2011). About Infusion Therapy. Retrieved March 3, 2011. Retrieved from http://www.nhia.org/about-home-infusion.cfm. US Government Accountability Office. (2010). Home Infusion Therapy: Differences between Medicare and Private Insurers' Coverage. Western Maryland Health System (WMHS). (2006, October). Vancomycin Therapy for MRSAIs it still the Gold Standard? Retrieved July 6, 2011, from http://www.garretthealth.org/pdfs/Vancomycin%20and%20MRSA%20October%20Newsleter.pdf Wilcox, M. (2008). Treating MRSA infection at home. Prescriber, 19(7), 7-8. Williams, L. A. (2011). Home infusion 101. International Journal of Pharmaceutical Compounding , 15(1), 6-10.

Joshua L. Webb, MS Marshall University Graduate College

Dr. Alberto Coustasse-Henke, MD, DrPH, MBA Management and Marketing and MIS - Lewis College of Business Marshall University Graduate College 100 Angus E. Peyton Drive South Charleston, WV 25303 Ph: 304 746-1968 Fax: 304 746-2063 coustassehen@marshall.edu

Dr. Dennis Emmett, DPA Management and Marketing and MIS - Lewis College of Business Marshall University Graduate College 100 Angus E. Peyton Drive South Charleston, WV 25303 DEmmett@marshall.edu

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A REVIEW OF RESEARCH ON DIRECT-TOCONSUMER ADVERTISING OF PRESCRIPTION DRUGS


Yam Limbu, Montclair State University Avinandan Mukherjee, Montclair State University

ABSTRACT This study reviews empirical research on direct-to-consumer advertising (DTCA) of prescription drugs published over the period from 1997 to 2012. Based on a careful review of one hundred and thirty empirical studies on direct-to-consumer advertising of prescription drugs, we identified seven key research streams in DTCA. Avenues for future research are proposed.

INTRODUCTION Direct-to-consumer advertising (DTCA) of prescription drugs is allowed currently only in the United States and New Zealand. During the last decade, promotional spending of prescription drugs has grown from $2.5 billion in 2000 to $3.3 billion in 2003, $4.2 billion in 2005, and $4.5 billion in 2009. There was a 330% increase in DTCA spending between 1996 and 2005. DTCA has been an issue of intense debate since the early years of its existence (Hoek, Gendall, and Feetham 2001; Royne and Myers 2008; Pol and Bakker 2010). Therefore, DTCA is undoubtedly an important topic that deserves researchers sincere attention (Farris and Wilkie 2005; Gellad and Lyles 2007). Unfortunately, it is one of the most understudied areas in pharmaceutical and healthcare marketing. Empirical research on the effect of DTCA is scarce as much of the extant research on DTCA is exploratory in nature and used the content analysis technique (Harker and Harker 2007). Comprehensive and empirically validated models of consumer responses to DTCA are missing from the literature (Wilson and Till 2007) and little is known about its effects on attitudes and behavior of concerned parties such as consumers, physicians, nurses, and other healthcare providers (Huh and Becker 2005; Harker and Harker 2007; Kim and Park 2010). Few advertising or marketing vehicles boast as controversial in history as direct-to-consumer advertising (also known as DTCA) of pharmaceutical drugs. Currently, the practice of marketing pharmaceutical drugs directly to the consumer through broadcast, print, Web and other media is currently legal in only two countries: the United States of America and New Zealand, though many European countries are closely studying DTCA policy and effects in these two countries as they consider possible future regulations allowing DTCA. In the United States, DTCA reached the forefront of pharmaceutical advertising following the 1962 acquisition of jurisdiction over DTCA by the Food & Drug Administration (FDA). Between 1962 and 1997, however, the vast majority of DTCA advertising took place in print; DTCA television advertising remained handcuffed by stringent FDA rules requiring all advertisements to present a brief summary of potential adverse reactions and contraindications the advertised drug. (Frosch, Grande, Tarn & Kravitz, 2010) That all changed in 1997, when the FDA relaxed its rules regarding television advertisements. The new requirements no longer called for prolonged important safety information to be displayed within the context of the actual television spot; instead, pharmaceutical companies were now allowed to disseminate information regarding drug risks and benefits by referring customers to either a toll-free phone number, concurrent print ad, related Web site, or to the customers choice of physician. (Frosch, Grande, Tarn & Kravitz, 2010) Direct-to-consumer advertising (DTCA) has been more recent in coming to New Zealand, the only other country where it is currently legal. DTCA is permitted in New Zealand under conditions dictated by the 1981 Medicines Act and the 1984 Medicines Regulations. (Coney, 2002, p. 213) Its brief time in the country as a legal Business and Health Administration Association Annual Conference 2012

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advertising medium has not been without controversy; in 1989, several unbranded advertisements ran by Smithkline and French and Wellcome raised concerns from the Department of Health that such unbranded ads might be interpreted as official Department of Health announcements. (Coney, 2002, p. 213) The first DTC television advertisement in New Zealand aired in 1994, the same year a Ministry of Health review of the Medicines Act recommended industry self-regulation, rather than an outright ban of DTC advertising. (Coney, 2002, p. 213) A further review of DTCA by the Ministry of Health in 2000 revealed that the country was evenly split on whether to ban or retain DTC advertising. (Coney, 2002, p. 214) However, lacking empirical evidence of the benefits and/or harms of DTCA, and in the interest of maintaining the economic strength and employment numbers of the countrys advertising industry, the New Zealand Ministry of Health decided pursue the retention of DTCA under stricter rules with a continued emphasis on industry self-regulation. (Coney, 2002) As a marketing vehicle for pharmaceutical companies, the power and reach of direct-to-consumer advertising (or DTCA) can hardly be disputed. A study published in 2003 on DTCA, initially slated to compare the health care experiences of DTCA-aware patients with DTCA-unaware patients, was redesigned after FDA research and pretesting uncovered a nearly universal exposure to DTCA in the United States. (Weissman, Blumenthal, Silk & Zapert, 2003) The same study found that approximately 86 percent of all consumers had heard or seen a DTC advertisement within the last year. (Weissman, Blumenthal, Silk & Zapert, 2003) Further confirming the powerful effect of DTCA advertising, 35 percent of respondents had been prompted by DTCA to engage in a conversation with their physician regarding the advertised drug or another health concern. (Weissman, Blumenthal, Silk & Zapert, 2003) This study aims to review empirical studies on direct-to-consumer advertising of prescription drugs with the aim of exploring the past and current trends in research in DTCA, identifying key themes on DTCA research, and providing potential agenda for future research. WHAT IS DIRECT-TO-CONSUMER ADVERTISING? Direct-to-consumer advertising is not a novel term among health communication and marketing researchers. Yet, there is a call for of an explicit definition of DTCA. Bradley and Zito (1997) coined the term direct-to-consumer advertising of prescription drugs and defined it as any promotional effort by a pharmaceutical company to present prescription drug information to the general public in the lay media. However, it is unclear whether lay media constitutes other emerging and sophisticated consumer-oriented media (e.g., website, social media). Other studies frequently employed the term direct -to-consumer advertising without specifying prescription drugs. Therefore, it is further ambiguous whether DTCA includes advertising of over-the-counter medications or only prescription medications. To further shed light on it, this study defines direct-to-consumer advertising as the different types of promotional efforts employed by pharmaceutical companies to provide prescription drug information to the general public through consumer-oriented media that includes the promotion of prescription drugs through not only lay media; but also via other emerging and sophisticated media such as, website, social media. METHODOLOGY To identify the key research streams in DTCA, we reviewed the content of empirical papers on DTCA published by executing an online search through multiple sources. A wide array of information including research title, year of publication, name of journal, key research theme(s), sample description, data collection and analysis method, sources of DTCA, drugs used in the study, study variable(s), and findings were recorded from each paper. As shown in Table 1, the initial sampling frame included twenty seven both scholarly and practitioner journals including Health Marketing Quarterly, Journal of Health Communication, Health Communication, Journal of Advertising Research, Journal of Medical Marketing, and Journal of Public Policy & Marketing. The journal articles using five key words -- Direct-to-consumer advertising, DTC Advertising, Direct -to-consumer advertising of prescription drugs, DTCA, and Prescription drug advertising -- were amassed from various sources such as university library electronic source, Google search, and journal websites. A random online search identified nine additional journals that published DTCA research, resulting in a total of 36 journals in the sample pool.

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Table 1 Leading journals publishing empirical research on DTCA (1997-2012) Journals Health Marketing Quarterly Journal of Health Communication Health Communication Journal of Advertising Research Journal of Medical Marketing Journal of Public Policy & Marketing International Journal of Advertising Journal of Advertising International Journal of Pharmaceutical and Healthcare Marketing Journal of Consumer Marketing The Journal of the American Medical Association Health Affairs British Medical Journal Annals of Family Medicine Journal of Business Ethics Journal of Current Issues and Research in Advertising Journal of Marketing Percent 9.2 7.1 6.1 6.1 6.1 6.1 5.1 4.5 4.1 4.1 2.0 2.0 2.0 2.0 2.0 2.0 2.0

Preliminary results indicate that in the sixteen year period from 1997 to 2012, at least one hundred and thirty empirical articles have been published in the domain of DTCA within our sampling frame. In this study, we opted to integrate the articles from the year 1997 as it was the year the Food and Drug Administration loosened restrictions on DTCA of prescription drugs in the United States. Majority of the studies were published between 2004 and 2009 (61.1%); the 2009 represents the highest number of publications (15.2%). The most frequently used data collection method was survey (49%); followed by experiment (14.3%), content analysis (8.2%), and interview (3.1%). Commonly employed sampling unit was consumer (53.1%); followed by DTC advertisement (9.2%), physician (7.1%), and student (5.1%). 64.3% of the studies utilized primary data while only 23.5% used secondary data. Interestingly, 36.7 % of the primary data included student sample. Most studies relied on descriptive statistics and simple statistical techniques such as simple regression analysis (15.3%), analysis of variance/multivariate analysis of variance (16.3%), and t-test/Z-test (11.2%). Only few studies utilized sophisticated analysis such as structural equation modeling, time series analysis.

RESULTS
Research themes on DTCA (1997 to 2012) Table 2 shows the frequently used research themes in direct-to-consumer advertising studies over the period from 1997 to 2012. A careful review of the content of research papers resulted in nine key themes: consumers attitudes toward DTCA; doctor-patient interaction; content of DTC advertisements; awareness, literacy, and memory; information source and search; DTCA expenditure and its impact on financial performance; physicians attitudes toward DTCA; demographics; and government regulations and ethical issues. We will discuss the first seven themes in detail below.

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Table 2 Summary of empirical studies on DTCA from 1997 to 2012 Key themes Consumers attitudes toward direct-to-consumer advertising Physician-patient interaction Contents of DTC advertisements Awareness, literacy, and memory Information source and search DTCA expenditure and financial performance Physicians attitudes toward DTCA Demographics Regulations and ethical issues Others % of Sample 21.3 16.5 15.2 11.1 9.3 7.5 6.0 5.6 2.3 7.2

Consumers attitudes toward direct-to-consumer advertising This study indicates that consumers attitude toward direct-to-consumer advertising (ADTCA) is the most commonly used research stream in DTCA. Majority of the studies concludes that consumers have favorable attitudes toward DTC advertising (e.g., Handlin, Mosca, and Forgione, 2003; Herzenstein, Misra, and Posavac, 2004). However, consumers still have less favorable attitudes towards prescription drug advertising than non-prescription medications (Diehl, Mueller, and Terlutter 2008). ADTCA has been found to be a key to their behavioral intentions such as likelihood of searching for additional information and interacting with their physicians about the advertised drug (e.g., Herzenstein and Colleagues 2005; Deshpande et al., 2004; Peyrot et al., 1998; Singh and Smith, 2005; Herzenstein, Misra, and Posavac, 2004). Studies also reported a number of determinants of A DTCA such as exposure to prescription drug advertising (Alperstein and Peyrot 1993), consumer involvement and ad type (Limbu and Torres, 2009), and information sources (Lee, Salmon, and Paek, 2007).
Figure 1 summarizes consumers attitudes toward direct -to-consumer advertising.

Exposure to Prescription Drug Advertising Consumer Involvement Ad Type Information Source

Consumer Attitudes towards DTCA

Likelihood of Searching for Additional Information Interaction with Physicians about the Advertised Drug

There are several areas of future research here. The consumer socialization approach supports only one mechanism; there might be other mechanisms across different demographics. For instance, research can test hypotheses about how different demographics may use information sources differently and how the information

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sources directly or indirectly effect different demographic groups responses to DTCA (Lee, Salmon, and Park, 2007). Physician-patient interaction One of the main purposes of DTCA is to encourage the consumers to visit and interact with their physicians that may result in a request of prescription about the advertised medications. Studies have investigated a number of antecedents to consumers interacting physicians for information about advertised drugs. The majority of the studies have shown that consumers are more likely to interact with physicians if they have positive ADTCA (An, 2007; Herzenstein, Mishra, and Posavac, 2004; Singh and Smith, 2005; Wilson and Till, 2007; Lee, Salmon, and Paek, 2007; Sumpradit, Fors, and McCormick, 2002). Another study suggests that consumers involvement in healthcare, motivation to seek out and cognitively process health-related information influence their intentions of conferring with physicians (Wilson and Till, 2007). Lee, Salmon, and Paek (2007) reveal that consumers reliance on interpersonal channels for health information leads to engage in more active discussions with their health professionals. Exposure to DTCA, perceived information value, quali ty of the DTC ad, and a consumers perceived competence are significant predictors of consumers willingness to consult physicians about an advertised prescription medication (Huh and Becker 2005; Singh and Smith 2005). Khanfar, Polen, and Clausons (2009) findings indicate that televised DTCA for prescription medication can have a significant impact on patient-initiated prescription requests.
Figure 2 summarizes physicians-patient interaction.

Television based DTCA

Positive Attitude towards DTCA

Consumers Reliance on Interpersonal Channels for Health Info Exposure to DTCA

Consumer Involvement in Healthcare Motivation to seek out

Physician-Patient Interaction

Perceived Information Value

Quality of DTCA

Cognitive Processing of Health-related Information

Consumers Perceived Competence

Contents of DTC advertisements Another key stream of DTCA research focuses on content of advertisements. Few studies examined the side effects or risks, benefits, and symptoms (Davis 2000; 2009; Mackert and Love 2011; Park and Grow 2010; Roth 2003). For example, consumers responded the safety and appeal of drugs described with an incomplete disclosure of side effects significantly more positively than comparable drugs described with more complete side effects disclosure (Davis 2000). Other studies center on types of advertisements (Limbu and Torres 2009; Khanfar, Loudon, and Sircar-Ramsewak 2006), message appeals (Limbu, Huhmann, and Peterson 2012; Frosch et al. 2007; Business and Health Administration Association Annual Conference 2012

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Main, Argo, and Huhmann, 2004; Macias, Pashupati, and Lewis 2007), message framing (Kim and Park 2010); brief summary (Menon et al. 2003), media credibility and informativeness (Huh, DeLorme, and Reid 2004).
Figure 3 summarizes content of DTC advertisements.

Content of DTC Advertisements

Side Effects Risks, Benefits, Symptoms Type of Ads Message Appeals Message Framing Brief Summary Media Credibility Informativeness

Consumer decision process making has five steps which are problem recognition, information search, evaluation of alternatives, purchase decision, and post-purchase behaviors. Will the effects of gain and loss DTC ads be equivalent across the five steps? There is a possibility that the effects could differ substantially. Therefore, the target consumers could differ across the steps. Future researchers may explore this possibility to further contribute to the practice of DTC advertising (Kim and Park 2010). Awareness, literacy, and memory The fourth largest stream of DTCA research focalized on awareness (Roth 2003), memory and recall (Limbu, Huhmann, and Peterson 2012), and health literacy (Mackert and Love 2011). Roth (2003) found that message strategies (e.g., use of transformational messages and non-comparative advertisements, exclusion of symptom information) can improve the DTC prescription drug advertising awareness. Contrary to the current trend of increasingly employing emotional appeals (e.g., humor, and endorsers) in DTCA, Limbu, Huhmann, and Peterson (2012) found that emotional appeals in DTCA does not improve memory of target audience who are suffering from a condition. In same line, Mackert and Love (2011) argue on the role of DTCA in educating consumers as it fails to offer useful information (e.g., other strategies for dealing with conditions). Overall, researchers are critical on the role of DTCA in improving consumers a wareness, literacy, and memory.
Figure 4 summarizes awareness, literacy, and memory

DTCA Message Strategies

DTCA Awareness

Memory/Recall

Health Literacy

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Future research should study separate effects of messages in different DTC media. Furthermore, the extension of specific media and message strategies should be applied for DTCA message effects on patientphysician interaction. Consumer information source and search Studies examined the effectiveness of information sources and consumer search behavior for direct-toconsumer drug advertising. Lee (2009) investigated the effects of four information sources -- small-print information, the Internet, a toll-free number, and health-care providers for direct-to-consumer drug advertising -- on patients requests for prescription drugs from physicians. Lee, Salmon, and Paek (2007) examined the efficacy of mass media and interpersonal channel; and they found that consumers reliance on interpersonal channels, rather mass media, for health information had a direct and significant impact on their interaction with physicians. Similarly, Lee (2010) found a stronger and superior influence of expert opinion leadership (e.g., physicians, pharmacist) on consumer information search behavior than mass media (e.g., DTCA). While print DTC advertisements use more rational appeals and tend to be more informative than televised DTC ads, televised DTC advertisements use more lifestyles claims and emotional appeals (Macias, Pashupati, and Lewis 2007). A study by Menon et al. (2002) found that consumers trust in online prescription drug information have an impact on information search behavior such a way that a greater trust in online prescription drug information stimulates utilization of the Internet for information search after exposure to prescription drug advertising.
Figure 5 summarizes consumer information source and search.

Information Sources Small-Print Information Internet Toll-Free Number Health-Care Providers

DTC Drug Advertising Awareness

Consumer Search Behaviour

Customer Trust Expert Opinion Leadership

Future researchers should focus on various levels and combinations of mass media and interpersonal communication to decide the best marketing mix for different consumers segments for DTC advertising (Lee, 2009). Effect of DTCA expenditures on financial performance Few studies confirmed a positive role of DTCA on drug sales (Narayanan, Desiraju, and Chintagunta 2004), market share (Kalyanaram 2009), and return on investment (Narayanan, Desiraju, and Chintagunta 2004). In line with these findings, Amaldoss and He (2009) found an inverted U-shaped relationship between the brand specificity of DTC advertising and firms profits suggesting a positive role of moderate levels of brand -specific DTC advertising on profits. Conversely, Kopp and Sheffet (1997) found that the retail gross margins for advertised brands decline with the initiation of DTC advertising. Sen (2011) investigated an impact of market share on DTCA spending and reported a negative influence of market share on the ratio of DTC advertising to sales. Contrary to the general contemplations on DTCAs role in rising drugs price, Capella et al. (2009) uncover a non-significant role of DTCA expenditure on price elasticity; and thus suggesting that DTCA does not increase in drug prices.

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Figure 6 summarizes effect of DTCA expenditures on financial performance.

Direct-ToConsumer Advertisement

Drug Sales Market Share ROI (Return on Investment) Retail Gross Margins

DTCA Brand Specify


DTCA Expenditure

Profit Retail Gross Margins


Price Elasticity

Future researchers should increase the number of product categories and brands, and use adequate timeseries data (24 month data). Additionally, other important covariates like patents and generics should be studied to improve the research (Kalyanaram, 2009). Physicians attitudes toward DTCA Little studies attempted to explore physicians attitudes toward DTCA. Lipsky and Taylor (1997) assert that in general physicians have negative feelings about DTCA in both print and electronic media. Conversely, Weissman et al. (2004) argue that physicians have overall positive views on direct-to-consumer advertising recognizing that it improves communication and education; however, they also believe that DTCA can lead patients to seek unnecessary treatments. According to Huh and Langteau (2007), physicians perceive that DTCA influence on patients inquiries with their doctors and requests for advertised drugs. Physicians believe DTCA is not only likely to increase the prescription request; it also increases the likelihood of the advertised drug to be prescribed by them (Parker and Pettijohn 2003). According to Gnl, Carter, and Wind (2000), physicians attitudes are influenced by various factors such as experience, exposure to DTCA, number of patients they examine, etc. For example, more experienced physicians, physicians who see more patients, or those who have more exposure to pharmaceutical advertisements are more likely to accept DTC advertising of prescription drugs.

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Figure 7 summarizes physicians attitudes toward DTCA.

Experience Exposure to DTCA Number of Patients

Physicians Attitudes towards DTCA

Communication Education Prescription Behavior Pharmaceutical Band Prescribed

This theme provides further insight into the health and health care effects of DTCA. Future researchers should focus on the financial impacts of prescribing decisions. A better understanding of drugs cost, their effect on health and physicians' behavior in response to requests for advertised treatments from their patients would help to develop future health policy (Weissman et al., 2004). AGENDAS FOR FUTURE RESEARCH Based on the review of empirical research on direct-to-consumer advertising of prescription drugs, the current offered a comprehensive agenda for future research. Past research primarily focused on consumers and physicians attitudes toward DTCA, physicia n-patient interactions, content of DTC advertisements, consumer awareness, literacy, and memory, information source and search, and role of DTCA expenditure on financial performance. Yet, future research should be directed towards focusing on empirical research; testing comprehensive models of consumer behavior; and representing understudied areas such as role of internet, efficacy of television DTCA, and development of measures. Lack of empirical studies: Research clearly reveals that much of the extant research on DTCA is exploratory in nature and used the content analysis technique (Harker and Harker 2007). For example, as shown in Table 3, a large number of seminal and well-cited studies on DTCA are conceptual and exploratory in nature (e.g., Calfee 2002; Donohue, Cevasco, and Rosenthal, 2007; Wilkes, Bell, and Kravitz 2000; Holmer 1999). Therefore, in line with Wilson and Till (2007), who argue that comprehensive and empirically validated models of consumer responses to DTCA are missing from the literature, we strongly call for additional empirical research on DTCA. Research on television DTCA: While the majority of the DTCA empirical research especially experiment-based has relied on print advertisements as stimulus materials, in practice most DTC advertisements that consumers encounter in daily basis are on televised. The figure below clearly demonstrates an increasing preference of DTC researcher to focus on print media. Therefore, there remains an ample room for future research about televised DTCA.

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Online DTCA in emerging media: Pharmaceutical companies are putting enormous resources on internet marketing. For example, DTC brand websites are used as a vehicle for communicating DTC advertisements. However, efficacy of such online DTC ads has yet to be assessed. Thus, we recommend future researchers to endeavor to fill this gap. Develop measures: Our review shows that DTCA researchers are relying on poor measures to assess the recurrently investigated constructs such as attitudes toward DTC advertising (A DTCA) and patient-physician interaction. Interestingly, 58% of our sample studies used self-generated scales devoid of any validation. Most of them were single-item measure. Thus, there is an enormous opportunity to develop DTCA-specific measures such as patientphysician interaction, Intention to search more information about advertised drug, and attitudes toward DTC advertising (ADTCA). Ethical issues and regulations: While ethical issues, government regulations, and pros and cons associated to prescription drug advertising have been well-studied, only 2.3% of empirical research on DTCA addressed these topics (see Table 1). DTCA is one of the most controversial and dubious promotional practices that often draws the attention of regulatory bodies as well as consumer protection agencies. Some critics are concerned on the value of it to consumers and society and are in favor of banning it. Therefore, more rigorous empirical research are sought to scrutinize whether DTC advertisers offer value to consumers and they abide by FDA guidelines and regulations. Country of Interest: The current research confirms that predominantly 93.1% of the studies on direct-to-consumer advertising focused on United States while only 3.2% centered on New Zealand, another country that allows DTCA. Therefore, researchers should pay a sincere attention to this untapped market. Nurses and Pharmacists Attitude toward DTCA: Past empirical studies mainly focused on consumers and physicians and little is known about the perceptions of nurses and pharmacists on DTCA. In todays healthcare system, these parties play a pivotal role in patient care. Hence, an investigation of their attitudes and behavior regarding DTCA should have enormous managerial and public policy implications. CONCLUSION If any clear takeaway can emerge from the DTCA debate, it is that more research is needed. Current and past findings lay a clear groundwork for where the logical next steps can be taken. Specifically, additional studies are needed in three key areas: consumers, content, and compliance. A key takeaway from DTCA studies is the massive paradigm shift towards a consumer-driven healthcare decision model. As DTCA ads bypass physicians and Business and Health Administration Association Annual Conference 2012

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pharmacists and reach the consumer directly, understanding the different reactions of consumers to these ads and identifying various triggers will allow pharmaceutical manufacturers to tailor ad content for optimal patient outcomes. Secondly, the current content of DTCA ads requires further critical scrutiny before the medium can be seriously considered as a vessel of positive health benefits, including compliance. As seen earlier, DTC ads have been found to lack educational value, which is perhaps why certain studies have shown that consumers do not find the ads informative, effective, or motivating. Nevertheless, these consumers remember the ads and retain the limited information presented, and this combination of lack of pertinent information and consumer retention often results in the formation of misconceptions about both the nature of DTCA and the advertised drugs. Such misconceptions can potentially lead to inappropriate healthcare or compliance behavior. In addition, though the elderly consume the most ethical drugs per capita, they are the least responsive to DTCA, indicating a potential content disconnect that can be likely be rectified through further research and refinement. Finally, more research is needed on all possible compliance-stimulating components of DTCA advertising. Many benefit theories have been proposed, but few have been studied. Does the positive imagery of DTC advertisements trigger a compliance-enhancing placebo effect? If so, where is the ethical balance between choosing imagery that will stem non-compliance but might mislead consumers? In fact, all three areas of recommended research are intertwined; further study in compliance will eventually lead to better content, which will in turn stimulate more positive consumer feedback. Most importantly, though, the medium must be allowed to mature. As long as content producers and regulators continue to feel each other out, new boundaries will be generated and DTCA will remain both dynamic and hard to examine with any congruity. Regulatory standardization is recommended as a way to lock in standard DTCA practices and content boundaries. Standardizing DTCA regulations will go a long way towards eliminating many of the variables that make it so difficult to study. It will also make DTCA more attractive to countries on the fence over adopting legal direct-to-consumer advertising. More countries with legal DTCA will mean larger populations available for research, which in turn mean s greater levels of clarity regarding DTCAs strengths, weaknesses, benefits and flaws.

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Mackert, M., & Love, B. (2011). Educational content and health literacy issues in direct-to-consumer advertising of pharmaceuticals. Health Marketing Quarterly, 28(3), 205-218 Main, K. J., Argo, J. J., & Huhmann, B.A. (2004). Pharmaceutical advertising in the USA: information or influence? International Journal of Advertising, 23, 119-142. Menon, A.M., Deshpande, A.D., Perri III, M., & Zinkhan , G. M. (2002). Trust in On-line Prescription Drug Information among Internet Users: The Impact on Information Search Behavior after Exposure to DTC Advertising. Health Marketing Quarterly, 20(1), 17-35. Menon, A. M., Deshpande, A.D., Matthew, P. III, & Zinkhan, G. M. (2003). Consumers' Attention to the Brief Summary in Print Direct-to-Consumer Advertisements: Perceived Usefulness in Patient--Physician Discussions. Journal of Public Policy & Marketing, 22 (2), 181-191. Narayanan, S., Desiraju, R., & Chintagunta, P. K. (2004). Return on Investment Implications for Pharmaceutical Promotional Expenditures: The Role of Marketing-Mix Interactions. Journal of Marketing, 68(4), 90-105. Park, J. S., & Grow, J. M. (2010). Symptom Information in Direct-to-Consumer Antidepressant Advertising and College Students' Perception of the Lifetime Risk of Depression. Journal of Medical Marketing, 10 (2), 1-16. Parker, R. S., & Pettijohn, C. E. (2003). Ethical Considerations in the Use of Direct-To-Consumer Advertising and Pharmaceutical Promotions: The Impact on Pharmaceutical Sales and Physicians. Journal of Business Ethics, 48 (3), 279-290. Roth, Martin S. (2003), Media and message effects on DTC prescription drug print advertising awareness. Journal of Advertising Research, 43, 180-193. Sen, Kabir C. (2011) "An empirical investigation of the variations in direct-to-consumer prescription drug advertising", International Journal of Pharmaceutical and Healthcare Marketing, Vol. 5 Iss: 4, pp.248 261 Weissman, J. S., Blumenthal, D., Silk, A. J., Newman, M., Zapert, K., Leitman, R., & Feibelmann, S. (2004). Physicians Report On Patient Encounters Involving Direct-To-Consumer Advertising. Health Affairs, 23, 219-233

Yam Limbu, Ph.D. Assistant Professor Montclair State University Department of Marketing 1 Normal Ave. Montclair, NJ 07043 USA Email: limbuy@mail.montclair.edu

Avinandan Mukherjee, Ph.D. Professor and Chair, Department of Marketing Editor International Journal of Pharmaceutical and Healthcare Marketing Montclair State University School of Business Montclair, NJ 07043, USA Phone: (973) 655-5126; Fax: (973) 655-7673 Email: mukherjeeav@mail.montclair.edu

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PRICE EFFECTS ON PRESCRIPTION BEHAVIOR OF PHYSICIANS


Gurumurthy Kalyanaram1, NMIMS University Demetrios Vakratsas2, McGill University Mala Srivastava, Narsee Monjee Institute of Management Studies

ABSTRACT In this paper, we address two research questions: Does physician prescribing behavior depend on drug prices? Are physicians who treat more managed care patients more price sensitive?

This is an exploratory study. Here, we examine the price sensitivity of physicians for drugs in two topselling drug classes for the period, 1997-2000. Our independent variables of study are price, HMO orientation, DTC, detailing, and interaction effects. We find that physicians are price sensitive with respect to frequency but not probability of prescription. Keywords: Pharmaceutical marketing; pricing; public policy; prescription behavior.

INTRODUCTION In this paper, we address the following two research questions in an exploratory manner. Does physician prescribing behavior depend on drug prices? Are physicians who treat more managed care patients more price sensitive?

Our review of the extant research suggests that little attention has been paid to these issues in the literature, which has mainly focused on the effects of communication-related efforts such as Direct-to-Physician (DTP) and Direct-to-Consumer (DTC) activities. Our study seeks to fill a void in the understanding of the effects of prices on physician-level prescription behavior. Specifically, the intended contributions of our study are a) to expand the rather limited empirical base of knowledge regarding the effects of price on physician prescription behavior and b) to examine the potential role of a physicians HMO patient composition, which we call HMO orientation, on prescribing behavior. Our independent variables of study are price, HMO orientation, DTC, detailing, and interaction effects. DATA The main sources of our data are the National Ambulatory Medical Care Survey (NAMCS) sponsored by Centers for Disease Control and Prevention for physician prescription data, SDI Health Reports for drug promotional data (detailing and DTC advertising) and Thomson Reuters for wholesale pricing data. The physician prescription data for this study comes from National Ambulatory Medical Care Survey (NAMCS). The annual NAMCS randomly selects 1,200-1,500 office-based physicians and requests them to record information on a sub-sample of their patient visits for a one week period. We focus on physician prescription behavior for drugs in two therapeutic classes: proton pump inhibitors (PPI) and SSRI anti-depressants. Our dataset contains information from four annual NAMCS surveys covering the period 1997-2000 for which information on the HMO patient composition of a physicians practice is provided. We include all complete observations for physicians that have prescribed at least one drug in one of the two drug classes. It should be noted that each

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physician in our data is sampled only once in the four-year period, thus there are no repeat observations for physicians. The two drug classes were chosen because they address broad patient needs for common chronic conditions, and represent a significant share of the pharmaceutical market (IMS, 2009). These drugs are fairly general in application: they treat a large variety of ailments, are indicated for different patient populations and are prescribed by a number of different clinical specialties. Degree of substitutability and lack of generic substitutes were also important considerations in the choice of drug classes for this study as our goal is to examine price sensitivity in the prescription of closely substitutable brand-name drugs. EMPIRICAL MODEL We model physician multi-drug prescription behavior using the Zero-Inflated Poisson (ZIP) model, which is an extension of the well-known Poisson model (Lambert, 1992). The extension essentially deals with the large, inflated, number of zeros which may derive from two different sources. In order to explore our research questions we relate physician-level and drug-level variables to the probability and frequency of prescription. Specifically we use the logistic function to model the probability of prescription3:

e 'x ij ij = 1 + e 'x ij
Where is a vector of parameters to be estimated, and xij is a vector of physician-level and marketing mix variables to be discussed in detail below. We model the frequency of prescription through the rate of the Poisson process ij:

ij = e ' x ij
Where is a vector of parameters to be estimated. Thus, we assume that the same set of explanatory variables, xij, influence both the probability and frequency of prescription. EMPIRICAL FINDINGS AND DISCUSSIONS The model is calibrated using ZIP estimation approach. Table 1 reports estimation results for the two drug classes. Interaction effects for the probability of prescriptions were not significant, thus were dropped from the final model. For ease of exposition we report the parameters common to all drugs in a class first and the brand-specific constants last. We begin our discussion with the pricing effects on physician prescription behavior since they are the focal point of our study. Price has a negative effect on prescription frequency for both the drug classes. Thus, it appears that with respect to prescription frequency physicians are highly sensitive to pricing. However, with respect to probability of prescription physicians are not price sensitive. In fact, the empirical results for probability of prescription are mixed. It is statistically insignificant for PPI, and significant for SSRI but it is positive in sign. Accordingly, the results suggest that while physicians would not exclude a drug from prescription due to its higher price, they would prescribe it at a lower frequency. Thus, physicians appear to be selectively price sensitive. It appears that prices do not impede prescription penetration but do have a negative effect on prescription frequency. Our findings on price sensitivity are further corroborated by the interaction effects for HMO-oriented physicians, which show that HMOoriented physicians are more price sensitive. In both the drug classes, the interaction effect of price and HMO orientation is statistically significant and negative.

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Table 1: ZIP estimation results (t-ratios) PPI Probability of Prescription 2.12 (0.31) 19.45 (0.47) 6.56 (1.95) -0.12 (-1.17) -0.87 (-1.71) 762 -1964.2 Frequency of Prescription -3.15 (-2.9) -0.39 (-2.92) -0.78 (-2.49) 0.03 (0.45) 1.03 (4.13) 0.12 (0.37) 0.16 (6.77) 0.57 (1.81) SSRI Probability of Prescription 4.32 (3.34) -0.29 (-0.52) 7.45 (5.12) -0.13 (-2.24) 0.14 (0.68) 1114 -4424.6 Frequency of Prescription -5.10 (-5.32) -1.24 (-2.12) 0.74 (4.92) 0.07 (0.29) -5.12 (-7.35) 2.23 (2.82) 0.14 (6.72) -0.29 (-1.82)

Price Price x HMO orientation DTC DTC x HMO orientation Detailing Detailing x HMO orientation Prescription Volume HMO orientation No of physicians Log-likelihood

We did not include formulary orientation in our current model. However, there is some empirical work to show that formulary-oriented physicians, similar to HMO patients, are more price sensitive with respect to frequency of prescription in some classes of drugs. This work also finds that HMO effect on price sensitivity is further to (and greater than) the formulary effect, suggesting a more active role of physicians in cost considerations which extends beyond the formulary. Turning our attention to the two communication-related variables, detailing and DTC advertising, we find that these have generally a positive effect on probability of adoption though statistical significance is not high for PPI drug class. This can be attributed to the informational value of these activities which results in increased physician awareness of a drug, eventually leading to a higher prescription probability. However, the effects of DTC and detailing on prescription frequency are mixed as in certain cases we find them to be negative. Specifically, DTC has a negative effect on prescription frequency for PPI drugs, but a positive one for SSRIs, whereas detailing has a negative effect on SSRI prescription frequency but a positive one for PPI. The negative effects of the communication-related activities could be attributed to supersaturation (see also Gonul et al, 2001). The positive effect of DTC on prescription frequency in the SSRI is consistent with previous research suggesting that physician prescription behavior is influenced by DTC advertising through patient requests for anti-depressant drugs (Kravitz et al, 2005). HMO orientation influence communication sensitivity with respect to prescription frequency only for the SSRI class with HMO-oriented physicians being more responsive to detailing. There are similar empirical results mixed, albeit with regard to formulary-orientation. Brand-specific effects are significant in both the classes for prescription frequency but only in the SSRI for probability of prescription. Thus, it seems that physicians tend to have strong inclusion (exclusion) preferences in the SSRI class. This could be due to the nature of the drug class which treats a variety of patients with different causes and at various severity degrees. Consequently, physicians may deem certain drugs to be more appropriate for their patients. Finally, the effects of prescription volume on prescription frequency are as expected strongly positive but generally not significant on probability of prescription, with the exception of an unexpected negative effect in the SSRI class. Similarly the main effects of HMO orientation on prescription probability are insignificant, suggesting that essentially there are no barriers to a physicians decision to prescribe a drug or not (probability of Business and Health Administration Association Annual Conference 2012

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prescription). The effects of HMO orientation are statistically reasonably significant on the frequency of prescription suggesting that there is considerable screening in terms of prescription frequency. This is an exploratory empirical study which provides interesting but somewhat inconclusive insights. While this study adds to the empirical knowledge-base, more work is necessary in this area to establish more definitive insights. Notes: 1. Dr. Gurumurthy Kalyanaram is currently the Inaugural University Dean for Research at NMIMS University, Mumbai, and he is also President of GK Associates. Dr. Demetrios Vakratsas was instrumental for the research presented in this paper. Dr. Vakratsas did the analysis and produced the research manuscript for the most part. For the sake of brevity, we have not provided all the technical details of this model.

2.

3.

REFERENCES Gonul, F., Carter, F., Petrova, E., & Srinivasan, K. (2001). Promotion of Prescription Drugs and its Impact on Physicians Choice Behavior. Journal of Marketing, 65 (July), 79-90. Kravitz, R. L., Epstein, R. M., Feldman, M. D., MPhil, Franz, C., Azari, R., Wilkes, M.S. , Hilton, L., Franks, P. (2005). Influence of Patients Requests for Direct-to-Consumer Advertised Antidepressants. American Medical Association, 293(16), 1995-2436. Lambert, D. (1992). Zero-inflated Poisson Regression, With an Application to Defects in Manufacturing. Technometrics, 34(1), 1-14. IMS Health Reports (2009). IMS Health. Retrieved from http://www.imshealth.com/portal/site/ims.

Dr. Gurumurthy Kalyanaram Inaugural University Dean for Research NMIMS University Mumbai, India and President, GK Associates kalyan@alum.mit.edu

Dr. Demetrios Vakratsas Associate Professor of Marketing Desautels Faculty of Management McGill University, CA

Dr. Mala Srivastava, Professor Narsee Monjee Institute of Management Studies Mumbai, India

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TRACK NATIONAL AND GLOBAL HEALTH POLICY

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INTERNATIONAL HEALTH MANAGEMENT EDUCATION: PHASE II FINDINGS, RESULTS AND IMPLICATIONS


Daniel J. West, Jr., University of Scranton Anthony C. Stanowski, ARAMARK Healthcare S. Robert Hernandez, University of Alabama-Birmingham Bernardo Ramirez, University of Central Florida

ABSTRACT The results and findings of a second international study conducted by The University of Scranton, the University of Central Florida and Atlas Health Foundation will be presented along with future implications for competency development and management training. The survey research was conducted for the Commission on Accreditation of Healthcare Management Education (CAHME) and supported by the Aramark Charitable Fund. The study was designed to: 1. Examine the supply and demand of trained healthcare administrators in six (6) additional countries (Germany, Ireland, Czech Republic, South Korea, Netherlands and Colombia); 2. Survey other accrediting programs in business, medicine and/or public health; 3. Secure expert opinions and advise; 4. Further assess the extent of international healthcare management education activities of CAHME accredited programs and their faculties; and 5. Develop a detailed strategy and plan of action to implement international demonstration site visits. Survey results will be shared and discussed along with global health management implications. Areas for future research are examined. Keywords: Accreditation, competencies, post graduate education, leadership

Daniel J. West, Jr., Ph.D., FACHE, FACMPE Professor & Chairman Department of Health Administration & Human Resources Panuska College of Professional Studies The University of Scranton Scranton, PA 18510 Tel: 570-941-4126 Fax: 570-941-5882 Email: westd1@scranton.edu Anthony C. Stanowski Vice President Industry Relations ARAMARK Healthcare 1101 Market Street, 19th Floor Philadelphia, PA 19107 Tel: 215-238-3550 Email: stanowski-Anthony@aramark.com

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S. Robert Hernandez, Dr. P.H. Professor and Program Director Administration- Health Services Doctoral Program Department of Health Services Administration University of Alabama at Birmingham 604 Webb Building 1530 3rd Avenue South Birmingham, AL 35294-3361 Tel: 209-934-1665 Email: hernande@uab.edu

Bernardo Ramirez, MD, MBA Assistant Professor & Director of Global Health Initiatives Department of Health Management & Informatics College of Health and Public Affairs University of Central Florida 1200 W. Intl Speedway Blvd. Building 140/202e Daytona Beach, FL 32114 Tel: 386-506-4077 Email: bramirez@mail.ucf.edu

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THE IMPACT OF THE MILLENIUM DEVELOPMENT GOALS IN ARGENTINA, BRAZIL AND CHILE
Jose D. Alicea-Rivera, University of Scranton Daniel J. West, Jr., University of Scranton

ABSTRACT The Millennium Development Goals have been a great initiative throughout many countries around the World since its creation in 2000. Among the countries of Argentina, Brazil and Chile, this initiative has been one of the major factors that have contributed to their economic growth, social improvement, and health services and quality development. Regardless, there are other major factors that may be of either positive or negative influence to the development of the Millennium Development Goals in each country.

INTRODUCTION During the month of September 2000 members from the United Nations were gathered together in order to create an initiative with the purpose of promoting health and eradicating of poverty throughout the World by 2015. This initiative was strategically planned and divided into goals, also known as The Millennium Development Goals (MDGs). The MDGs are composed of a total of eight goals that target the development and promotion of human rights and social determinants of health with the focus on coordinated efforts raging from poverty, hunger, gender inequality and diseases reduction, along with the advancement in education, sustainable use of natural resources and the regulation of the cooperation between developed countries by 2015 (World Health Organization, 2011). This initiative has obliged governments to elaborate strategic alliances between international health institutions and Non-Governmental Organizations (NGOs) in order to create the opportunity to fight poverty, hunger and diseases, stop environmental degradation, promote primary education and gender equality worldwide. Each developmental goal is designed differently by each UN country to meet its individual needs. Nevertheless, the main objective of the MDGs is providing growth and improvement throughout the world as a common initiative between all countries. Millennium Development Goals Millennium Goal I seeks the eradication of extreme poverty and hunger. This goal has three aims or targets in order to end/lower poverty and hunger. The first target is to reduce the number of people who are living on less than a dollar a day by 50%. The second target is to achieve full and productive employment and decent work for all, including women and young people. This target is measured by growth rate of the Gross Domestic Profit (GDP) per person employed, employment-to-population ratio, and the percentage of employed people living below $1 (PPP) per day. Finally, the third target is to reduce the number of people who are suffering from hunger by 50%. This target is measured by the prevalence of underweight children under-five years of age, and the percentage of population below minimum level of dietary energy consumption. Millennium Goal II seeks the achievement of universal primary education by focusing on the insurance that all boys and girls complete a full course of primary schooling. It is measured by net enrollment ratio in primary education, total percentage of pupils starting grade 1 who reach last grade of primary, and literacy rate of 15-24 year-olds, woman and men. Millennium Goal III promotes gender equality and women empowerment. This goal is designed to eliminate gender disparity in primary and secondary education preferably by 2005, and at all levels by 2015. This target is measured by ratios of girls to boys in primary, secondary and tertiary education. It is also measured by the share of women in wage employment in the non-agricultural sector and the proportion of seats held by woman in national parliament. Business and Health Administration Association Annual Conference 2012

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Millennium Goal IV seeks the decrease of child mortality. This goal targets the reduction of the mortality rate among children under five by two-thirds. The goal is measured by both the under-five mortality and infant mortality rates along with the proportion of 1 year-old children immunized against measles. Millennium Goal V seeks the improvement of maternal health. This goal has two primary targets. The first target is to reduce the maternal mortality ratio by 75 percent. This target is measured by maternal mortality ratio and the proportion of births attended by skilled health personnel. The second part of this MDG is to achieve universal access to reproductive healthcare by 2015. This second target is measured by contraceptive prevalence rates, adolescent birth rates, antenatal care coverage, and unmet need for family planning. Millennium Goal VI seeks to combat HIV/AIDS, malaria and other diseases. In order to achieve this, this goal was divided into three targets. The first target is to halt and begin to reverse the spread of HIV/AIDS. This target will be measured by the HIV prevalence among population aged 15-24 years, condom use for high-risk sex, proportion of population aged 15-24 years with comprehensive correct knowledge of HIV/AIDS, and the ratio of school attendance of orphans to school attendance of non-orphans aged 10-14 years. The second target is to achieve universal access to treat HIV/AIDS for all those who need it by 2010. This target is measured by the proportion of population with advanced HIV infection with access to antiretroviral drugs. The third target concentrates on halting and beginning to reverse the incidence of malaria and other major diseases. This target is measured by the incidence and death rates associated with malaria, the proportion of children fewer than 5 sleeping under insecticide-treated bed-nets, the proportion of children fewer than 5 with fever who are treated with appropriate anti-malarial drugs. As for tuberculosis; it is also measured by the incidence, prevalence and death rates associated with tuberculosis along with the proportion of tuberculosis cases detected and cured under directly observed treatment short course. Millennium Goal VII seeks to ensure environmental sustainability. This goal is of severe complexity due to the fact that it has been divided into four targets. The first target aims at integrating the principles of sustainable development into country policies and programs; reversal of the loss of environmental resources, and the second target aims at reducing biodiversity loss by 2010. These first two targets are measured by the proportion of land area covered by forest, CO2 emissions per capita and per $1 GDP (PPP), consumption of ozone-depleting substances, and proportion of fish stocks within safe biological limits. These two targets are also measured on the proportion of total water resources used, proportion of terrestrial and marine areas protected, and the proportion of species threatened with extinction. The third target addresses the number of people who are living without sustainable access to safe drinking water and basic sanitation with the objective of reducing the actual percentage of people without safe drinking water by half. This third target is measured by both the amount of population using an improved drinking water source and the amount of population using an improved sanitation facility. The last target of the seventh MDG is to achieve significant improvement in lives of at least 100 million slum dwellers by 2010. This last target is measured by the proportion of urban population living in slums. Millennium Goal VIII promotes global partnerships for development. This last goal is divided into four targets. The first target aims to develop further an open, rule-based, predictable, non-discriminatory trading and financial system. This target also promotes the commitment to good governance, growth and poverty decrease; both nationally and internationally (World Health Organization, 2011). The second target addresses the special needs of the least developed countries. This target encourages the least developed countries exports to be tax free along with an improved program of debt relief and cancellation of official bilateral debt (World Health Organization, 2011). The third target promotes the special needs of landlocked developing countries and small islands developing States through the Program of Action for the Sustainable Development of Small Island Developing States. Finally, the last target within the eighth goal aims at dealing extensively with the debt problems of emergent countries throughout national and international initiatives with the purpose of making debt sustainable from a long-term perspective. MILLENNIUM DEVELOPMENT GOALS ACTUAL STATUS The Continent of South America has three interesting sub-developed economies that are on their way of economic expansion and country growth as shown in Table 1. The Millennium Development Goals have played a major role in the development of Argentina, Brazil and Chiles health profiles development, as well as general economic progress since the planning and implementation of the MDGs within these countries in 2000.

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Table 1: Country Indicators Total Population % Living Urban Area in 2010 GDP Per Capita 2009/2010 GDP Real Growth Rate 2009/2010 -3.0%-0.6%-1.7%GDP % Expended in Healthcare 2009/2010 10.1%-9.5% 7.5% -9.0% 8.2% -5.3% Unemployment Rate 2009/2010 8.7%-7.9% 8.1%-6.7% 9.6%-7.1% Population Below Poverty Line in 2009

Argentina Brazil Chile Source: Central Intelligence Agency, 2011 Argentina

$13,700$14,700 $10,200$10,800 $14,800$15,400

In the early 21st Century, Argentina, a vast country of natural resources, began the new millennium with a devastating economic and political crisis which led to a series of unfortunate events, including the rise of the poverty level within the Argentinean population. Argentinas poverty level has been unstable throughout the last ten years. Due to the financial crisis in 2002, the poverty level increased from 6.1% in 1990 to 21.5% in 2002. Furthermore, from June 2007 to June 2009, the poverty level decreased 40.6% from 23.4% to 13.8% respectively, but not until 2010 in which it increased again to 30% (Central Intelligence Agency, 2011). In addition, the goal to reduce maternal mortality by 50% in Argentina has not yet been reached as of yet. Regardless, during 2010, the maternal mortality rate was 4.6% (per 10,000 populations), representing a decrease of 30% (World Health Organization, 2011). Since primary and secondary education is obligatory since 1994, Argentinas universal education goal of obtaining 100% of literacy level among citizens is about to achieved. This percentage has increased from 91% in 2001 to 95% 2007. However, according to the Program for Development of the United Nations the lack of Argentinas ability to achieve their education goal is due to people living in rural areas (Programa de Naciones Unidas para el Desarrollo, 2009). The unemployment rate has also dropped over the years from 17.3 in 2003 to 7.9 in 2008. It is believed that the recent governments interest and improvement of Argentinas social infrastructure after the 2002 -2003 crisis was cause of this positive outcome. Primary level literacy is one of the goals that Argentina has completely achieved since 100% of the population was already alphabetized by 2008. This initiative promoted gender equality greatly since this achievement includes both sexes (Programa de Naciones Unidas para el Desarrollo, 2009). Argentina also aims at decreasing their mortality rate by 2/3 by 2015. Although this goal still awaits its achievement, the mortality rate has been decreased by 48% from 25.6% in 1990 to 13.3% in 2007. On the contrary, there has been little or no change with Argentinas maternity rate. This rate has been a relatively stable tendency since the period of 1990-2007 from 5.2% to 4.4% (Programa de Naciones Unidas para el Desarrollo, 2009). Furthermore, some of the primary causes are Coronary Heart and Cerebrovascular Diseases, Influenza/Pneumonia and Lung Cancer as shown in Table 2.1. These diseases are also the primary causes of death in Brazil and Chile with the exception of Lung, Colon-Rectum and Breast Cancers which each of the rates are relatively high, 2.2, 1.7 and 2.5 (respectively) per 10,000 population. Both Colon-Rectum Cancers and Breast Cancers rates are worrisome since their world comparison is ranked 22 nd and 15th respectively by the WHO. Appropriately it is noted that although Argentinas Coronary Heart Diseases has the highest percentage (16.8%) of total causes of deaths between three countries, it is Brazil who has a higher rate with 8.1 vis a vis Argentinas 7.1 per Business and Health Administration Association Annual Conference 2012

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10,000 population. Also, despite Diabetes Mellitus and Hypertension are two of the primary causes of death in Argentina, their rates, 1.8 and 1.2 respectively, are lowest between the three compared countries. Table 2.1: Primary Causes of Death in Argentina Causes of Death 1. 2. 3. 4. 5. 6. 7. 8. 9. Coronary Heart Disease Cerebrovascular Disease Influenza & Pneumonia Lung Cancer Diabetes Mellitus Colon-Rectum Cancers Kidney Disease Breast Cancer Hypertension Other (Rest) Deaths in 2010 36,415 22,859 20,366 10,033 8,911 8,575 7,807 6,702 6,487 4,880 Rate Per 10,000 population 7.1 4.4 3.6 2.2 1.8 1.7 1.2 2.5 1.2 1.2 Total Distribution (100%) 16.8% 10.5% 9.4% 4.6% 4.1% 4.0% 3.6% 3.1% 3.0% 2.3% 38.6% World Rank 154 151 90 51 133 22 102 15 151 116

10. Road Traffic Accidents

Source: World Health Organization, 2011. Note: This table includes both sexes. The actual HIV prevalence rate, 0.5%, has been constant and barely decreased since 2000.The goal, to decrease HIV prevalence rate by (0.37 per 10,000), is the second goal that Argentina has already achieved since the rate reached 0.37 (per 10,000 population) in 2007 (Programa de Naciones Unidas para el Desarrollo, 2009). Although there are 110,000 Argentinians living with HIV/AIDS, this disease is not one of the primary causes of death. Brazil Brazil, the new emerging economy in South America, is one of the few countries that might achieve all of their goals in time by the year 2015. Even with their decrease of their Gross Domestic product over these past three years (2008 - $10,900, 2009 - $10,300, and 2010 - $10,400), Brazil has the financial capability to invest and improved their actual status since is still has an industrial production growth rate of 11.5%. The percentage of the population living on less than a US $1 per day has decreased from 9.9% to 5.7% over a period of 13 years (1990-2003). According to the Pan American Health Organization (PAHO), if this percentage of living on less than a $1 was considered, Brazil would be already close to accomplishing the first MDG (Pan American Health Organization, 2008). Most importantly, the percentage of malnourish children has also decreased from 19.8% to 7.7% in a period of 5 years (1999-2004). Regardless, there are still millions of poor people, surpassing other countries total population, and it is estimated that 1 million children are under weight. Access to education and gender equality has also been increasing within the population of Brazil. From 1992-2003, the rate of primary school attendance increased from 81.4% to 93% respectively and gender equality within mid-schools also increased from 15.1 Males & 21.3 Females to 38.1 Males & 48.2 Females. Also, child mortality decreased from 1996 to 2004 with rates of 332 to 226 respectively (per 10,000 live births). Brazil may look like the most ideal country to follow but they are lacking implementation of some major MDGs objectives. One of these objectives is through the maternal mortality rate which increased from 5.16 to 7.61 (1996-2004 respectively) (per 10,000 live births). Another ongoing issue in Brazil that distinguishes Brazil from Argentina and Chile is the Violence Rate as one of the Primary Causes of Death as shown in Table 2.2. The violence rate in Brazil has being a continuous issue in Brazil that represents almost 6% of the total deaths in the country, making it the 5th Primary Cause of Death in the Country. This percentage ranks number 19th worldwide and since the targets and objectives from Brazils Business and Health Administration Association Annual Conference 2012

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Millennium Development Goals do not address this issue, there is little or no information/data to report. Sadly, Brazil also has the highest death rate of Coronary Heart Diseases (8.1), Cerebrovascular Diseases (7.4), Diabetes Mellitus (3.8), and Hypertension (3.2) per 10,000 population, among others, between these three countries. Table 2.2: Primary Causes of Death in Brazil Causes of Death Deaths in 2010 133,992 123,034 61,987 60,951 56,841 53,466 43,373 42,071 22,747 12,573 Rate Per 10,000 population 8.1 7.4 3.8 3.6 2.8 3.2 2.7 2.2 1.4 1.4 Total Distribution (100%) 13.8% 12.6% 6.4% 6.3% 5.8% 5.5% 4.5% 4.3% 2.3% 1.3% 37.2% World Rank 134 117 84 91 19 68 83 57 104 102

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Coronary Heart Disease Cerebrovascular Disease Diabetes Mellitus Influenza & Pneumonia Violence Hypertension Lung Disease Road Traffic Accidents Lung Cancer Breast Cancer Other (Rest)

Source: World Health Organization, 2011. Note: This table includes both sexes. The number of people living with HIV/AIDS in Brazil has increased from 600,000 (1998) to 730,000 (2007), the HIV/AIDS adult prevalence rate has been constant since 1996-2007 in 0.6%. This percentage of HIV/AIDS occurrence within Brazilian has been the result of a synergetic work effort between international organizations and both the private and public industry in Brazil. Regardless of Br azils prevalence, HIV/AIDS is not one of the primary causes of death. Chile In the last decade, Chile has served the world as an economic role model (Central Intelligence Agency, 2011). Inspired by change and political crisis, Chiles economy has been aimed at a superior level for foreign trade throughout the last twenty years. By 2010, exports are responsible for at least 25% of their total GDP. Moreover, Chile has a total of 57 joint regional trade agreements throughout the world (including US, China, India, Mexico, among others), making them one of the countries with the highest level of regional trade agreements. Within a period of 10 years, Chile has greatly decreased poverty from 12.9% (1990) to 4.7% (2003). By 2005 it was the only country in America that had already cut the poverty level in half. In addition, their goal of having a 1.7% proportion of the population with an income of less than one dollar a day has been already achieved by 2006 when they reached 1.1% (MIDEPLAN, 2008). Unlike other countries, Chile has a very small proportion in terms of malnourish children less than 6 years old. They have also achieved their 0.5% goal of decreasing malnourish children when the rate decreased from 0.7% in 1994 to 0.5% in 2000. By 2006, this rate was already 0.3%. Obesity within the same age category, on the contrary, is vaguely an issue in Chile. During 1996, 6.2% of children younger than 6 suffered from obesity and by 2000 this percentage increased to 7.2%. Their actual goal is to reach 6% obesity percentage by 2015 (MIDEPLAN, 2008). During a period of ten years (1990-2000), Chile was able to slowly increase access to primary school for children from 88% to 91% (respectively) until 2006 when the rate decreased to 88%. Primary level literacy rate has also increased slowly within the same period of time from 98.4% to 98.7% and, although it has not been enough to achieve their goal of 99.8% by 2015, it has promoted gender equality within Chile since same genders have the same Business and Health Administration Association Annual Conference 2012

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percentage of alphabetization. The countrys literacy rate by 2002 was 95.7% and it is estimated that this number will increase to 99.1% by 2015 (MIDEPLAN, 2008). Child mortality has decreased by more than half. During 2005 the rate was 79 (per 10,000 population) live births compared to the year 1990 in which the rate was 160 (per 10,000 population). The goal to reduce it to 53 by 2015 and it still has not been achieved. Also, the maternal rate goal of 100 (per 10,000 populations) has not been achieved. Regardless, it has decreased drastically since its peak of 400 (per 10,000 populations) in 1990 to 198 in 2005 (MIDEPLAN, 2008). Additionally, Road Traffic Accidents is not a Primary Cause of death in Chile compared to Argentina and Brazil. Chile also has the lowest rates of Coronary Heart Disease (5.1) and Influenza/Pneumonia (2.1) as a cause of death per10,000 population, but what truly distinguish Chile is Dementia being one of their primary cause of death as shown in table 3.3. By 2010, there were 4,059 deaths related to dementia (including the Alzheimers disease) which represented a rate of 2.0 per 10,000 population, ranking number 8 th in the World. Stomach Cancer also distinguishes Chile from Brazil and Argentina since 4.3% of the total deaths in 2010 were cause by it, ranking 17 th worldwide. Table 2.3: Primary Causes of Death in Chile Causes of Death Deaths in 2010 9,799 8,757 4,364 4,059 3,784 3,681 3,378 3,351 3,058 2,587 Rate Per 10,000 population 5.1 4.5 2.1 2.0 2.0 1.8 1.7 1.8 1.7 1.4 Total Distribution (100%) 12.6% 11.3% 5.6% 5.2% 4.9% 4.8% 4.4% 4.3% 3.9% 3.3% 39.7% World Rank 177 149 132 8 123 131 116 17 44 87

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Coronary Heart Disease Cerebrovascular Disease Influenza & Pneumonia Dementia Diabetes Mellitus Hypertension Lung Disease Stomach Cancer Liver Disease Lung Cancers Other (Rest)

Source: World Health Organization, 2011. Note: This table includes both sexes. Chiles estimated HIV prevalence cannot be compared to Argentina or Brazil because their rates have been constant. Chiles rate has slightly increased over the past years from 0.25% in 2000 to 0.4% in 2009. In addition, the number of people living with HIV has also increased from 20,000 in 1998 to 40,000 in 2009 (CIA,2011). Surprisingly, in order to calculate this HIV/AIDS increase, Chile utilizes other measures, HIV prevalence not being one of them. According to the Central Intelligence Agency, Chile had an HIV prevalence rate of 0.4 and 40,000 people were living with HIV/AIDS by 2010 as shown in Table 3. Regardless of Chiles prevalence, HIV/AIDS is not one of the primary causes of death. Table 3: Health Indicators by Country Life Expectancy by male and female 72/79 69/76 74/81 Infant Mortality (per 10,000 live births) 111.1 211.7 73.4 Maternal Mortality (per 10,000 live births) 4.6 11 1.6 Total Fertility Rate 2.33 2.18 1.88 HIV/AIDS Adult Prevalence Rate 0.5 0.6 0.4 People living with HIV/AIDS

Argentina Brazil Chile

120,000 730,000 40,000

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Table 4: Health Profile Contraceptive Prevalence Births attended by skilled health personnel Measles Immunization in 1-year-olds Number of Physicians (per 10,000 population) Number of Nurses & Midwives (per 10,000) Obesity by Male & Female (2008)

Argentina Brazil Chile Source: World Health Organization, 2011 MITIGATING FACTORS Political Factor The political factor has been the major contributor to most of the Millennium Development Goals success within the countries of Argentina, Brazil and Chile. These three governments strategically prioritized social development as a primary target since the MDGs implementation planning. Within these countries, Argentina may be seen as the greatest example since they had to overcome a politic and economic crisis during 2002-2003 while other countries already started their MDGs implementation. This achievement was caused by the adoption of aggressive policies that obliged both private and public entities neither to perform vast layoffs to decrease salaries in order to keep Argentinas workforce employed and with full compensation. This political initiative stopped the development of the economic crisis in Argentina. Increasing access to health was also another aggressive initiative from the Argentinean government. This supplementary policy favored the access of both health and essential medicines to the population, consequently reducing the infant mortality rate (Programa de Naciones Unidas para el Desarrollo, 2009). Similarly, Chile aimed at social policies as part of their political planning. By 2002, their government created a new Health Reform in order to promote access to health and raise health quality within the country. By 2008, Chiles government created a Provisional Reform with the purpose of providing pensions to previous citizens that did not have the right to own personal pensions. Moreover, their new social priority from a political perspective is to promote equality within citizens, regardless of their social or economic class, and, most importantly, to cease risk opportunities that might threat low income families (MIDEPLAN, 2008). Economic Factor The economic factor has also played a major role in the development of the Millennium Development Goals of these three countries. Evidently, as shown in Table 1, these countries have an actual positive Gross Domestic Product (GDP) and Growth Per Capita Rate. These indicators clearly represent the capability of investing in both social and health development. Regardless of the fact, these countries have their own political priorities. The political priority in Argentina was social development and by 2003 the Argentinean government invested 20% of their GDP in order to put a stop to the economic and political crisis of 2002-2003. This political initiative succeeded due to the economic planning and investment within the year 2003. By 2008, social development represented 23.7% of their GDP expenditure (Programa de Naciones Unidas para el Desarrollo, 2009). This percentage assisted the country of Argentina in regaining stability. Geographic Factor The geographic factor also plays a major role in the development of the Millennium Development Goals. Although most of the population of these three countries lives within urban areas, access to health in rural areas is a major issue since there is little or no health workforce or facilities. Areas such as el Chaco Sur Americano (SouthAmerican Chaco) which includes Argentina, Bolivia, Paraguay and Southwestern Brazil, and some other regions in Western Brazil, lack health professionals and schools since most of health professionals, shown in Table 4, work Business and Health Administration Association Annual Conference 2012

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within urban areas. The majority of the population living in these areas is indigenous and during the years these people have been marginalized by governments. Since there is little or no government involvement within these places, there is a lack of quantitative data in order to properly analyze these regions. In order to address this issue, in 2006 the Pan American Health Organization lunched an initiative called Faces, Voices and Places with the purpose of accelerating progress toward the achievement of the Millennium Development Goals. The initiative focuses its efforts on the most vulnerable communities in different regions in the Americas and the Caribbean including Argentina, Brazil and Chile, from a perspective of health and development (Pan American Health Organization, 2011). Education Factor Argentinas geographical factor has also affected the education in the country since it has not been able to obtain 100% level of literacy within the population. This is a result of having 5% of children or people fewer than 17 years of age living in unfavorable rural sectors (Programa de Naciones Unidas para el Desarrollo, 2009). Their actual national literacy rate, people of age 15 and over who can read and write, is 97.2% and they are expected to reach their goal regardless of the effect of the geographical factor on their education system. Still, 97.2% is a decent number for an emerging economy and, actually, Argentina has the highest literacy rate between the three compared countries and their government expends 4.9% of their Gross Domestic Product (GDP) on Education (CIA, 2011). Chile, on the contrary, has a lower Literacy rate of 95.7%, compared to Argentina. There is little or no information regarding the reason of why Chile does not have 100% national literacy rate. It could be assumed that the main reason of this issue due to the geographical factors and regions of indigenous population, same as Argentina and Brazil. Furthermore, by 2010 the Chiles government expends only 4.0% of their GDP on Education, making it the country with the lowest contribution on education between the compared countries (CIA, 2011). Unfortunately, Brazil has an even a lower literacy rate than Argentina and Chile. By 2010 their literacy rate was only 88.6%, which makes it the lowest literacy rate between the three compared emerging economies and as same as Chile and Argentina, the reason may be due to the vast rural area that Brazil has to the West which makes it impossible for children to travel to schools, or even to build schools. Although it has the lowest literacy rate between the three, Brazil has the highest government expenditure on education with 5.08% of their GDP, raking number 55 th worldwide (CIA, 2011). Wealth Inequity Factor According to the World Factbook from the Central Intelligence Agency, Brazil and Chile are within the top 20 wealth inequity countries. Calculated with the Gini Index, a tool that measures the degree of inequality in the distribution of family income in a country, Brazil has the highest rate of wealth inequity between the three compared countries with 53.9 (CIA, 2011). This coefficient has increased from 49.6 (2004) to their actual 53.9 (2009) and ranks number 13th worldwide. This creates a worrying issue in Brazil since 26% of their citizens are already below the poverty line and may increase the percentage of the population living on less than a US $1 in the years to come if this coefficient does not stop increasing. One of the major reasons within this inequity in Brazil is the different salaries between professionals from urban and rural areas. These salaries create a direct threat to Brazils Health System since most health professionals are willing to work in urban areas because of them, leaving the rural areas without competent staff or adequate health professionals, and making it impossible to compete with other private health institutions located in urban areas (Pan American Health Organization, 2008). By 2009 Chile also had a high Gini Index Coefficient with 52.1, making it the 16 th highest wealth inequity region of the World (CIA, 2011). Unlike Brazil, this coefficient, who was 52.0 in 2003, has barely increased but it may still affect the total population who are below the poverty line (11.5%) and increase the population living on less than a US $1. Argentina has the lowest Gini Index Coefficient in the whole South-American Region with 45.8. Compered to Brazil and Chile, Argentina is the only country whose coefficient decreased from 48.8 in 2007 to their actual 45.8 in 2009, making it the 36th country with the highest wealth inequity and it is also estimated that by 2010 their Gini Coefficient decreased to 41.1 according to the World Factbook (CIA, 2011). Although there is not a concrete report explaining these events in Argentina, it is speculated that the previous political corruptions, the last economic crisis, Business and Health Administration Association Annual Conference 2012

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and their actual 30% of population living below the poverty line are some of main factors that are decreasing this coefficient. CONSLUSION It is evident that the Millennium Development Goals have been a fundamental factor for the development of the countries of Argentina, Brazil and Chile from a macro perspective. Most of the goals set up by the governments are on their way to be achieved by 2015 while some others have been already achieved. Regardless, it is because of these goals that these three countries are emerging as potential power economies. Although, the recent economic and political crisis in Argentina proves that these are vulnerable countries, the MDGs indicators have been of great assistance and guidance by creating awareness and promoting social and health development within the countries governments. Nevertheless, some factors such as the geographical factor are impeding the development and the successful achievement of some of these goals. It will be interesting enough to see if these three countries do reach and achieve all of their eight goals by 2015 and contemplate the reasons that really allowed these achievements.

REFERENCES

Central Intelligence Agency (2011, March 10). Publications. Retrieved April 2011 from https://www.cia.gov/library/publications/the-world-factbook/fields/2046.html. Central Intelligence Agency (2011). World Factbook. Retrieved September 2011 from https://www.cia.gov/library/publications/the-world factbook/rankorder/2172rank.html?countryName=Argentina&countryCode=ar&regionCode=soa&rank=34#ar. INDEC (2008). Mortalidad. Retrieved August 2011 from http://www.indec.gov.ar/principal.asp?id_tema=66. MIDEPLAN (2008). Millennium Development Goals Executive Summary. Chile Ministry of Planning. Pan American Health Organization (2008). Health Systems And Services Profiles: Brazil. Pan American Health Organization. Pan American Health Organization (2011). Millennium Development Goals. Retrieved April 2011 from Pan American Health Organization: http://www.paho.org/english/mdg/cpo_bienvenida.asp. Pan American Health Organization. (2011). Faces, Voices and Places. Retrieved August 2011 from http://www.paho.org/english/mdg/MDGs32p2.pdf. Programa de Naciones Unidas para el Desarrollo. (2009). Objetivos de Desarrollo del Milenio. Consejo Nacional de Coordinacin de Polticas Sociales. UNAID: WHO (2008). Epidemiological Fact Sheet on HIV and AIDS. Geneva: UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance. World Health Organization (2011). Countries. Retrieved April 2011 from http://www.who.int/countries/en/. World Health Organization (2011). Health Topics. Retrieved April 2011from http://www.who.int/topics/millennium_development_goals/en/. World Health Organization (2006). Mortality Country Fact Sheet 2006. Retrieved August 2011 from http://www.who.int/whosis/mort/profiles/mort_amro_bra_brazil.pdf Business and Health Administration Association Annual Conference 2012

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Jose D. Alicea-Rivera, MHA Candidate Graduate Student Department of Health Administration & Human Resources The University of Scranton Email: alicearivej2@scranton.edu

Daniel J. West, Jr., Ph.D., FACHE, FACMPE Professor & Chairman Department of Health Administration & Human Resources Panuska College of Professional Studies The University of Scranton Scranton, PA 18510 Tel: 570-941-4126 Fax: 570-941-5882 Email: westd1@scranton.edu

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THE POLICIES AND CHOICES OF ABORTION


Robert D. Fenstermacher, University of Scranton Daniel J. West, Jr., University of Scranton _____________________________________________________________________________________________ ABSTRACT Current Policies regarding abortion. The history of abortion will also be examined along with how policy in this country and others have changed. Current problems with policy will be talked about along with possible solutions.

Current policy in abortion has a couple problems. First there is the sensitive issue of Pro life versus Pro choice. Second there is the problem with who pays for these procedures and whether insurance companies should and will cover it. There are also issues regarding that every State has different laws dealing with it and with encouraging less mothers to go through with it. Laws and attitudes regarding abortion have been always influenced by religious beliefs and official churches. The Roman Catholic Church tolerated abortion for hundreds of years. The church changed its teaching on abortion around the early 19th century, and now is pretty restrictive. Currently the protestant churches are more tolerant than the catholic churches on abortion. The position of the Catholic Church regarding abortion has always been that it is evil. Long since the first century Christian writers have maintained that the Bible forbids abortion, similar to the fact that it forbids murder. The law of Moses in the Bible ordered strict penalties for causing an abortion. A quote from the Bible reads If mean who are fighting hit a pregnant woman and she gives birth prematurely, but there is no serious injury, the offender must be fined whatever the womans husband demands and the court allows. When regarding abortion the Catholic Church refers to the second commandment saying that though shall not murder. Other evidence includes things like the Letter of Barnabas and the Apocalypse of Peter. When religion lost tolerance, laws on abortion began to take shape. The earliest law in the United States was made in New York, in 1829. This law only allowed abortion if there was a threat to the mothers life. Most other countries followed the United States and similarly tightened laws. During this time when laws became stricter, illegal abortions became much more common. During the beginning of the 20th century, women began campaigning for the right to control their fertility. The first family planning clinic in Britain was opened in 1921 by Marie Stopes. The Soviet Union became the first country to legalize abortion in 1920. The new government saw this as a womans right . Other countries followed with laws and made abortion legal in cases of rape, fetal handicap, and threat to the mothers health. The United States set up the National Association for Reform of Abortion Laws in 1932 and the Abortion Law Reform Association was set up in 1936 in Britain. More pressure to liberalize abortion came after two world wars and the effects of the atomic bombs and a drug routinely was given to women. Some of the statistics on abortions include that 6 million American women become pregnant. For more than half of them, it is by accident. All of these are unintended pregnancies. According to statistics thirteen percent of these pregnancies end in miscarriage, forty percent result in birth and the remaining forty seven percent in abortion. Two out of three women will have one unintended pregnancy and forty seven percent of women between fifteen to forty-four will have an abortion by age forty-five. Abortions are classified as either spontaneous or induced. Induced abortions are those in which a procedure is used to intentionally end the pregnancy by removing the embryo or fetus. Sometimes, a pregnancy occurs outside the uterus, in a Fallopian Tube. These pregnancies are aborted because the fetus cannot survive and will endanger the life of the woman. There are about 1.5 million legal abortions in the U.S. every year. More than half of the women who have abortions in the United States are younger than twenty-five. The ethnic distribution is that there are 64.3 percent white, and 35.7 percent of other races. Women who are not married make up 79.7 percent of the women getting abortions. About seventy percent of the women in the U.S. who have an abortion want to have children in the future. About twenty one percent of all abortions are performed on women who are nineteen years old or younger. Worldwide statistics show there were an Business and Health Administration Association Annual Conference 2012

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estimated 26 to 31 million legal abortions and 10 to 22 million abortions that were performed. Thirty nine percent of the populations in the world live in countries that allow abortion on request. Most other countries have laws that permit abortions under certain circumstances. Different countries and cultures vary in their attitudes and regulations concerning abortion. Different countries and cultures are different in the attitudes and regulations with abortion. Abortion only to save the life of the mother is allowed in most Islamic countries, in half of the countries in Africa, about two thirds of the countries in Latin American, and in three countries in Western Europe. In some countries, such as India, abortion for sex selection is common. For cultural and financial reasons, make children are considered more desirable. Some countries, such as China and Korea, actually encourage abortion by offering incentives such as paid leave and subsidies. In some areas, women are forced to have abortions under laws that limit family size. Abortion actually has a long history. In the 4 th century Aristotle encourage abortion for parents with too many children. Hippocrates also talked about abortion along with the ancient Egyptians. The first known opposition to abortion occurred in the early centuries of Christianity. Already in ancient times, the question was asked to whether the fetus is a person. Plato and Aristotle believed a child had life before birth but its rights were not as important to the needs of society and family. Thomas Aquinas believed that life begins when the soul enters the body. He believed the soul entered the body forty days after conception. Aquinas felt that aborting the fetus before its soul had entered the body was not a sin and did not begin until one had a soul. Later on history the stage in pregnancy when the mother first feels the baby move became identified as the time when the soul entered. Abortion after this had occurred was considered a sin by the church. In the United States abortion was legal until the mid 1800s. Reasons for abortion included health, financial pressures, and covering up any scandals of having sex outside of marriage. During this time period doctors and unlicensed abortionists used poisons and sharp objects into the uterus. Before pregnancy tests were available it was difficult to determine when a woman was pregnant. In 1838 Charles and Anna Lohman advertised their abortion services in the New York Herald. They had quite a bit of success and then opened branch offices in Boston and Philadelphia. Eventually the medical establishment began to express concern over the risks of abortions from unlicensed practitioners. This leads to the first laws regarding abortion. By the middle of the nineteenth century, The Comstock Law made it a criminal offense to import, mail, or transport any article or medicine for the prevention of conception or for causing abortion. A nurse named Margaret Sanger, advocated contraception so that women could avoid the suffering associated with abortion. In 1916 she opened a birth control clinic in a poor immigrant neighborhood. She ended up being arrested and imprisoned for doing this. Sanger was a pioneer in giving women, especially poor women access to birth control and abortion. In 1921 Sanger decided to form the American Birth Control league that later became the Planned Parenthood Federation of America. There are a number of circumstances when women consider abortions. One of these includes abnormalities. There are 250,000 babies born each year with physical or mental disorders. Current tests can now identify some fetal defects. Some of these defects can be things that cause disorders such as Down syndrome. Other things that can be detected thorough prenatal testing include neural tube defects. Neural tube defects cause a range of disabilities with little or no handicap. A number of women feel unable or unwilling to handle the financial, emotional, and physical burden of raising a severely handicapped child. Abortions for fetal abnormalities are called selective abortions. Another circumstance that women decide on having an abortion is rape or Incest. Some women may decide to abort a fetus as a result of rape because it would be a reminder of their pain and humiliation. Some feel that experiencing the pregnancy would just prolong the victimization. There are different sides to having an abortion as the result of rape. Some pro life advocates feel the child cannot help that it was produced as a result of an illegal act. Abortion is not a cure for rape or incest and may actually increase the womans feelings of guilt and add to her victimization. Some babies especially in more countries other than the United States are aborted for sex selection. It is difficult to know how many babies are aborted as a result of sex selection. Some women of course also end pregnancy as a result of fetal development not happening properly. One important procedure that was developed was the vacuum aspiration method of abortion. This method allows the contents of the womb to be carefully sucked out and only minimal use of instruments are required. In Britain The Abortion Act passed in 1967. This law allowed a woman to choose an abortion if two doctors agree that either her own, or her familys physical or mental health would suffer by going ahead with the pregnancy. As far as different methods for ending an abortion the vacuum aspiration is used in 98 percent of all abortions. The less common method that is used is the dilation and curettage method where the doctor scrapes the lining of the uterus with a spoon like instrument. 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was used more often. There are also numerous risks when it comes to abortion. Some of these risks can include things like blood clots, tears in the cervix or perforations in the uterus, incomplete abortion, or a bad reaction to anesthesia, and infection. Complications end up being actually rare when a procedure is performed by a qualified professional at a licensed medical facility. Risk of injury or death is pretty low. When antibiotics were introduced during the twentieth century the risk of abortion went way down. Another risk that is associated with having an abortion is an increased risk of breast cancer as well as sadness and grief. There are also emotional and psychological risks of abortion. Having an abortion can cause risks of sadness or grief. It can also cause feelings of relief. Some people call some of these problems post abortion syndrome. There are many factors that effect how strict or liberal laws are. For example, China is worried about overpopulation while Romania is concerned about under population. In most countries where laws are more liberal the country usually acknowledges that women have a right to make a decision about abortion. Denmark became the first country to allow abortion in the first three months of pregnancy. Countries such as France, Italy, Holland, and Sweden also now have abortion requests in the early weeks. In the United States laws vary from state to state regarding abortion. No federal funds though are allowed to be spent on abortion or abortion counseling. Estimates are that about half of all abortions that are performed are done illegally. It also has been estimated by the World Health Organization that 200,000 women die each year after illegal abortions. One thing that is also interesting is that there are more abortions in the United States than in other countries. Most abortions are performed on unmarried women. In most states abortion becomes illegal once the fetus becomes viable. The point of viability of course varies, but it occurs usually between the 24th and 28th weeks. There are many different opinions on abortion. Most people accept abortion in certain situations. Only about 10 percent of adults feel abortion should be permitted. Twenty Five percent feel it should never be forbidden. The Catholic Church is against abortion the most. Some well-known anti-abortion groups include the National Right to Life Committee and Operation Rescue. There are also some alternative options to abortion including adoption. Adoption has become more acceptable in recent years. For most of the 20th century, abortions were illegal in the United States. The U.S. Supreme court decision Roe v Wade in 1973 was a very important decision that gave a right to privacy. It gave women the right to choose whether or not to bear children, and that this right includes a legal right to have an abortion. A lot of people have been advocates of Roe v Wade; however some also view it as a license to kill unborn children. During the 1970s people who believed that abortion was murder began to form organizations opposing the practice. The anti- abortion movement grew in size and influence during the 1980s. Anti - abortion activists have also committed acts of violence. Vandalism, bomb threats, and death threats have been commonplace. Some examples of this also included a Michigan doctor who performed abortions and his wife were kidnapped and held for a week before being released by several men. In 1965 during Griswold v. Connecticut the Supreme Court struck down a state statute that outlawed the use of contraceptives on the grounds that the statute intruded into a constitutionally zone of privacy surrounding marital sexual relations. Roe v Wade did legalize abortion, but it did not resolve the debate to whether abortion is morally acceptable. Actually, this has made it more obscure and difficult. One of the less settled issues is whether parents have the right to decide whether or not their minor child may have an a bortion. Most minors who have abortions do so with a parents knowledge. A woman considering abortion needs appropriate medical care. Ideally she would go to her family physician or gynecologist. There are a lot of abortion activists. Some of the organizations include the National Abortion and Reproductive Rights Action League. They were founded in 1969 when abortion was still illegal in the U.S. In recent years the organization has focused on combating violence and the anti-choice, radical movement. There is also the National Conference of Catholic Bishops Secretariat for Pro Life Activities. This organization represents the Catholic Church in abortion activities. A couple others include the National Right to Life and Operation Rescue, Operation Rescue, and Planned Parenthood. Pro-Life action League and Religious Coalition for Reproductive Choice and Voters for Choice are similar organizations. After Roe V. Wade, working right-wing Republican Party activists stepped up efforts to reach out to socially conservative voters that were concerned about what they perceived as a decline in American family life and morality. These right wing activists nudged aside the more moderate Republicans who had long dominated the partys leadership, the social, pro family issues that concerned these conservative voters. These became key Business and Health Administration Association Annual Conference 2012

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elements of the partys appeal. Opposition to abortion was one such element, and it helped draw many of the growing numbers of born again conservative evangelical Christians a s well as Catholic right to lifers into politics. Socially conservative activists helped in 1980 to put a wave of anti-abortion Republican candidates into office. Another case that had an effect on abortion was Webster v Reproductive Health Services. Pro Choice activists mobilized in opposition for doing so. This case attempted to strike down Roe vv Wade. The decision did not please pro choice nor anti-abortion activists. Anti- abortion advocates were disappointed that the Supreme Court had not, as they had hoped, taken the opportunity to strike down Roe once and for all. The Missouri law restricting abortions had been approved. Hundreds of anti-abortion laws have been introduced in state legislatures across the country since Webster. Another thing to consider is that human life begins at conception. A number of experts believe that life begins when conception begins. Missouri Laws Definition of Life states that the life of each human being begins at conception. Unborn children have protectable interests in life, health, and well being, The natural parents of unborn children have protectable interests in the life, health, and well-being of their unborn child, and the laws of the state shall be interpreted and construed to acknowledge on behalf of the unborn child at every stage of development, all the rights, privileges, and immunities available to other persons, citizens, and residents of this state. The other side of this issue is that human life does not begin at conception. Of course the argument here is that no one knows when the soul might enter the body and that consciousness and awareness only occur when the brain is fully developed. Many people point out that the fetus is a person. This argument is supported by evidence such as how developed the fetus is to a regular human being, whether it moves, and others things. Then there is the other side of the argument that says a fetus is not a person. Some people argue that is not a person because it lacks the ability to evaluate itself and to understand he physical setting of the womb. Some clinics are also pro choice clinics. They perform pregnancy testing, birth control, testing, and exams. There is also the issue that they have to go to the clinic twice. Women really do not like the 24hr waiting period that goes along with informed consent laws. The one benefit is that for some women who are scared and nervous about going to a clinic they may get a chance to meet clinic staff and receive some extra counseling. Some things that are included in informed consent laws are that some states require women to hear a state-mandated lecture 24 hours before having an abortion. Some informed consent laws also have emergency provisions that allow the statemandated lecture and waiting period to be waived. A waiver may be granted if you are having an abortion because of a fetal anomaly. State mandated lectures usually include information on the abortion procedure, the risks and benefits of abortion and childbirth, how long you have been pregnant, and the name of the doctor who will perform the procedure. Women who live in a state where a face-to face session with a doctor is required for the mandated lecture will probably have to make two appointments. There are usually also state prepared booklets on fetal development usually containing pictures and descriptions of embryos and fetuses. When it comes to consent laws, one or both of your parents or a legal guardian will have to sign a form stating that you have their permission for the abortion. In a lot of cases, consent laws mean that one or both parents must come to the clinic with you and sign the forms there. If parents do not come to the clinic, the form will have to be signed, notarized and given to your provider. Some states also have notification laws. These laws state that parents must be told ahead of time that you are going to have an abortion, but you do not need the parents permission. There are also a few states that have passed a mandatory counseling law that simply require minors to receive counseling on their reproductive options and have a responsible adult come with them to the clinic. Other laws include things like judicial bypass where there is a provision for women under 18 who feel they cannot or do not want to tell their parents. Parental involvement laws state that a woman under 18 does not have to tell her parents or go to court for a judicial bypass if she is an emancipated minor. Several states have laws that allow minors to notify or get the consent of an adult family member other than their parents. There is also a physician bypass where doctors can waive parental involvement requirements if they believe a young woman is mature and informed enough to make her own decisions. Some minors who do not want to tell their parents end up going out of state where there are no parent involvement laws. Now we will look at the payment options when it comes to abortion. When a patient goes to an abortion clinic a staff member will talk with you about how much your abortion will cost and how you intend to pay for it. Clinics take cash and offer different types of payment plans. Some people also use Medicaid to assist in payment for abortion procedures. Other options include credit cards, partial payments, and reduced fees. There are abortion assistance funds that have provided grants and interest-free loans to thousands of women facing a range of difficult

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situations. Funds are however limited and depending on the procedure, the abortion can cost anywhere from $200$800. There is also anti choice harassment that goes on near abortion clinics. One of these activities includes prayer vigils. These are often organized by religious groups, such as local churches and not political anti choice organizations. During vigils members of the group will stand, kneel or walk back and forth in front of the clinic. Catholic groups who have vigils usually recite the rosary. Picketing is another form harassment that can go on at clinics. These can vary from a small group of a couple protestors to groups ranging to 20 to 50 protesters who have signs that say Dont kill your Baby. They also may taunt and yell at women and give them antiabortion materials. Picketers may also try to stop you when you are driving into the clinics parking lot, or they may try to talk or give literature to your partner or anyone else accompanying you. This aggressive harassment is meant to make women feel guilty or ashamed and scare them with inaccurate or distorted information. They will carry signs of stillborn or dismembered babies in many situations. They also might hold up dolls or plastic replicas of fetuses. Some women who cross picket lines can also expect to see a range of signs and slogans such as Abortion is murder, Baby Killer, This clinic hurts women, abortion is violence against women, abortion hurts, women come our of here unconscious, etc. Sidewalk counselors are people at clinics who are trained by anti choice groups. They will approach individual women outside clinics and try to give them anti choice literature and talk them out of having an abortion. Counselors will approach women and try to have conversations with them which are somewhat deceptive. The women usually do not know that these people who are approaching them are counselors. They usually will hand the women some literature pamphlets filled with inaccurate and distorted information. Some of the counselors start out as friendly, but then the counseling can turn aggressive and threatening in nature. Other methods that are used to deter women at abortion clinics include things like blockades that involve large groups of anti choice picketers. Some of these groups can involve hundreds of picketers. When there are picketers, women who are trying to enter the clinic would be stopped, surrounded, and prevented from getting out of their cars. More extreme methods by picketers include them lying down in front of womens cars or jumping on hoods to try to cover their windshields. Another issue is that some clinics and groups are able to find out and publicize the names of women who are scheduled for abortions on a particular day. The picketers can photograph and videotape women entering clinics, or copy down their license plates, numbers, and get their names, addresses and phone numbers from the DMV. The impact of this type of harassment can be psychologically devastating. Butyric acid is a foul smelling chemical that is used to vandalize clinics and close them. In one of these typical attacks they break into clinic hours and pour chemicals on the floor. The fumes penetrate the clinic and really can make people quite sick. There is also vandalism, arson, and shootings that are used to help deter potential clinic patients. There are a number of court cases and decisions that have affected current Health Care Policy and legislation that has developed over the years. Some of these cases included cases like Hodgson v Minnesota. This case was decided before the Supreme Court whether the two-parent notification for a minors abortion unconstitutional. The court heal that a pregnant minor has the option of an alternative court procedure to her decision if she can demonstrate either her maturity or that performance of an abortion without notification would be in her best interests. Another case includes Ohio v the Akron Center for Reproductive Health. This case decided whether Ohios abortion for minors law was unconstitutional. The courts ruled that the minors have the right to expedited review. There are also certain circumstances relating to this case that may perform an abortion to parental notice and consent. A physician may perform an abortion related to parental notice and consent if he provides at least twenty four hour notice in person or by telephone to one of the women s parents. The physician as an alternative, may notify the minors adult brother, sister, stepparent, or grandparent if the minor and the other relative each file an affidavit in the juvenile court stating that the minor fears physical, sexual, or severe emotional abuse from one of her parents. If the physician cannot give notice after a reasonable effort, he may perform the abortion after at least forty eight hours constructive notice by both ordinary and certified mail. The third and fourth circumstanc es depend on a judicial procedure that allows a minor to bypass the notice and consent provisions just described. The statute allows a physician to perform an abortion without notifying one of the minors parents or receiving the parents consent if a juvenile court issues an order authorizing the minor to consent, or if a juvenile court or court of appeals, by its inaction provides constructive authorization for the minor to consent.

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The case Rust v Sullivan attempted to answer the question whether the federal government imposes a gag rule on federally-funded family planning services. The regulations deal with three principals on the grant of federal funds for Title X projects. First, the regulations specify that a Title X project may not provide coun seling concerning the use of abortion as a method of family planning or provide referral for abortion as a method of family planning. Because Title X is limited to preconception services, the program does not furnish services related to childbirth. Only in the context of a referral out of the Tital X program, is a pregnant woman given transitional information. Title X projects must refer every pregnant client for appropriate parental or social services by furnishing a list of available providers that promote the welfare of the mother and the unborn child. Second, the regulations broadly prohibit a Title X project from engaging in activities that encourage, promote, or advocate abortion as a method of family planning. Forbidden activities include lobb ying for legislation that would increase the availability of abortion as a method of family planning, developing or disseminating materials advocating abortion as a method of family planning, providing speakers to promote abortion as a method of family planning, using legal action to make abortion available in any way as a method of family planning, and paying due to any group that advocates abortion as a method of family planning as a substantial part of its activities. Third, the regulations require that Title X projects be organized so that they are physically and financially separate from prohibited abortion activities. To be deemed physically and financially separate, a Title X project must have an objective integrity and independence from prohibited activities. The regulations provide a list of nonexclusive factors for the Secretary to consider in conducting a case-by-case determination of objective integrity and independence, such as the existence of separate accounting records and separate personnel, and the degree of physical separation of the project from facilities for prohibited activities. The next case is Planned Parenthood v Casey case. This case helped decide whether Pennsylvania abortion laws are constitutional. The issue in this case was five provisions under the Abortion Control Act of 1982 which was also amended in 1988 and 1989. This act requires that a woman seeking an abortion give her informed consent prior to the abortion procedure, and specifies that she be provided with certain information at least 24 hours before the abortion is performed. For a minor to obtain an abortion, the Act requires the informed consent of one of her parents, but provides for a judicial bypass option if the minor does not wish to or cannot obtain a pa rents consent. Another provision of the Act requires that, unless certain exceptions apply, a married woman seeking an abortion must sign a statement indicating that she has notified her husband of her intended abortion. The Act exempts compliance with these three requirements in the event of a medical emergency. In addition to the above provisions regulating the performance of abortions, the Act imposes certain reporting requirements n facilities that provide abortion services. Another decision regarding abortion involves Bray v Alexandria Womens Health Clinic. This case was about whether the Civil Rights Act of 1871 can be used to prevent abortion blockades. The court held in this case and reversed a twenty year precedent that under this act it reaches not only conspiracies under color of state law, but also purely private conspiracies. There are many issues involving abortion that relate to ethics and laws. Some of these include things such as when does life begin? Some people believe life begins at contraception, but others believe it happens later. The Harvard criterion is a set of criteria to declare that a person is dead. It requires there be no response to external stimuli, no deep reflexes, no spontaneous movements of respiratory efforts, and no brain activity. Using these criteria definitely shows that a fetus is not a living being. Religion also plays a big part in determining pro-life movements. A lot of prolife activists say its impossible to separate ones own beliefs from what so ciety should impose. There are a number of passages from the Bible that have been used to argue against abortion. Some of these include Exodus 21:22-25, Job 10:8, Psalms 139:13, and Ecclesiastes 11:5. There has also been an argument that abortion has been used as a racial tool. The majority of abortions are by black women and some people argue that abortion is a tool used to control the African American population by people who are racist. Some pro life advocates believe that abortion is murder. People argue that abortion is not a choice and it is a child. They feel that it is impossible for anyone to determine or tell when life begins.

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Others argue though that abortion is a womans right. When people discuss something with a lawyer or a doctor you have the right that the information will be kept confidential. A doctor cannot perform surgery on a person without consent even if they feel the operation is in the patients best interest. A lot of pro choice advocates feel that the decision to have an abortion should be kept private and confidential. Advocates of pro-choice feel no one should be forced to have an abortion, but that people with strong convictions should let each person decide for themselves. The Catholic Church has been criticized in its opposition to abortion and opposition to contraception. There are numerous alternatives to abortion that are taught. Some of these ideas include things like limiting abortion and deciding when it is acceptable and when it is not. The development of better contraception is another idea that is constantly trying to be developed. There are also advocates of abstinence saying that one should not be sexually active unless married. Genetic counseling and gene therapy are also talked about when abortion is talked about. By evaluating parents chances of passing on inherited diseases through genetic counseling it has become more common for parents to know whether the child may carry an inherited disease. Adoption is another issue that could reduce the amount of abortions that are performed. There are many families waiting to adopt a child but the process is expensive and requirements tight. One of the other issues is that many of the families wanting to adopt are waiting for a healthy white infant. A lot of children though waiting for adoption are older, a different race or nationality, or have special needs. If the process of adoption was made less expensive and rules loosened more families might be willing to adopt. Recent studies have shown that support for abortion has not changed over the years in the United States. Most Americans, regardless of what generation they come from are deeply conflicted with how they feel regarding their position on abortion. Fifty Six percent of Americans told the Gallup Poll that abortion should be legal. Most religious groups according to The Public Religion Research Institute favor a Pro Choice stance on abortion. There is also a new abortion drug is the RU 486 pill. A lot of people argue that this new drug is an extremely safe method of abortion. If used properly, RU 486 has no serious medical complications. Two of the pills important effects are its effectiveness and its safety. It induces abortion in 96 percent of all cases. The pill works by producing a heavy menstrual flow equivalent to a womans normal period. RU 486 does involve a few more complications than the vacuum method but it has a very high success rate and it is also very rare to have any type of side effects. RU 486 can also be use to assist women in getting through difficult deliveries. RU 486 is only the body briefly which is one of the main reasons that the side effects are kept low. There are other advocates though that claims the pill RU 486 is not safe for women. They say it block the hormone progesterone and can cause serious complications. They feel that RU 486 causes a helpless developing unborn child to starve to death. They feel that the effect of the toxic chemicals with this drug on women is one of the reasons that it needs to be kept off the shelf. RU 486 abortions also end up being bloody and painful. RU 486 is really designed to replace surgical methods of abortion with chemical ones. Another recent event that is occurring is an organization called Planned Parenthood is taking on a number of the states in regard to medical services. Planned Parenthood has provided abortion services to patients for years. They have recently taken on the state of Indiana. Indiana became the first state to prohibit health care contacts with and grants to any entity that performs abortions or operates a facility where abortions are performed. This law ends up applying to state funds as well as federal funds administered by the state including money for Medicaid. In addition to Indiana other states are starting to move in the same direction. Planned Parenthood has decided to file suit to take on these issues and prevent other states from passing similar legislation. In forming new Health Care Policy regarding abortion a number of the problems mentioned above need to be addressed in new and upcoming legislation. The intention of my Policy is to make abortion laws more Uniformed from State to State. I believe that if more States and the Federal government work together that abortion laws can be made uniform while also maintaining States rights. New regulations would include that abortions performed would be covered by most health insurance and that clinics be run and regulated by the Federal government. The policy would stop more illegal abortions from being performed, offer new federal employment positions, and offer other benefits as clinics mostly all being the same and offering similar services. The policy would also outline very specifically under what circumstances and abortion could be performed and when it could not. Harassment and Protests from Pro Life groups would need to be kept to a certain distance from the Clinics. Under the new policy an adult woman in all the current States would be given the choice to whether she wants to have an abortion and what method she wishes to use. 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abortion counseling. The new policy would also have a uniformed policy regarding Minors and parental Consent. For minors parental consent would be required with a signed consent form, but the option would be given also that if a Mother can convince a judge during a hearing that she is a mature enough consent may not be needed. Minors and parents would be required to go through pre abortion counseling before making a decision. Other issues with the development of new policies is that education on abortion in public schools will also be a requirement in sex education along with more education regarding alternatives such as contraception and abstinence. Adoption reform is another issue to be outlined in new policy. Adoption laws will become a little bit easier and hopefully the process can be made less complicated as well as take place more within a reasonable amount of time. If applications for adoption can be made shorter as well as adoption interviews speeded up this will greatly save time and speed up the process. The other thing this will help do is reduce the cost of adoption. Hopefully by reducing the cost, this will encourage more families to adopt. When more mothers see this as an easier option to go through more abortions may be prevented. In conclusion, if new policy is developed abortion numbers should come down. The process would also be more easily understood as well as uniform throughout the country. New policy would also make abortions easier to be covered by health insurance and get paid for. A few side effects of course is that Pro Life groups may become more aggressive in rejecting new policy along with private clinics who want to maintain there current business and clientele. Obviously, these issues will have to be managed but overall the quality, education, and understanding of abortion should be made better if these new policies are implemented.

REFERENCES Andryszewski, T. (1996). Abortion Rights, Options, and Choices. Brookfield, CT: The Millbrook Press, Inc. Wharton, Mandy (1989). Understanding Social Issues. New York, NY: Gloucester Press. Harrison, M., & Gilbert, S. (1993). Abortion Decisions of The United State Supreme Court. Beverly Hills, CA: Excellent Books Press. Catholic Answers (2011, June 20). Abortion. Retrieved from www.catholic.com/library/Abortion. Kaufmann, K. (1997). The Abortion Resource Handbook. New York, NY: Fireside Press. Crary, D. (2011). Survey Shows Americans Conflicted Abortion Views. Williamsport Sun Gazette, June 11. Bender, D., & Leone, B. (1997). Abortion Opposing Viewpoints. San Diego, CA: Greenhaven Press. Porche, D. J. (2011). Health Policy Application for Nurses and Other Healthcare Professionals. Sudbury, MA: Jones& Bartlett Learning. Lee, P. (1996). Abortion&Unborn Human Life. Washington DC: The Catholic University of America Press. Yoest, C. , & Burke, D. (2011). Planned Parenthood Takes On The States . The Wall Street Journal, June 27. Day, N. (1995). Abortion Debating The Issue. Springfield, NJ: Enslow Publishers Inc. Poppema, S., & Henderson, M. (1996). Why I Am An Abortion Doctor. Amherst, NY: Prometheus Books.

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Robert D. Fenstermacher, GA Department of Health Administration & Human Resources The University of Scranton Tel: 570-435-2703 Email: fenstermacr2@scranton.edu

Daniel J. West, Jr., Ph.D., FACHE, FACMPE Professor & Chairman Department of Health Administration & Human Resources Panuska College of Professional Studies The University of Scranton Scranton, PA 18510 Tel: 570-941-4126 Fax: 570-941-5882 Email: westd1@scranton.edu

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CUBAN PHARMACY IN THE CONTEXT OF ITS HEALTHCARE SYSTEM: TRANSITIONING TOWARD PHARMACEUTICAL CARE PRACTICE*
Alina Martinez Sanchez, San Jorge University J. Warren Salmon, University of Illinois at Chicago ____________________________________________________________________________________________ ABSTRACT As with many countries across the globe, professional Pharmacy is moving from a product orientation (dispensing medications) to a focus on patient care in Cuba. Such transformations are most difficult, especially for developing nations (Coville, 1994). To alter the roles and responsibilities of pharmacists, Cuba is beginning to enhance existing practice settings, first with revamping educational programs. The main change is the introduction of pharmaceutical care as the professional practice model (Sanchez, 2010). The pharmacy curriculum now has experiential training to provide students with the new knowledge, skills, and abilities required for pharmaceutical care. The Cuban health successes in raising the overall health status of the population have led it to become a model for other developing nations (WHO, 2009). Using national data and the most recent figures from the Cuban National Institute of Statistics, this assessment of Cuban health care and its new Pharmacy practice model notes the transformations being carried out in the community pharmacy setting, along with improvements in Pharmacy education. An analysis of barriers in the context of the Cuban health system is provided in an overview of current trends that have linked a national network of pharmacies.

INTRODUCTION Cuba, in the Mediterranean Sea, is made up of 14 provinces, divided into 169 municipalities, with a population of 11,242,628 in 2010, approximately 75.8% of its citizens living in urban areas. As with many countries across the globe, professional Pharmacy is moving from a product orientation (dispensing medications) to a focus on patient care in Cuba. Such transformations are most difficult, especially for developing nations (Coville, 1994). To alter the roles and responsibilities of pharmacists, Cuba is beginning to enhance existing practice settings first with revamping educational programs. The main change is the introduction of pharmaceutical care as the professional practice model (Sanchez, 2010). The pharmacy curriculum now has experiential training to provide students with the new knowledge, skills, and abilities required for pharmaceutical care, legislated in 2005. The health care approaches applied within Cuban society are consistent with those put forward by the World Health Organization (WHO, 2009). The experiences in the Republic of Cuba have produced positive exchanges yielding many mutual benefits from its collaborations with the Pan-American Health Organization/World Health Organization (PAHO/WHO). The public health aspect of the Cuban system, combined with a formal primary care system, was early on institutionalized with very limited resources at times. Its health care system was not a straight trajectory, given the ups and downs of a poor developing economy. Following the end of the Soviet aid, during the "Special Period" of 1990-93 when economic development became the Island's primary focus, resource constrictions affecting the health sector, along with natural disasters, the embargo imposed by the United States, among other factors, limited health sector developments. While health professionals and diplomatic visitors over the years have rendered varying interpretations of the Cuban health care system, nevertheless, international health assessments have been favorable of its prenatal programs; an infant mortality rate of 4.9/1000 live births; childhood vaccination rates; accessible neighborhood clinics and pharmacies; and life expectancy reaching 77 years (Kaiser Network, 2010). One of the authors (Sanchez) participated in this period of change as a Pharmacy educator in Cuba, and the other author (Salmon) witnessed these achievements first hand during an Island visit (University of Illinois, 1996); many others associated with the American Public Health Association have confirmed such during numerous official visits (www.professionalsabroad.com).

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Nevertheless, recent changes in Cuban Pharmacy Care toward ensuring a greater contribution of pharmaceutical services for quality health improvements have generally gone undocumented (Reed, 2000). Our analysis here shares the pharmaceutical care emergence in Cuba and assesses its barriers, for learning by other developing nations. STRUCTURE OF THE CUBAN HEALTHCARE SYSTEM The political, social, and economic dimensions in health are a real priority in Cuba and have been across almost a half century. Equity in the allocation of health resources has been established with a high level of health achievement and consumer satisfaction. The strength of Cuba's human capital investment propelled these health status gains, which are coupled with synergies from social interventions in health. The Cuban population is welleducated with free public education to the highest level; and for some time Cuba has had very high literacy rates (especially compared to other developing nations and all of South America). The Ministry of Health (MINSAP in Spanish) implements health policy through the national, provincial, and municipal levels. The People's Power National Assembly (its parliament) and the provincial and municipal assemblies all have working health committees. The National MINSAP presides over methodological, regulatory, and coordination and control functions. Municipal activity is centered in the polyclinics and in the health areas geographically designed to serve the populations. The People's Councils for Health, and the inter-sectoral coordination bodies, ensure compliance with the regulation of research development, technology integration, and quality control over pharmaceuticals, cosmetics, food chemicals potentially harmful to health, and medical devices. Sanitary inspection by MINSAP is under the direction of the Centers for Hygiene and Epidemiology Unit. Pharmaceuticals are subject to quality control supported by good manufacturing practices (GMP). The Drug Development Center is responsible for evaluation and certification and registration, issuance of necessary rules and regulations, inspections, and certifies production laboratories; it also authorizes clinical trials for new pharmaceuticals. The State assumes full responsibility for the health care of the Cuban citizenry. The 1983 public health law laid out the general activities to be carried out to protect the health of the citizens. Despite the development obtained by the health sector in recent years, the public health law needs to be continually adapting to new determinants in the public health environment, both internal and external (e.g. new medical discoveries and technologies, innovations in the delivery system, expanded roles of health professionals, natural disasters, etc.). By the 1980s Cuba's healthcare system began to merit attention from the WHO, UNICEF, and other international agencies anxious to identify viable models of health services delivery for the rest of the developing world (WHO, 2009). Then also, tertiary care facilities and research received priority policy attention in Cuba; medical specialization expanded to 55 fields, and the National Institutes were established as centers of excellence, including programs for prenatal screening, an organ transplant program, installation of the first nuclear magnetic resonance machines in Latin America, etc. By the end of the 1980s Cuba had expanded medical education to 21 medical schools spread across the country. EXPORTING PHYSICIANS AROUND THE WORLD Unknown to the bulk of the American population, Cuba since 1973 has exported physicians to numerous developing nations in need of modern medicine. Blacks in a rural area of South Africa, who had never had access to Western medicine under the apartheid regime, were given a 300 Cuban medical delegation on the basis of the friendship between Nobel laureate Nelson Mandela and Fidel Castro. This facilitated exchange was noted to one of the authors (Salmon) on a visit to South Africa. Cuba has one of the highest physician/population ratios in the world, nearly twice that of the United States. Over time, it is estimated that 37,041 physicians and other health workers have been sent to 77 countries in such medical brigades, including Ethiopia, Angola, Nicaragua, and Venezuela (Millman, 2011). When Cuban health professionals work for national health authorities abroad, they may earn needed foreign exchange revenues for Cuba; many medical exchanges, however, serve as Cuba's development aid to nations struggling in times of great national need. This work is complemented by the Cuban pharmaceutical industry, which has long looked into medicines for several neglected endemic diseases across the developing world. Business and Health Administration Association Annual Conference 2012

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After the 2010 earthquake, Cuba pledged to reconstruct the Haitian healthcare system based on its own model of public health/primary care, to include 101 clinics and 30 community hospitals with the Haitian Specialties Hospital to be staffed by 80 Cuban physician specialists. Additionally, 312 medical scholarships are being offered to Haitian students to study in Cuba, which adds to the past 11 years of Cuban assistance to its poorest island neighbor. Moreover, this medical aid has been implemented "under a crippling economic blockade from its powerful (other) neighbor for nearly a half century." (Kirk & Girvan, 2010). Currently, the post-earthquake commitment by Cuba promises to treat 75% of the Haitian population and save hundreds of thousands of lives. An analysis of the news coverage on the Haitian Donors Conference, where this pledge by Cuba was made, revealed that the 5 major U.S. media corporations, only 1 of 38 posts mentioned this extraordinary Cuban contribution, the amount which incidentally exceeds more than the total of the G7 countries combined for Haiti, excepting the high amount provided by U.S. voluntary sources (Kirk & Girvan, 2010). Recently a New York Times piece favorably commented on the Cuban commitment to Haiti since the hurricane of 1998 (Archibold, 2011). It is interesting to note that in 1959 after the fall of Fulgencio Batista's regime, most physicians left Cuba, presenting a most difficult dilemma for care to the impoverished population. Consequently, Fidel Castro encouraged the remaining physicians to reconstruct a totally new public health care system that would indeed serve the whole population. Previously, many Cubans had never had access to Western physicians, who had mainly served those in the middle and upper classes under Batista. Given this challenge, Cuban physicians developed what has been acclaimed by WHO as one of the most effective public health systems in all of the developing world. Many infectious diseases were wiped out; nevertheless now with an aging population (11%), Cuban medicine faces (as all nations around the world) more chronic degenerative diseases, which opens up opportunities for pharmacists. Infant mortality rates in Cuba (4.9 per 1000 live births) remains better than many developed nations, including the United States (6 per 1000 live births) (CIA, 2011). In sum, Cuban health care has served its population very well, historically changing the Island's social epidemiology, as well as allowing for the production of medical personnel to serve as good will ambassadors across many countries. The Latin American School of Medical Science in Havana is perhaps the world's largest medical school with about 10,000 students, all of whom are foreigners (Cuba: Dr. Diplomat, 2007). Most come from Latin American countries, but the enrollment also includes 91 Americans who were unable to enter U.S. medical schools. The Cubans gave all of these students scholarships and free room and board to study medicine there so that they will be able to obtain their M.D. degrees in a 6-year program; wonderfully, these students will experience and understand an effective healthcare system's functioning so that they can return home to serve their populations in need. Moreover, hundreds of Cuban doctors are routinely deployed after hurricanes and other national disasters strike across Latin America. More than 15,000 doctors and dentists are working for the Venezuelan government. Ecuador, another ally of Cuba, has received much needed medical assistance also. A Cuban medical delegation was deployed, alongside assistance by several Arab nations, for Pakistan's earthquake in 2005. Thus, this medical diplomacy has enhanced Cuban clout abroad, but at the same time it has placed strains on its pharmaceutical industry that can barely find the resources to annually produce ample drugs to meet the needs of its own population. Given the U.S. embargo, these drugs need vary from year to year as occasional hurricanes and other health calamities arise at home or may be demanded abroad. Someday the Cuban experience in empowering the Pharmacy profession in implementing effective pharmaceutical care models may also be usefully exported to the developing world. ADVANCEMENTS IN THE CUBAN HEALTH SYSTEM Hallmarks of Cuban medicine from the 1980s are its biotechnology industry, which would put Cuba in the forefront of global vaccine research and medicines for neglected diseases in the Southern hemisphere; and the introduction of the family doctor program in1986 (doctor and nurse teams are located next door to their patient communities). Cuba's health system was built on a strong foundation in primary care with its focus on communitybased family practice facilitating public health activities in the community, including epidemiological surveillance. By the early 1990s, over 95% of Cuban families received primary medical attention in their own neighborhoods (Anuario, 2009). Cuba has a qualified health workforce of 329,669 personnel in 2009: 74,880 doctors (of whom 34,261 are family physicians), 11,572 dentists, 2993 pharmacists, and nursing and auxiliary personnel of 106,433. 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also 133,778 technicians and health assistants (technicians include Pharmacy, laboratory, radiological, and dental assistants, among others). Health worker training is subject to the principles of central planning, taking into account the needs of each territory and the country in general (Anuario, 2010). The State guarantees a job for all graduates to meet the increased demand for health services. The Cuban system is financed out of the State budget. The population receives free, preventative, curative, and rehabilitation services which range from primary care, routine medical attention, and dentistry all the way through hospital care requiring the use of highly sophisticated medical technologies. In addition, all necessary diagnostic testing and drugs are provided free of charge to pregnant women and to persons receiving outpatient care in certain programs. Out of pocket expenditures for families may include drugs prescribed for outpatient treatments, hearing aids, dental and orthopedic apparatuses, wheelchairs, crutches, and similar articles, and eyeglasses. The prices of these items remain low, being subsidized by the State. In 2008 the most recent data for statistics that are available, Cuba managed a total of 4,230,938,600 pesos, equivalent to 376.44 pesos per capita spending (Informe sobre, 2010). Life expectancy in Cuba has climbed to 77 average years (75.1 for men and 79.2 for women) in stark contrast to the figure of 62 years in Haiti (lowest level of the region and falling unfortunately due to the recent earthquake). Lack of data on internationally comparable income prohibited the 2010 Human Development Index (HDI) for Cuba to be calculated. Yet this report includes figures showing sustained remarkable results in both health and education, the two components of the HDI. Cuba spends about 9.9% of its gross domestic product on health in its highly organized healthcare system, similar to countries like Germany (8%) and France (8.7%) but comparatively higher than neighboring Latin countries, such as Bolivia 3.4%, Ecuador 2.3%, and Jamaica 2.4%. The population growth rate has ranged from 0.3% to 1% per anum while its life expectancy remains close to many developing nations (Health expenditure, 2007). PHARMACY SERVICES Contributing to Cuba's effectiveness in primary care is its provision of Pharmacy services which have become an important aspect of drug policy. The overall objectives of national drug policy are aimed at ensuring equitable availability and affordability to essential drugs, in addition to promoting therapeutically sound use and economically efficient drug utilization. The latter is the responsibility of pharmacists, thus the ongoing effort at upgrading toward pharmaceutical care. Cuba currently has 2117 pharmacies in varied distribution with a national average of 18.34 pharmacies per 100,000 inhabitants. This is a small range compared to provincial capitals in Spain (values 21.6 to 72.5), some provinces of Cuba (e.g. Ciego de Avila and Guantanamo) have indices of 22.17 and 21.05 per inhabitants, respectively, which are values similar to the highs of Switzerland (22.41) and the United Kingdom (20.64) (Fernandez & Fernandez, 2005). Established in 1991, the National Drugs Program is to ensure more rational use of pharmaceuticals and to improve the quality of medical care. In 1994, the program became reformulated with measures requiring a medical prescription for most drugs; to regulate prescriptions written by doctors according to their medical specialty; to assign patients to drug distribution units in their area of residence; to strengthen the work of the local pharmacotherapeutic committees; and to maintain the regulations on the distribution of consumer products intended for long-term or lifelong use. A special effort has been made to revise the essential drug lists, which the World Health Organization recommends every nation to adopt. Cuba reduced the number of active principles to 343 distributed among 29 drug classes with 439 dosage forms. Traditional and natural medicinal products used by the populace are included. The official drug control center is responsible for ensuring that products meet international quality standards (GMP and GSP). The 1996 national health system of pharmacoepidemiology strategy was created as a national network for evaluating and controlling rational drug use in each territory. Substantial State investment and accelerated training of engineers and scientists promoted Cuban biotechnology to establish itself in the global market (Everson, 2007). Ernst & Young puts exports of biotech products at US$300 million in 2005, including several innovative vaccines; genetic engineering is progressing also. A deep product pipeline adds to the some 100 patents already registered, with another 500 patents throughout the

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world. Collaborations are established with Canada and Great Britain, among a number of emerging economies and developing nations. Cuban research also prioritizes developing affordable vaccines for diseases affecting poor populations, including typhoid fever and cholera, a fundamentally needs-driven, rather than market-driven approach. Cuba also produces generic drugs, including HIV/AIDS anti-retrovirals, selling them to developing countries at a fraction of the price sold by transnationals (Everson, 2003). The objectives of the pharmaceutical services are designed to achieve excellence in their contribution to the population's health maintenance through optimal management of economic resources, a special necessity for any developing nation. The MINSAP has been implementing a series of measures to achieve this by determining the level of economic efficiency and the degree of public satisfaction. At this point Cuba faces an imperative of improving the whole system of distribution and sales of medicine to achieve optimal supply to patients. When in Cuba, one author was told by pharmaceutical industry officials of their difficulties they had in obtaining even APIs (Active Pharmaceutical Ingredients) from the rest of the world to replenish their annual drug supply (Salmon, personal communication, 1996). The U.S. embargo limits buying modern pharmaceutical products from the European Union which is restrained from trade with Cuba if they maintain a presence in the United States. The U.S. Trade Sanctions Reform and Export Enhancement Act (TSRA) of 2000 now allows some food and agricultural products from the U.S. to be sold to Cuba on a pre-paid cash basis; nevertheless, the continuation of the embargo now after 2000 requires both Congressional and Presidential approval before any changes in such restrictions. In essence, the northern neighbor of Cuba potentially damages advances in the nutritional status of the Cuban people and their medical services by these impositions on the international purchase of food and medicines. PROMISE FOR AN END TO THE U.S. EMBARGO A recent United States Department of Agriculture report stated: The Cuban economy has made remarkable progress toward recovery from the economic disaster generated by the collapse of the Soviet Bloc. To deal with losing large amounts of economic assistance and subsidized imports from its major export market, Cuba was forced to implement a severe austerity program and to undergo a transformation of its economy[this] also forced Cuba towards smaller scale systems reliant upon more sustainable, organic production practicesthe loss of exports to Soviet Bloc countries forced Cuba to look to global markets and decide how it could profitably meet the demand-driven needs of those markets in an effort to generate hard currency export earnings. Cuba also had to turn to these markets for foreign investment to acquire new technologies and capital to allow Cuba to modernize and improve its long-depleted stock of productive capital and to purchase necessary production inputs (USDA, 2008). For the past 20 years, a litany of articles and editorials in the American media (even in the business press) may indicate a changing view from U.S. circles about the imposed embargo against Cuba. For sure, Europe and Canada are not in the same policy stance, for their businesses are obtaining benefit from investment and trade with Cuba, where U.S. corporate interests from the pharmaceutical, mining, tourism, and agribusinesses have historically sought markets across the developing world. The Papal tour, along with visits by former President Jimmy Carter and then-Governor George Ryan (Republican-Illinois), (with a Midwest agribusiness contingent), gave both closer looks inside Cuba and indicated a desire to altering the American mood that has unfortunately lasted well beyond the end of the Cold War. President George W. Bush had been easing trade and travel, preceded by a little change by the Clinton Administration; but these were minor steps. President Obama, given his campaigning, has yet to find his rhetoric fulfilled, constricted perhaps by the Miami-based Cuban exile community. Beyond U.S. business interests, the embargo denies the Cuban people vital food and medicines. For sure, travel and greater educational and cultural exchanges with Cubans would promote invaluable benefits for both sides of the Florida Keys, and open up collaborations for improving health care in both nations health care systems. Pharmaceutical industry scientific exchanges equally hold great promise.

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PHARMACY EDUCATION AND PRACTICE Weaknesses identified in Cuba for the control of economical dispensing of medicines are in: 1) Procedure and frequency of monitoring; 2) Customer service; 3) Administration procedures; 4) Dispensary operations; 5) Control of drugs, narcotics, and explosives; 6) Management and quality assurance. Of course, the implementation of Pharmaceutical Care will receive prime attention in continuing policy and Pharmacy practice, as well as the above. To these ends, the Cuban Health Ministry through its National Directorate of Pharmacy and Opticals implemented a new Manual of Procedures for Community Pharmacy to upgrade the whole system of distribution and sale of drugs to achieve optimal supply to meet patients' needs (Ministerio de Salud Pblica de Cuba, 2005). Accordingly, these regulations extended beyond Pharmacy itself toward activities of storage, dispensing, and drug development so that pharmacists can join health teams in direct patient care. This broadening of the scope of pharmaceutical activities with Pharmacy Clinical Services, Drug Information, Pharmacovigilance, and Pharmacoepidemiology remains a critical challenge as it does in even advanced economies. Managed care pharmacy (defined as the practice that encompasses the entire supply of medicines, medical devices, and the care process) is thus enabled to ensure good patient care outcomes with equity, efficiency, effectiveness, and cost control. Measurable cost containment and an overall impact on health and quality of life are the objectives. The clinical activity in Community Pharmacy has the pharmacist's role now advising on aspects of pharmacotherapy, such as establishing dosing regimens; detecting and preventing drug-related problems; advising patients, families, and health team members in both hospital and community settings. The pharmacy must be run by a pharmacy graduate with professional qualifications, or medium pharmacy technician, if unavailable. Based on the incidence of adverse health events caused by poor, or non-compliance with drug therapies, supervision of drug treatment for patients through the 'pharmaceutical care' practice takes into account: DrugRelated Problems; Drug Interactions; Adverse Drug Reactions; Contraindications; Treatment Guidelines; Clinical Laboratory Testing; Diet Advice; and Lifestyle Modifications. As Pharmacy professional leaders the world over now realize: bringing along the bulk of practitioners to a new model of Pharmaceutical Care takes time (usually in stages), professional commitment, and organizational support in various clinical settings to achieve an ideal practice implementation. A main "Pharmacotherapy Profile" provides the pharmacist with a record that includes personal information, fundamental patient history, and behavior to medications (allergies, sensitivities, reactions, and effects), full prescribed medications, and compliance data. The Pharmacotherapy Profiles may vary depending on each different Clinical Pharmacy Service. In the health team, the pharmacist's clinical role is to advise on aspects of pharmacotherapy, such as: establishing dosing regimens, detection and prevention of related problems, drug information for patients and health team members, etc. Given this new role, scientific rigor must be incorporated by the professional pharmacy staff, including: direct supervision of drug therapies in patients; Pharmacovigilance; Drug Information Service; Drug Delivery Systems; Programs of advice, guidance and education for staff health and patients; and promoting rational drug use. Finally, quality assurance must be considered: defined as the totality of characteristics of a product, process, or organization that affects satisfying the needs of a person or group in the community. Quality Assurance is closely linked to compliance with Good Pharmacy Practice (Manual de Normas y Procedimientos en Farmacia Comunitaria, 2005). Pharmacy studies began in Cuba in 1734, but became regulated in 1833. The basic principles of modern Cubas educational system are that it is free, public, and secular. The professional, ideological, and cultural levels of graduates is seen as an indication of success in the Cuban educational enterprise (WHO, 2009). Three universities offer the Bachelor of Science in Pharmacy (BScPharm) degree. The curriculum includes basic science courses and specialized coursework in pharmacy. According to Cuban economic and social reality, the mission of the pharmacy profession is two-fold namely: to provide medicines to populations with growing health care needs, and to help people obtain the best outcomes from medication therapies, hence directly improving public health. One of the main aims of pharmacy education in Cuba is to achieve the balance between, and integration of, the enabling sciences, applied pharmaceutical sciences, social sciences, and clinical education (Sanchez, 2010). Similar trends have been Business and Health Administration Association Annual Conference 2012

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described in pharmaceutical education in the USA; Cuba also includes the development of leadership attributes, critical thinking skills, societal responsibility, and social and emotional intelligence into the pharmacy curriculum. Moreover, in Cuba, extracurricular or co-curricular activities that focus on serving surrounding communities are now common at universities and colleges. Factors, such as the Island's increasing need for pharmaceutical products and services, led to particular emphasis on problem-based learning. Experiments, case studies, discussion groups, class assignments, demonstrations, and practical experience in pharmacy are among new teaching methods. In addition, modern automated delivery systems enable students to access lecture material online. Government initiatives to encourage pharmacists to apply this professional direction began with the Cuban Pharmacy Legislation in 2005. As to curricular changes, several pharmaceutical care courses have students discussing this new model and indentifying differences from previous practice models. Offering students better opportunities to develop clinical skills during time at the University has Pharmacy educators instilling in their students a high level of motivation, commitment, and the self-confidence in order for them to assume responsibility for improvement of drug therapy outcomes in patient populations. Similar curricular changes developing pharmaceutical care have taken place in Chile (Martinez-Sanchez, 2010). Likewise, pharmacy programs in Canada train practitioners to promote excellence in patient-focused care, based on the philosophy of pharmaceutical care. Increased emphasis on competency-based teaching and assessment is being given to ensure that Cuban graduates learn sufficient clinical skills to deliver new cognitive pharmacy services (Martinez Sanchez, 2011). These considerations led to the incorporation of Social Pharmacy in the curriculum. Understanding that Social Pharmacy is interdisciplinary to enable pharmacists to take part in, and take responsibility for drug matters at a societal level. This initiative provides students with exercises to improve communication competence, critical thinking, problem solving, and analytical and ethical reasoning. The Social Pharmacy discipline represents only 2% of total curriculum hours, yet its introduction was the first academic approach to teaching pharmaceutical care in Cuba (Martinez Sanchez, 2011). Curricular changes (such as improving documentation of activity) constitute a notable approach to this patient-centered practice. The last decade's orientation toward pharmaceutical care practice includes a concern about the logistics necessary for its application across the country. Research revealed a high interest on the part of Cuban pharmacists to excel in quality of services, health education, pharmacoepidemiology, pharmacotherapy, management of information on medicines, and public health issues (between 60 to 100 of the total 50 pharmacists surveyed) (Mateu & Sedeno, 2005). The Cuban Ministry of Science, Technology and Environment, under the auspices of the University of Oriente, conducted research that sought to advance education in pharmacy. Historical records of the curriculums used in pharmacy education in Cuba were examined for: the selection process for enrolling students in the BScPharm program, the curricular foundations, and the development of the curriculum in response to new trends in pharmacy practice. As result, a pedagogical model to implement pharmaceutical care was designed and validated. This research received an Award from the National Council of Scientific Societies of Health of the Republic of Cuba on 2003, and was published in the Latin American Journal of Pharmacy (Martinez Sanchez, 2009). Despite efforts so far in generalizing the practice of pharmaceutical care, it is far from standardized and not embraced by the majority of practicing pharmacists today. The pharmacist's role continues mainly devoted to activities not directly related to patient care, while clinical roles in the practice of pharmaceutical care remain limited. Such is to be expected, as usually health authorities, as well as health care teams, are applying pharmaceutical care experimentally (Lores, 2009). In the United States and in Commonwealth nations, clinical work by pharmacists has advanced through similar stages of development, hardly ever reaching an ideal. All developing nations face a multitude of barriers to working toward pharmaceutical care. Each nation and its profession must adapt to make the model fit its unique circumstances under the available resources that can be committed over time.

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BARRIERS IN THE PATH TOWARD PHARMACEUTICAL CARE To analyze such barriers, the domains presented by the International Pharmaceutical Federation (FIP) in studies on implementing pharmaceutical care in Europe are useful: Although achieving a remarkable advancement according to its healthcare system, Cuba remains a poor, developing nation. Barriers to resources: Resources to upgrade Pharmacy professionals need to be directed toward the adoption of specific practice standards in implementing the model, mainly relying upon individual people's efforts in certain locales. A specific model of practice in both community and hospital settings must be developed feasibly and flexibly depending upon the practice environment and the specific patient case mix. Standards must be clear to eliminate any ambiguity between clinical Pharmacy and pharmaceutical care concepts. Documentation needs to provide evidence that pharmacists are performing up to expectations and that patient populations are beginning to see significant improvements in health outcomes. Showing how to save money in the health system through the practice of pharmaceutical care translates into humanistic results. This challenges for pharmacists in conserving time for patient care, which remains the most significant obstacle standing against the new model worldwide. Barriers related to attitudes and opinions: A principal barrier is the pharmacists themselves. As Hepler has stated: Many pharmacists are standing at the threshold of professional maturation; indeed, many have crossed over that threshold into the patient care stage. Professional maturity has most in common with maturity as a person. One attribute common to both is a world view and expectation that one thrives best by using ones profession to serve a larger cause beyond one. Another attribute is the acceptance of responsibility for ones actions. Some pharmacists understand these concepts but have been unable to cross the threshold because they cannot clearly see opportunity (Hepler, 1990). Some Cuban pharmacists in both community and hospital sectors have embraced the concept of pharmaceutical care; they are engaged in experimental projects, with results not yet translating into general standardized practice. Thus, motivation has yet to be engendered for strong advocacy for a "pharmaceutical care movement in Cuba." For example, in Cuba doctors and nurses are highly valued by society within and outside healthcare. Elsewhere also, lower expectations on the part of pharmacy professionals, along with little financial incentive, among other factors, have been reported as continued barriers to providing pharmaceutical care (Bell, 1998). A research project in Santiago of Cuba aimed at establishing a strategy for implementation of pharmaceutical care assessed the perception and attitudes of patients, pharmacists, and managers. It sought to determine how different social groups perceived pharmaceutical professionals' different clinical services provided and the degree of satisfaction with them. This article published in the Brazilian Journal of Pharmaceutical Sciences identified implementation barriers from the social perspective which allows for corrective measures to be taken (de Oliveira, 2008). The inter-professional relationships between pharmacists and physicians will rely upon pharmacists' communication skills to convince physicians to supply additional medical information along with the prescription. The Pharmacy profession needs to market their services to physicians as being complementary, and not competitive (Albro, 1993). The role of management organizations in the health care system will be crucial as they contribute to the recognition of functions of pharmaceutical professionals to improve quality of life. Barriers related to education and skills: Pharmacy graduates today are better prepared for patient care roles than any previous generation. However, this does not mean that students and practitioners yet understand what patientcentered care truly means; this is an ongoing process of social learning by all involved in the healthcare teams. Pharmacists must seek opportunities to acquire new knowledge and skills required from their new role, becoming lifelong learners. Barriers to implementation of pharmaceutical care in China have similarly reported the need for effective continuing educational programs, availability of greater resources to pharmacies, and effective collaboration with Business and Health Administration Association Annual Conference 2012

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other health professionals. Other research aimed to establish New Zealand community pharmacists in commencing pharmaceutical care reported the lack of: therapeutic knowledge; clinical problem-solving skills; finance; appropriate space; patient demand; access to patient records; and data on the value of pharmaceutical care by over 50% of the 377 respondents (Dunlop & Shaw, 2002). In addition, characteristics of the therapeutic relationship include respect for patients, trust, cooperation with other health providers, empathy, sensitivity, caring, and responsibility for interventions--all need to be modeled and reinforced continually by the faculty. Understanding pharmaceutical care practice is time-consuming and challenging. Preparing personnel, as well as accreditation of practice sites, are also essential (Sakthong, 2007). In Cuba, Pharmacy education curriculums and pedagogical approaches have been modified to accommodate some of these new directions in practice, with a sharper focus on teaching patient care skills. There is also an increased emphasis on competency-based teaching and assessment to ensure that Pharmacy graduates secure the clinical skills required to deliver new cognitive Pharmacy services. In order to make a substantive contribution to outcomes management, the Pharmacy profession has embraced this new practice model by taking direct responsibility for individual patients' medication-related needs. Pharmacists can indeed make unique contributions to the outcomes of medication therapy and to their patients' quality of life. If the profession can demonstrate its ability to manage health and disease, improve outcomes, and reduce costs within the evolving healthcare system, pharmacists then will secure a vital role in the managed health care arena in this new millennium (Gouveia, 1997). NEW TRENDS Today Cuban pharmacists recognize that much remains to be done in this transformation process. One of the greatest opportunities came with the development strategy of the Municipal Home Pharmacy Network (MHPN), (Ministerio de Salud Pblica de Cuba), which has 175 units of multidisciplinary bodies for the evaluation and control of the rational use of drugs in each territory. The pharmacies in the Network integrate the national pharmacoepidemiology and drug administration as its therapeutic resource over, not only conventional drugs, but locally-produced drugs, dispensary, natural and homeopathic, and traditional medicine techniques. The Municipal Home Pharmacy Network (MHPN) has two main objectives: 1. To develop at the starting point a group of specialists in General Comprehensive Medicine, a human resource specialist in the discipline of pharmacoepidemiology, to ensure assessment of the quality of prescription drug use and to target more rational use of drugs in the health care system. To improve the quality of Pharmacy service provided by the community pharmacies network, contributing to improving the population's health care and satisfaction.

2.

This achievement will include a set of actions:

1. To create a national network for pharmacoepidemiology.


1.1 Provisions of resources and methodological documents set. Human resources consist of: Pharmacist (Director) and the General Medical Integral (Chairman of the Municipal Drug Therapy), to be subordinate to the Municipal Director of Health. 1.2 To select the Pharmacy in each municipality that meets the conditions established for the areas of retail, clinic, warehouse, repackaging, office management, quality control laboratory. 1.3 At the provincial level to create a provincial group of Pharmacoepidemiology, directed by a physician with training in Pharmacoepidemiology subordinate to the Deputy Provincial Director of Medicines. 1.4 At the national level, the Center for the Development of Pharmacoepidemiology (CDF) will report to the First Deputy Minister of Public Health.

2. To train staff working in each of the network pharmacies. 139

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2.1 To implement the Course in Pharmacoepidemiology to train doctors who are part of the team. 2.2 To develop courses to national and international levels to complement the training of chairpersons of the pharmacotherapy committees. 2.3 To implement a continuing education program for professional technical staff, who work in pharmacies of the National Network.

3. To design methodological tools for strategy development


3.1 To establish regulations governing the work of the Municipal Committee Chairmen. 3.2 Update the regulations to the work of therapeutic committees in the areas of ambulatory health and hospitals. 3.3 To establish Provincial Regulation Group of Pharmacoepidemiology and Pharmacy Network of the territories. 3.4 To establish the requirements and functions of provincial and municipal offices of the National Network of Pharmacoepidemiology. The evaluation process will include visits to the Provinces to establish regulation requirements in the main municipal drug stores and then to evaluate their development in practice. CONCLUSION Pharmacoepidemiological surveillance across Cuba will be a unique national process that may hold great benefit for modeling by other developing nations. Addressing new social epidemics, neglected diseases, and rising chronic degenerative disease patterns will necessitate the use of a variety of newly introduced powerful and dangerous drugs into a developing nation' population; upgraded practitioners will have to become clinically familiar with this wave of pharmacotherapies, and mechanisms for monitoring them must be established. Systems for monitoring drug safety will be at the cutting edge; these systems may also provide tools for understanding provider and diverse consumer behaviors in drug usage. Pharmacoepidemiology thus represents a higher humanistic approach to controlling cost escalation by improving the quality of medical care in any health care system. Nevertheless, few studies have been published about the impact of pharmaceutical care in Cuba, and less related to its relation to the work of doctors and nurses, as well as in aspects relating to material and political support necessary for this change. A future research agenda would include: the redesign of pharmacies, salary incentives, IT system needs, and so on. Although there is an approach as described in the Manual de Normas y Procedimientos en Farmacia Comunitaria, Direccin Nacional de Farmacia y ptica cited above, the exercise of the practice of pharmaceutical care remains limited because pharmacists largely perform administrative and management functions, as well as those related to drug supply; the functions of Clinical Pharmacy are still applied as an experiment and have not been sufficiently recognized by health authorities, and, in many cases, even by the health teams. The structure, functions and mission of the Cuban health system are a stronghold for the development of the Pharmacy profession, recognizing the contribution of the pharmacist in improving human health. The responsibility of all pharmacists in the continuous improvement of their professional activities through ongo ing training, research, and a patient-centered pharmacy practice is the intended direction. In the future, standardization of a methodology for the practice of pharmaceutical care as a function of the structural health care system, as well as validation of the results of this practice in humanistic, economic and professional terms, will be the test for the Cuban health system's next great achievement. Pharmacy education must continue its development towards a pharmacist capable of fulfilling this mission, with a concomitant social commitment. Ongoing reforms in the Cuban polity toward a mixed economy (private buying and selling of cars and houses, etc. (Burnett, 2011) and its leadership now stressing new productivity gains for economic advancement, portend a balancing act with the past "commitment to history" (Chase, 2011). Notwithstanding, Cuban health workers have historically been able to meet significant challenges and to ably advance health in the population. This direction for the pharmacy profession may mark an additional achievement also.

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Note: * Our thanks to Naimah Malik for assistance in the preparation of this manuscript.

REFERENCES Albro, W. (1993). How to communicate with physicians. Am Pharm, 3(4), 59-61. Anuario Estadstico Cuba (2010). Recursos. Cuadro 115. EJECUCIN DEL PRESUPUESTO Y GASTOS PORHABITANTE.1959,1960,1965,19702008. Retrieved from http://bvs.sld.cu/cgibin/wxis/anuario/?IsisScript=anuario/iah.xis&tag8000=2008&tag8001=Recursos&tag6000=I&ta g5009=STANDARD&tag5008=10&tag5007=Y&tag5001=search1&tag5003=anuario&tag5021=e&tag5013=GUES T&tag5022=2008. Anuario estadstico de salud (2009). Repblica de Cuba. Retrieved from http://files.sld.cu/dne/files/2010/04/anuario2009e3.pdf. Archibold, R. (2011). Cuba Takes Lead Role in Haitis Cholera Fight. New York Times, November 7. Central Intelligence Agency (2011). World Fact Book, Washington, DC: U.S. Government Printing Office. Chase, M. (2011). Cuba rethinks the Revolution. The Nation, November 7, 21-26. Coville, P. (1994). Pharmacy practice around the world. International Journal of Pharmacy Practice, October 4-5. Cuba: Dr Diplomat (2007). Economist, January 27, p. 35. Dunlop, A., & Shaw, P. (2002). Community pharmacists' perspectives on pharmaceutical care implementation in New Zealand. Pharm World Sc 24 (6), 224-230. Everson, D. (2003). The Market Brief: The Biotechnology Market in Cuba. Dept. of Foreign Affairs and International Trade, Canada: Market Resource Center. Ottawa, CA, March, p. 3. Everson, D. (2007). Cuba's Biotechnology Revolution. MEDICC, 9(1), 8-10. Fang, Y., & Yang, S.(2011). Pharmacists perception of pharmaceutical care in community pharmacy: a questionnaire survey in Northwest China. Health & Social Care in the Community, 19(2), 189197, doi: 10.1111/j.1365-2524.2010.00959.x. Fernandez E., & Fernandez, S.A. et al. (2005). Exploring the availability of the Cuban community pharmaceutical services. Rev. De la OFIL, 15; 1, 21-27. Retrieved January 10, 2012, from http://www.revistadelaofil.org/PDFs/OFILn151.pdf. For further information on APHA health study tours of Cuba. Retrieved from www.professionalsabroad.org. Gastelurrutia, M.A., & Fernndez Llims F. (2007). Barriers for the implementation of cognitive services in Spanish community pharmacies. Aten Primaria, 39(9), 465-72. Retrieved January 10, 2012, from http://www.gastelurrutia.com/pdf/barreras.pdf Gouveia, W.A., & Shane, R. (1997).The three dimensions of managed care pharmacy practice. Am J Manag Care, 3(2), 231-9. Health expenditure (2007). Health services - Health - World Development Indicators. Country Comparison Graph. Retrieved from http://www.nationsencyclopedia.com/WorldStats/WDI-expenditure-public-gdp.html. Business and Health Administration Association Annual Conference 2012

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Informe sobre Desarrollo Humano (2010). Edicin del Vigsimo Aniversario. La verdadera riqueza de las naciones: Caminos al desarrollo humano. Retrieved from http://hdr.undp.org/en/media/HDR_ES_Complete.pdf. KaiserNetwork.org (2007). In the quest for Global Health, What puts Cuba on the Map? Rockefeller Foundation and Atlantic Philanthropies, July 23. Kirk, E.J. & Girvan, N. (2010). Cuba In Haiti: Selective commendation, selective indignation, 4(22), p. 478. Retrieved from http://www.pambazuka.org/en/category/features/63886. Manual de Normas y Procedimientos en Farmacia Comunitaria (2005). Direccin Nacional de Farmacia y ptica; Ministerio de Salud Pblica de Cuba. Martinez Sanchez, A.M.(2010). Pharmacy education in Cuba, Pharm World Sci., 32(6), 696700, doi: 10.1007/s11096-010-9434-5. Martinez Sanchez A.M.(2011). Teaching patient-centered care to pharmacy students. Int J Clin Pharm, 33 (1), 5557, doi:10.1007 / s1109 6 -010-9 456-z. Mateu, L., Gonzlez San Miguel, H.M., & Sedeo, C. (2005). Observatorio farmacutico: conocer y transformar. Rev OFIL, 15 (4), 33-38. Retrieved from http://www.revistadelaofil.org/Articulo.asp?Id=54. Millman, J. (2011). New prize in Cold War: Cuban Doctors. Wall Street Journal, 1/15, p.1. Ministerio de Salud Pblica (2000). rea Medico-Farmacutica. Centro para el Desarrollo de la Farmacoepidemiologa. Estrategia de la farmacoepidemiologa y de la farmacia principal municipal (FPM). RESUMED 13(5), 229-31 . Retrieved from http://bvs.sld.cu/revistas/res/vol13_5_00/res06500.pdf. Ministerio de Salud Pblica de Cuba (2005). Manual de Normas y Procedimientos en Farmacia Comunitaria. Direccin Nacional de Farmacia y ptica. Havana, Cuba. Retrieved from http://www.sld.cu/galerias/pdf/sitios/revfarmacia/manual_normas_y_procedimientos._farmacia_comunitaria._2005. pdf. Nicas, J. (2011). Airlines Rev up for flights to Cuba. Wall Street Journal, October 24, p. B1. Reed, G. (2000).Challenges for Cubas Family Doctor -and-Nurse Program. MEDICC Review, 2(3). Retrieved from http://www.medicc.org/publications/medicc review/II/primary/sloframe.html. Salmon, J. W. (1996). Personal communication. Ministry of Pharmaceutical Industry, Havana, Cuba, December 8. Sanchez, A.M. (2010). Pharmacy education in Cuba. Pharmacy World Science, September 15. Sakthong, P. (2007). Comparative analysis of pharmaceutical care and traditional dispensing role of pharmacy. Thai J. Pharm. Sci. 31, 100-104. The Health Care System of Cuba: Report of a Delegation. University of Illinois at Chicago, Chicago, Illinois, January 1996. U.S.D.A. (2008). Cuba's Food & Agricultural Situation Report. Office of Global Analysis. Washington, DC. World Health Organization (2007). Country Cooperation. Strategy. At a glance. Retrieved from http://whqlibdoc.who.int/hq/2009/WHO_DGR_CCO_09.03_Cuba_eng.pdf

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Alina Martinez Sanchez, Ph.D. Faculty of Health Sciences San Jorge University Campus Universitario Villanueva de Gllego Autova A-23 Zaragoza-Huesca Km. 299. 50.830 Villanueva de Gllego (Zaragoza), Spain Tel: 976 060100 Fax: 976077584 Email: saudade680227@yahoo.com

J. Warren Salmon, Ph.D. Professor of Health Policy and Administration School of Public Health University of Illinois at Chicago 1603 W. Taylor Street, MC 923 Chicago, Illinois 60612 Phone: 708 7710854 Fax: 7086898151 Email: JWSalmon@UIC.EDU

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OBESITY IN SCHOOL-AGE CHILDREN


Nashat Zuraikat, Indiana University of Pennsylvania Carla J. Baldessaro, Indiana University of Pennsylvania

ABSTRACT One of the biggest health challenges facing the nation is the obesity epidemic. Two-thirds of adults and one-third of children and teens are either obese or overweight. The economic costs are astronomical and account for $147 billion in direct care costs. What we once thought was true regarding life span and health improvements, we now know to be a falsehood since obesity is related to over 20 major chronic diseases. Recess is an area that is currently being overlooked as an opportunity to engage school-age children to enjoy physical activity. Research has shown that by increasing physical activity, childrens productivity, concentration, and attention and behavior in the classroom has improved. The purpose of this study was to evaluate the effectiveness of a walking program entitled Northern Cambria Colts Walk for Health at Northern Cambria Elementary/Middle School. The program involved all 462 students in grades K through 4 for the school year 2010-11. Each class was assigned an age appropriate distance and when the class met the criteria for the month, a charm was given to each student as an incentive. The findings of the study revealed that a slight decrease of 1% in the BMI greater than 95%. Over the one year time period of the initiative and implementation of the program.

Nashat Zuraikat, PhD, RN Professor of Nursing Indiana University of Pennsylvania E-mail: zuraikat@iup.edu

Carla J. Baldessaro Indiana University of Pennsylvania

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TRACK ETHICAL & LEGAL ISSUES IN HEALTHCARE

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HOSPITAL INDICATORS USED BY CEOs TO DETERMINE THE LEVEL OF ETHICAL INTEGRATION IN THEIR ORGANIZATIONS
John J. Newhouse, Saint Joseph's University

ABSTRACT How CEOs judge the level of ethical conduct and behavior in their organizations becomes a critical issue for several reasons. First, ethical integration is a major management strategy in the overall quality assurance and continuous quality improvement agendas. Second, it supports the hospitals or health systems mission, vision, and values. Third, it improves the overall clinical outcomes of patients and the overall performance outcomes of staff and physicians. Finally, it creates a perception on the part of consumers, patients, and the general public that the institution is well grounded in its approach, treatment, and relationship to those its serves. This study examined how hospital CEOs in Pennsylvania, New Jersey, Delaware, and Maryland understood the level of ethical integration within their institutions. It targeted six major categories of content important to CEOs asking them to assess how components in these areas allowed them to understand what was the level of ethical integration their organizations represented: market environment, patient satisfaction, organizational structure and resources, organizational culture, administrator/manager action, and administrator/manager behavior. Three dependent variables were used in this qualitative survey based study: hospital types, net operating margins, and operating budgets. The findings were similar by hospital size in terms of operating margins and operating budgets. They were also similar in terms of hospital type that disclosed comparative integration levels in community types hospitals, in regional medical centers, in urban teaching institutions, and in specialty hospitals. Differences in the level of ethical integration occurred between hospital types and size. There were differences also in terms of the six major content categories. Areas such as the market environment and patient satisfaction showed differences in the value of serving as indicators of ethical integration. However, strong similarities existed in terms of administrator/manager action and administrator/manager behavior. The study illustrated that CEOs vary in how they view the indicators for ethical integration based upon these dependent variables. The financial resources of the organization, its relative size within a given marketplace impact how the senior administration views its ethical practice. Although this research did not address personal attitudes toward the value of ethics within a health care organization held by CEOs, it was clear that as these senior officers surveyed the level of ethical behavior and practice across their organizations, they saw this picture differently depending upon both internal and external factors that represented their realities.

Dr. John J. Newhouse Department of Health Services Saint Joseph's University 5600 City Ave. Philadelphia, PA 19131 Phone: 610-660-1578 Email: jnewhous@sju.edu

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THE DOCTORS WHO COMMIT MEDICARE FRAUD


Vivek Pande, University of Wisconsin - La Crosse William Maas, University of Wisconsin - La Crosse

ABSTRACT Healthcare fraud is an already enormous, and ever growing problem in the United States. Estimates of the annual cost of this fraud range from $60 billion to as much as $250 billion. The exact amount cannot be determined with any certainty because much of this fraud is never detected. The problem of healthcare fraud is particularly acute when it comes to public health entitlement programs such as Medicare and Medicaid. Unlike private insurers which use sophisticated databases and algorithms to detect fraud and reject fraudulent claims before they are paid, Medicare and state Medicaid programs generally pay all claims and attempt to recover fraudulent payments only after the alleged fraud has been uncovered (this approach, d erisively termed pay and chase, has been much criticized). Accordingly, in July 2011, the U.S. Department of Health and Human Services commenced a pilot program to run Medicare claims through a computerized risk prediction model to attempt to detect fr aud before claims are paid, and thereby keep bad actors out of Medicare and Medicaid. This paper identifies the characteristics of physicians who are bad actors, i.e., they have previously been convicted of Medicare and/or Medicaid fraud. Their names were first gathered from public databases (such as the OIG exclusion list). Because these databases are often incomplete and erroneous, the names were further crosschecked and verified with court records to identify: (i) the specific Medicare fraud these physicians were charged with (e.g., billing for services not provided, upcoding, unbundling, kickbacks etc.), (ii) the disposition of the criminal proceedings (e.g., plea bargain, conviction etc.), (iii) length of prison sentence and/or probation imposed (if any), and (iv) amount of fines assessed and/or restitution ordered (if any). Using other sources of data such as records from the AMA, state medical licensing boards, media reports and internet searches, the paper then demographically categorizes these doctors by: (i) age, (ii) gender, (iii) geographic location, (iv) medical school attended, and (v) medical specialty, and compares these demographics to the demographics of the medical profession as a whole. The paper also outlines what professional sanctions (e.g., medical license suspension, revocation, surrender) were imposed for Medicare fraud and how many of these physicians are still practicing medicine. Lastly, in light of this accumulated data, the paper makes specific recommendations regarding physician training, licensing and discipline, to reduce the amount of Medicare fraud perpetrated by doctors in the future.

Vivek V. Pande University of Wisconsin - La Crosse 223C Wimberly Hall 1725 State Street La Crosse, WI 54601 Phone: (608) 785-6833 Fax: (608) 785-8549 E-mail: vpande@uwlax.edu

William E. Maas University of Wisconsin - La Crosse 223B Wimberly Hall 1725 State Street La Crosse, WI 54601 Phone: (608) 785-6825 Fax: (608) 785-8549 E-mail: wmaas@uwlax.edu Business and Health Administration Association Annual Conference 2012

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WHEN DOES A NON-PROFIT BECOME A FOR-PROFIT ORGANIZATION? AN ANALYSIS OF HYBRID ORGANIZATIONAL STRUCTURE IN THE HEALTHCARE AND INSURANCE INDUSTRY
Devlin Aaron Fisher, Duquesne University Christopher J. Marquette, Central Connecticut State University ___________________________________________________________________________________________ ABSTRACT An important legal issue facing the healthcare and insurance industry today is when a non-profit corporation no longer warrants non-profit status. Normally, income and profits are subject to federal income taxation pursuant to the rules contained in the Internal Revenue Code. However, provisions in the code allow for chartering tax exempt entities known as non-profit corporations. Rules regarding whether an organization qualifies as a tax-exempt entity are stipulated in 501(c) (3) of the code. This regulation states that a non-profit corporation is one that is organized and operated exclusively for a charitable, scientific or educational purpose and that no part of the organizations net earnings inures to the benefit of any private shareholder or indi vidual. A majority of the hospitals in the United States are chartered as non-profit organizations. They qualify based on their charitable purpose of promoting the public health. Many are also affiliated with other non-profit organizations such as religious denominations and universities. Some of these institutions purvey the educational and scientific purposes as well, teaching medical students and performing medical research. Complications can arise when a non-profit corporation forms joint ventures with for-profit corporations or charters for-profit subsidiaries. The healthcare industry has an abundance of organizations with this hybrid structure. Particularly prevalent among these situations is the case of a non-profit hospital owning for-profit insurance subsidiaries. Relevant rulings lead to the conclusion that a non-profit corporation no longer warrants nonprofit status if a subsidiary for-profit corporation begins to direct the actions of the non-profit parent corporation. In the last decade, the healthcare industry has seen significant consolidation through mergers and acquisitions. Included in these mergers and acquisitions are hybrid organizations acquiring hospital and healthcare facilities. A pertinent question is whether or not these acquisitions are designed to expand the network of the subsidiary for-profit insurance corporation, whereby the parent could lose its non-profit status. Another consideration is the competitive dynamics of this trend. The Sherman Antitrust Act of 1890 prohibits contracts restraining trade in interstate commerce. The Clayton Antitrust Act of 1914 extends Sherman to specifically include mergers and acquisitions that substantially reduce market competition as impermissible activities. For most of the 19th century, Sherman was applied solely to pure commerce. In 1982, however, the Supreme Court ruled in American Society of Mechanical Engineers vs. Hydrolevel Corporation that a non-profit organization was liable for antitrust violations. A second pertinent question is whether these healthcare industry mergers and acquisitions violate antitrust law. A further complication is the fact that the insurance industry has a limited exemption from Sherman under the McCarran-Ferguson Act of 1945. A third pertinent question is what rule of law should apply to hybrid healthcare-insurance corporations. Should they be ruled under applicable law pertaining to the parent non-profit or the subsidiary insurance corporation? This study analyzes these complex and confounding issues and provides meaningful insight to policymakers, regulators and healthcare executives.

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Devlin Aaron Fisher Duquesne University 127 Edward J. Hanley Hall Law Library 900 Locust Street Pittsburgh, Pa 15282-0700 (724) 531-0288 fisherd1@duq.edu

Christopher J Marquette Central Connecticut State University Department of Finance and Business Law 469 Vance Hall 1615 Stanley St. New Britain, CT 06050 (860) 832-3221 marquettechj@ccsu.edu

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WHAT ARE ETHICALLY ACCEPTABLE OPTIONS IN THE PROTESTS OF PHYSICIANS TRADE UNIONS?
Eva Grey, St Elisabeth University of Medical and Social Sciences

ABSTRACT Current healthcare has focused a lot on the rights of patients. One of the main documents in this area is The WMA Declaration of Lisbon on the Rights of the Patient.(1) The end of 20th century brought out the problem of rights of the health care professionals and balance between the rights of professionals and patients. Lack of legislation and practical implementation of rights of doctors can lead to protests on their part. This presentation is analyzing ethical aspects of the tools that were used by physicians trade unions to guarantee the rights of doctors in Slovakia in the fall of 2011.

INTRODUCTORY MATERIAL Slovakia, a country in Central Europe, was until 1989 a part of the Czecho-Slovak Socialist Republic. The socialistic idea of equality and ruling power of workers and farmers lead to diminishing of the status of doctors, which had been relatively high in the previous history. During socialism, the profession of a physician was officialy put at the same level as that of any other employed person. Even though a certain respect for doctors persisted in the opinion of public, the salaries of doctors were on a similar level as the salaries of competent workers with minimal education. Young doctors made about as much money as experienced cleaning ladies. After 1989 a process of liberalization started and slowly brought changes in many professions. But the changes for teachers and health care workers were minimal, since they were mostly state employees. With the creation of private health sector, most profit went to the owners and managers of private clinics, though the salaries of health care workers in them increased a bit, too. Dissatisfaction of the doctors has been slowly growing and a lot of them have left Slovakia to work abroad. RESULTS AND DISCUSSION Reforms in healthcare system were not very systematic and many hospitals were constantly creating debt. In 2010, a process of transformation of malfunctioning hospitals to state AS was introduced by the central-right wing coalition government, lead by the current health care minister. The idea behind it was to make the managment of each hospital responsible for the financial functioning of the hospital. It included the responsibility to avoid debt creation. Covering the debts of currently indebted hospitals, as well as a reduction in hospital departments, was considered a precondition to the succesful transformation. The state planned to invest 350 million Euros for the process. By november 2011, about 100 million had already been invested. A social panic was created that the politicians want to sell the hospitals to rich investment groups which would lead to expensive and unaccessible health care for common people(2). This triggered the long fermenting dissatisfaction of physicians with their status and low financial remuneration into protests. Public protests lead by physician trade unions included reduction of health care services. Leaders of protests requested a huge increase of doctors salaries. The minister offered a step-bystep increase, which was not accepted. A strike of doctors in many Slovak hospitals was initiated on 1st of December with about 1200 doctors not working. Eventually the offer of the minister was accepted by physicians trade unions. CONCLUSION Even though the complaints of doctors were justified, the public opinion and the opinion of most bioeticists was, that the strike was an extreme measure, which took patients as hostages in the fight for better salaries of

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doctors. Many people who sided with the doctors at the begining critisized the strike as an unacceptable tool that endangered lives of innocent patientsaa. REFERENCE Bn, Andrej (2011). Diagnza asti lekrov? Konformnos. Tde. 5.12.2011 doma/diagnoza-casti-lekarov-konformnost.html http://www.tyzden.sk/nazivo-

World Medical Association declaration of Lisbon on the Rights of the Patient. Adopted by the 34th World Medical Assembly Lisbon, Portugal, September/October 1981, and amended revised at the 171st Council Session, Santiago, Chile, October 2005 http://dl.med.or.jp/dl-med/wma/lisbon2005e.pdf

Eva Grey St Elisabeth University of Medical and Social Sciences Bratislava E-mail: eva.grey@gmail.com

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TRACK HEALTHCARE EDUCATION

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A FAILING GRADE FOR ABSTINENCE EDUCATION IN TODAYS SOCIAL CLIMATE


William K. Willis, Clayton State University

ABSTRACT As health care dollars and resources become more scare on both the federal and state level, the question needs asked, why are monies and resources spent on programs that fail to deliver adequate results? Health care reform can and should, come, in part, from the re-evaluation of programs that are not providing results under todays social climate. Abstinence education is one such program where inputs are high, while outputs are relatively useless as a deterrent to teen pregnancy, STDs, and other social issues.

William "Kent" Willis Assistant Professor Health Care Management College of Business Clayton State University Phone: (678) 466 4392 E-mail: WilliamWillis@mail.clayton.edu

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COMPETENCE NEEDED IN GLOBAL HEALTH MANAGEMENT EDUCATION


Bander Alaqeel, University of Scranton

ABSTRACT Trends toward improving the quality of global health management education programs center on the role of higher education systems, yet competence in the discipline remains critical. Continuing change based on countries evolving needs and social mission towards health policy must be coupled with research-based findings regarding teaching methodology. While each country customizes its healthcare system by policy, new aspects of teaching methodology do transfer independent of location and priorities. The role which university systems play in educating future educators in the health management teaching field is discussed, with emphasis on academic excellence, accountability to social welfare, and best practices in curriculum structure. This article reviews the comparative effectiveness of global health management education programs. A call is made for global accounting of best practices, both practical and scholarly.

Bander Alaqeel, PT MHA Student Department of Health Administration & Human Resources The University of Scranton 417 McGurrin Hall Scranton, PA 18510 E-mail:alaqeelb2@scranton.edu

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NUTRITIONAL PROVISION IN THE AURORA AREA: A COMMUNITY-PARTICIPATORY EFFORT EXECUTIVE SUMMARY


Ileana Brooks, Aurora University Robert Daugherty, Aurora University

ABSTRACT This paper will focus on an on-going interdisciplinary and community collaborative research and planning effort focusing on the problem of obesity and wellness that is being conducted in Aurora, Illinois. The project grew out of a collaboration of community health, education, and recreation organizations and Aurora University that formed an entity known as the Healthy Living Council. During its first two years of operation the Healthy Living Council received a grant from the Kane County Health Department under its "Fit for Kids" initiative. The grant funding enabled the Council to begin collecting data and information on the nutritional and recreational resources in the community and begin to explore the current health lifestyles of children and families. In the session we will present and discuss the results of our first two years research and planning that focused on the identification, codification and partial analysis of nutritional and physical fitness and recreation organizations and activities. Areas of discussion will focus on the organization of the community coalition that is participating in the research and planning effort, how data and information were identified and studied, and how the information will be utilized in both the Aurora and county-wide health and wellness project concentrating initially on childhood obesity. The presenters will demonstrate the research tools and methodologies used for data collection, and discuss the collaborative research methodology and process that included faculty members from Aurora University, students, and community members. We will also discuss how the work of the Healthy Living Council at the Aurora community level relates to the larger Kane County Fit for Kids initiative and the implications for community and policy change to better the health outcomes for the citizens of Aurora.

EXECUTIVE SUMMARY The Resource Committee is a subcommittee created by the Healthy Living Council to fulfill part of its obligations under the Kane County Fit for Kids Project Grant. The Resource Committee was charged with collecting information and data relative to all resources in the community that relate to physical activity and nutritional provision. This paper will discuss the methodology, implementation, and results of nutritional provision in the Aurora Area. The Resource Committee initially developed a comprehensive listing of the resources in the Aurora area in two major categories: healthy eating and healthy living. Specifically this list identified groceries and other retail outlets for consumable foods, and restaurants and fast food outlets for eating out. RESOURCE MAPPING HLC in collaboration with the City of Aurora has developed initial GIS maps that show: 1) Location of all grocery outlets (by type) in the Aurora city limits; 2) Location of all restaurants (by type: fast food full service) in the Aurora city limits; 3) Overlay map showing the location of schools and fast food outlets; 6) overlay map showing the of grocery outlets by low income census tract areas.

location

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RESTAURANT SURVEYS The Resource Committee (RC) chose to use a modified NEMS-R survey (Saelens et al, 2007) of restaurants in the Aurora area. Restaurants, both full service and limited service, were identified through the Kane County Health Department restaurant data base. Altogether 34 full service restaurants and 37 limited service restaurants in the Aurora city area were surveyed: a total of 71 restaurants. The data collection instrument identified six factors in restaurants: 1) Availability of nutrition information 51.4% of the fast food restaurants and 38.2% of the full service restaurants provided any information on nutrition. The fast food restaurants most often posted information in the restaurant (29.7%) and/or provided information on their website (40.5%). The full service restaurants most often provided the nutritional information either on their regular menu (32.4%), or on their website (32.4%). 2) Availability of healthy eating options 75.7% of fast food restaurants and 85.3% of full service restaurants offered any healthy food options. Within that category 62.2% of fast food restaurants and 73.5% of full service restaurants offered a healthy entre; 59% of fast food and 76.5% of full service restaurants offered a healthy salad, and 29.7% of fast food and 57.6% of full service restaurants offered other types of healthy foods. 3) Promotion of health eating 67.6% of fast food and 73.5% of full service restaurants offered any of the promotion of healthy eating options. Within this category 43.2% of fast food and 38.2% of full service restaurants offered reduced size portions, 21.6% of fast food and 44.1% encouraged healthy requests, and 48.6% of fast food and 64.7% of full service restaurants allowed healthy substitutions. 4) Barriers to healthy eating 62.2% or fast food and 47.1% of full service restaurants had one or more of these barriers present. Within the category the study found that 59.5% of fast food and 44.1% of full service restaurants encouraged large portions; 18.1% of fast food and 8.8% or full service restaurants discouraged healthy requests; and one of the fast food and 11.8% of full service restaurants promoted all-you-can-eat options. 5) Price comparisons of healthy choices and other menu items 15.6% charged more, 18.8% less and 65.6% the same for healthy entrees compared to other entrees offered. Of the full service restaurants surveyed, 3.3% charged more, 6.7% less, and 90% charged the same for healthy entrees compared to other entre items. Of fast food restaurants surveyed, none charged more, 12.1% charged less and 87.9% charged the same for a shared entre; and of full service restaurants 10% charged more, none charged less, and 90% charged the same for a shared entre. 6) Availability of kids menu 29.7% of fast food and 29.4% of full service restaurants offered a kids menu featuring healthy choices. Conclusions of the Restaurant Survey Overall less than half (45.1%) of the restaurants surveyed appeared to provide any type of nutrition information to customers. More study needs to be done in this area to determine the quality of information that is provided, and how this compares with the information recommended by nutritional professionals. The offering of healthy options by restaurants depended upon the restaurants self -assessment of its healthy offerings, and what has yet to be determined is the actual extent and quality of these healthy eating offerings.

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70% of all restaurants surveyed would appear to be engaged in some type of promotion of healthier eating; what has yet to be determined is the actual extent and quality of the healthy eating promotion offered by these restaurants. Of the barriers to healthy eating, the more prevalent practice is the offering of large serving portions, with over 50% of all restaurants surveyed exhibiting this practice. Healthy entrees do not cost any more than other entrees (in 77.4% of all restaurants surveyed). Over 70% of restaurants do not offer a healthy foods kids menu, the national, and now local, attention focused on childhood obesity is clearly warranted. GROCERY SURVEYS

The Resource committee used an easily administered survey modeled on a healthy eating indicator shopping basket (HEISB) approach (Anderson, Dewar, Marshall, Cummins, Taylor, Dawson, and Sparks, 2007). A total of 49 grocery outlets were surveyed: 10 large grocery stores, 12 medium sized grocery stores, and 27 small outlets. Aurora is not an underserved grocery market. Of the 12 medium size grocery stores, 9 were ethnic Latino groceries, and of the 10 large grocery stores surveyed, 4 were Latino. All of the Latino grocery stores were located within lower income neighborhoods, and within walking access of the residents. A price comparison showed that on average the healthy foods surveyed were about 40% less The larger the grocery store, the more healthy food items (as defined by the HEISB survey list) carried. The larger grocery stores averaged 31 items, the medium stores 19 items. Larger grocery stores tended to have higher quality produce. Almost all the larger grocery stores and almost 90% of medium size grocery stores had average to good quality produce. PRELIMINARY CONCLUSIONS AND RECOMMENDATIONS Access to nutritional food both from grocery outlets and restaurants is not a problem for the residents of Aurora community; Information regarding nutrition and healthy eating is not easily available in either groceries or restaurants Follow-up research is necessary to provide more in-depth information

Ileana Brooks Aurora University Dunham School of Business Aurora, IL 60506 630-844-4892 (Phone) 630-844-7830 (Fax) ibrooks@aurora.edu

Robert Daugherty Aurora University School of Social Work Aurora, IL 60506 630-844-5430 630-844-7830 rdaugher@aurora.edu

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TRANSLATING WEB 2.0/3.0 TECHNOLOGIES FROM THE CLASSROOM TO THE REAL WORLD OF PRACTICE
Bernardo Ramirez, University of Central Florida Maysoun Dimachkie, University of Central Florida Reid Oetjen, University of Central Florida Dawn Oetjen, University of Central Florida

ABSTRACT Teaching health care management to graduate students and advanced practitioners requires advanced skill development, active learning, and practical demonstration. Additionally, these future health care managers must be compassionate in order to be successful. This presentation examines possible uses of technologies to advance beyond teaching course content to connect students to the real world of practice. By leveraging Web2.0/3.0 technological tools, attendees can build a knowledge base that will help our on-line curricula and enhance information fluency. These tools offer inexpensive and yet powerful learning platforms to demonstrate leadership, social networks, complex systems thinking, and organizational change, and other applications which could not be accomplished via traditional lecture, discussions, and case methods. This session will provide an introduction to elearning tools such as use of wikis, blogs, social networks, and other technologies for their potential to assist students gain understanding and experience in using technology in distributed learning coursework, the workplace and acquiring skills for success. Objectives: 1. To consider the prospects for adopting technology in distributed learning courses and the classroom to fulfill learning goals beyond teaching course content; that is applied learning goals. Delineate the differences and similarities among content and applied goals. Describe how technology can be used to integrate both content and applied goals. To identify opportunities for faculty to help connect our students with the real world of practice through teaching with technology. To examine possible uses of emerging technologies such as wikis, blogs, social networks and other Web2.0/3.0 applications to assist students in understanding and gaining experience in using technology that will be necessary to achieve success in the workplace. To consider the variety of perspectives that must engage and collaborate to facilitate the translation of technology from the classroom to the real world of practice. Discuss possible methods for assessing the outcomes associate with implementing applied goals. Discuss possible methods for evaluating the effectiveness of translating technology beyond the classroom to the real world of practice.

2. 3. 4.

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Teaching health care management to adult learners, (i.e., graduate students and advanced practitioners) not only requires skill development and practical demonstrations of conceptual ideas, but also active learning techniques; especially when trying to instill values of passion, care, and commitment to patient care. There are many new and innovative active learning tools for teaching health care management. This interactive presentation represents a collaborative and interactive approach to learning. The presentation will identify and examine a topic that has impact not only in the educational process, but also in the professional development area, translating technology from the classroom to the real world of practice. Even though most faculty have experience using technology to assist in teaching course content, little attention has been given to expanding the use of technology to achieve additional goals such as applied learning goals. Thus, our students often view the technology we use in the classroom as something limited to a teaching environment. Conversely, students may also view the technologies that they use outside of the classroom as associated with personal communication use or for entertainment purposes. What students and faculty commonly overlook is that a variety of these technologies also may have practical application and use in the workplace. This presentation considers the prospect of using technology simultaneously for both teaching and application. The presentation will include a discussion of the need to remove barriers that limit both faculty and student efforts to specific pedagogical learning goals. In addition, this presentation, will discuss the use of technology to connect students to the real world of practice so that they can apply what they have learned in the classroom. This session will provide an introduction to a diversity of Web2.0 technologies, such as wikis, blogs, and other forms of social media, providing our students with opportunities to gain understanding and experience in using them in the workplace and acquiring skills for success. To facilitate the discussion, we have assembled a diversity of input reflecting perspectives from faculty teaching a diversity of courses using distributed learning courses, including experiences with international faculty and students. The experience includes the use of institutional support structures that facilitate distributed learning across the university, as well as alumni and prospective employers who seek to employ graduates that have the skills, knowledge and experience to enter the workforce. We discussed possible best practices and some pitfalls to avoid when using these technologies.

Bernardo Ramirez, M.D., M.B.A. University of Central Florida bernardo.ramirez@ucf.edu Maysoun Dimachkie, Ph.D. University of Central Florida Maysoun.dimachkie@ucf.edu Reid Oetjen, Ph.D. University of Central Florida reid.oetjen@ucf.edu Dawn Oetjen, Ph.D. University of Central Florida dawn.oetjen@ucf.edu

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BARRIERS FOR CONTINUING PROFESSIONAL DEVELOPMENT FOR NURSES IN SAUDI ARABIA


Ahmad Aboshaiqah, King Saud University

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ABSTRACT Background: The provision of continuing professional development (CPD) for nurses is challenged with many barriers. Basic nursing education alone cannot effectively meet the challenging and complex demands of the expanding range of health care. Nurses need to be supported by education and training if high standards of care are to be maintained. CPD needs are challenged by multifactorial reasons that place barriers to fulfillment of these needs. These barriers include time, accessibility, staff motivation, marketing and advertising, financial issues. These barriers must be addressed if education and CPD is to be successful in increasing the knowledge and skills of staff and thereby improving the quality of patient care. Objectives: The purpose of the research was to identify the factors that Registered Nurses (RN) perceive as contributing to barriers to CPD at Saudi Arabia. Methods: A descriptive/correlation design was utilized in this study. A convenience sample of 400 registered nurses was surveyed using a researcher-constructed instrument determined to be valid and reliable. Descriptive statistics were used to summarize the characteristics of the subjects. Correlation analyses were used to address study aims. Results: The results showed that 91% of the participants were females, with 53.8% of them below the age of 35 years, 60.5% of them with total experiences below 11 years, , and the majority with undergraduates' degree: 54.6% with bachelor, and 41.4% with diploma degree. 94.9% of the participants were familiar with CPD. The majority 77.3% preferred that the announcements of CPD activities through e-mail/intranet, followed by the poster/flyers with 59.9%. In addition to that the result showed that 79.5% of the sample attended the educational activities based on the board requirements. The study revealed that the following as the three major barriers affecting the participants to attend the professional activities, 38.2% agree that the financial support was the major barriers, followed by the commitment/scheduling problems to attend the educational activities with a percentage of 29.7%, and finally the ability to attend the class regularly with a 19.6%. Conclusion: Staff nurses need to be supported by CPD if high standards of care are to be maintained. Management needs to provide adequate time for nurses to attend programs. The planning and development of CPD must address these barriers if it is to be successful in increasing the knowledge and skills of staff, and thereby improve the quality of patient care.

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Dr. Ahmad E. Aboshaiqah, BSHA , RN, MS, MHHA, PhD. Assistant Professor Chairman of Nursing Administration and Education Department College of Nursing King Saud University Kingdom of Saudi Arabia P.O Box 642 Riyadh 11421 Office : 4693747 E-Mail: aaboshaiqah@ksu.edu.sa

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EXAMINATION OF A HEALTH MANAGEMENT EDUCATION AND TRAINING GRANT


Kevin C. Flynn, University of Scranton Daniel J. West, Jr., University of Scranton __________________________________________________________________________________________ ABSTRACT The University of Scrantons Department of Health Administration and Human Resources was awarded a two-year congressionally-directed federal grant entitled, Health Profession Education and Training Grant (HPETG), which was recently approved for a one-year no-cost extension. The dual purpose of the grant is to first, enhance the visibility of The Leahy Community Health and Family Center, a clinic dedicated to the dual purpose of identifying and meeting the health and wellness needs of underserved individuals in the greater Scranton community, while providing a place where faculty can guide students in a practical educational experience; second, educate the campus community, the residents of Northeastern Pennsylvania and colleagues in the international health community to: 1. Raise awareness for healthcare issues for faculty, students and community leaders; 2. Implement an annual healthcare summit for civic engagement and enrichment; and 3. Develop sustainable healthcare related academic affiliations and initiatives. This presentation examines the factors and conditions needed to achieve successful outcomes of a federal grant and reviews the activities and success achieved since 2009, including: Introduction of four-part educational series by Jesuit physicians to encourage faculty to reinvigorate Ignatian principles and values into healthcare curriculum in an effort to brand a J esuit-MHA degree. Completion of second three-part grant-writing seminar to enhance and improve faculty members ability to successfully write and receive grants. Review outcomes of annual healthcare summit to improve the health profile of residents of Northeastern PA. Continuation of exchange of faculty and healthcare curriculum with Saint Elizabeth University in the Slovak Republic. Review of working lunches seminars featuring prominent speakers to engage faculty and students on topical healthcare issues. _________________________________________________________________________________________ Kevin C. Flynn, MS, FACHE Senior Fellow and Adjunct Professor Department of Health Administration and Human Resources The University of Scranton 415 McGurrin Hall Scranton, PA 18510 Tel: 215-359-6290 E-mail: flynnk5@scranton.edu Daniel J. West, Jr., Ph.D., FACHE Chairman and Professor Department of Health Administration and Human Resources The University of Scranton 417 McGurrin Hall Scranton, PA 18510 Tel: 571-941-4126 E-mail: westd1@scranton.edu Business and Health Administration Association Annual Conference 2012

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TRACK GLOBAL HEALTH AND SOCIAL JUSTICE

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SYSTEM OF GERIATRIC CARE IN SLOVAKIA


Ivan Bartoovi, St. Elisabeth University of Health and Social Sciences

ABSTRACT The work is devoted to the system of geriatric care for seniors in Slovakia. It points on the demographic aspects of the aging of population, on the health conditions of the elderly, on the system of outpatient and hospital care for older patients and on the issues resulting from abolishing the geriatric departments by health insurance companies after 1 July 2011.

INTRODUCTION Slovakia is a relatively small country. Its area is 49 034 km. In 2009, the number of inhabitants was 5 424 925, out of this number those aged over 65 years represented 665 134, i.e., 12.26%. Until the year 2025 this group of population will increase to 20.05%. In 2009, the mean age of inhabitants was 38.5 years, the aging index was 80.0 (aging index = the number of people aged 65+ per 100 children aged 10-14), the life expectancy at birth was 71.27 years for men and 78.74 for women. In the period from 2002 to 2005, the life expectancy at the age of 60 was 16 and 21 years for men and women, respectively (National Health Information Centre, 2010). METHODS Based on statistical data and on ones own experience, the author points upon the ageing of the population in Slovakia and on the system of geriatric care and its current difficulties. RESULTS In Slovakia, general practitioners provide primary care for seniors (Bartoovi, 2006). Special geriatric care: the number of geriatricians working at geriatric outpatient departments totaled to 32.75, the number of geriatric outpatient departments in Slovakia was 98. Hospital acute diagnostics and treatment of the elderly is provided by geriatric departments and clinics (947 beds), intensive care is provided by units of intensive care (only 4 beds in Bratislava). Psychiatric care is provided by gerontopsychiatric departments (322 beds). Long term care facilities and departments provide care for chronically ill patients (2146 beds) and after-treatment departments (636 beds) provide care following the hospital care (Hegyi, 2011). Since 1 July 2011 the health insurance companies have abolished 29 facilities of geriatric type. In comparison with 2008, the number of geriatric departments decreased by 15.4% and of after-treatment departments by 45.5%. Whereas the number of seniors increases, the number of beds of geriatric type falls down. In the period from 2008 to 2010 the number of seniors above 65 years increased by 1.65%, at the same time the number of available geriatric beds declined by 18.51%. In addition, geriatric care in Slovakia is distributed very non-uniformly. The patients contribution to the costs of health care is constantly growing, which befalls mainly the elderly. Whereas in 2002 the contribution amounted up to 66 million EUR, in 2010 it was as high as 1 billion EUR (Hegyi, 2011). DISCUSSION Health status of seniors in Slovakia is not good. Mortality and morbidity are led by cardiovascular diseases, followed by malignant tumors. 6% of population suffers from diabetes, and a large number of patients at psychiatric outpatient departments indicate impaired mental health (Hegyi & Krajk 2010). Currently we witness Business and Health Administration Association Annual Conference 2012

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difficulties in the geriatric care in Slovakia caused by abolishing the geriatric departments by health insurance companies. CONCLUSION Aging of the population is an epidemiological phenomenon typical also for Slovakia. Unlike in most countries of the European Union, the health condition of Slovakian seniors is currently rather poor and requires a great extent of medical and social help (Hegyi & Krajk 2010). Albeit the Slovak legislation starting with the Constitution and ending with the antidiscrimination act creates a modern and European-like legal environment for a human and honest approach towards ensuring the rights of the elderly, the above mentioned facts give evidence on a decrease in economic and geographical availability of the care for seniors and a question arises if the ongoing changes are not a manifestation of discrimination of seniors.

Ivan Bartoovi, MD, PhD Associate Professor St. Elisabeth University of Health and Social Sciences Bratislava, Slovakia E-mail: ivan.bartosovic@gmail.com

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PRELIMINARY STUDY ON LONG TERM CARE IN CHINA: THE CONSUMERS PERSPECTIVE


Qiu Fang, Clayton State University Deborah Gritzmacher, Clayton State University Ronald Fuqua, Clayton State University _____________________________________________________________________________________________ ABSTRACT Faced with the challenges of an aging population, internal migration of labor, and rapid urbanization, Chinas current structure/tradition for providing care for the elderly is no longer viable to meet the needs of the younger population. This paper lays the groundwork for understanding the current situation in Chinas segment of health care, targeted toward the later years of the elderly population, or the Long Term Care market. This first study comes from the elderly citizens who would be placed in these facilities; the consumers perspective. China has undergone dramatic changes in both economic and social aspects for the past three decades. An average GDP annual growth rate of 9.7% during the time coupled with widened income disparity has profound impact on the daily lives of the Chinese. Chinese people find themselves undergoing metamorphosis adjusting to the market oriented economy in replacement of the central planned economy. A preliminary survey was conducted to collect data from NanChang City in the JiangXi Province of China, reflecting the consumers perception on long term care facilities. It explores the possibility that current and/or future generations are open to the idea of accepting Long Term Care facilities as alternatives to the thousand-year traditions. In the past, aged parents live with adult children (especially sons). The dynamics of the changes in demographics has resulted in Long Term Care becoming a social issue rather than mostly a private family matter. _____________________________________________________________________________________________

Qiu Fang Department of Health Care Management College of Business Clayton State University Morrow, GA 30267 qiufang@clayton.edu Deborah Gritzmacher Department of Health Care Management College of Business Clayton State University Morrow, GA 30267 deborahgritzmacher@clayton.edu Ronald Fuqua Department of Health Care Management College of Business Clayton State University Morrow, GA 30267 ronaldfuqua@clayton.edu

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EVALUATION OF THE UNIVERSITY EDUCATION IN THE SOCIAL WORK FIELD OF STUDY AND ALUMNI PROGRAM CONCEPT
Milan Schavel, St. Elizabeth University Miloslav Hettes, St. Elizabeth University _____________________________________________________________________________________________ ABSTRACT There is no quality evaluation in the field of social workers education, thus it is not possible to respond to graduates positions and requests from practice as reflection in using of acquired knowledge in applied activities. Universities in Slovakia in social and behavioral sciences do not have experience with alumni program. We present in this contribution some research results in the field of quality evaluation and content of submitted education as well as study field graduates willingness to participate in the development of social work and their readiness for further education. __________________________________________________________________________________________ INTRODUCTION Evaluation of the social workers education is an important part in the field of study in term of content as well as enhancement of education process alone. There were no presentations of results from research of further education of the social work graduates in Slovakia so-far. Universities do not have elaborated alumni program as part of education assistance and its enhancement or eventually as support for further education. In this contribution we shall demonstrate the results of research on evaluation of contents and quality of education. We will introduce the concept of alumni program for graduates of the university. METHODS We have realized research focused on education evaluation in term of contents and quality of provided education within social work field of study graduates. We have used a method of quantified data, which we have obtained by distributed questionnaire. In addition to descriptive statistics and bivariate analysis we have used method of two variables correlation. During elaboration of the concept of alumni program we have utilized the method of analysis of available resources for this issue, which were applied for our conditions. RESULTS Research and survey respondents referred on necessity to change the contents of education primarily in the content oriented on applied skills in the work with clients. They have willingness to cooperate with school and to participate on alumni program activities. All respondents irrespective of gender, age or length of practice have interest in further education. Respondents remarked on barriers in the field of further education. The majority of graduates are not involved in work of social segment. CONCLUSION Research results suggest necessity to change education contents. It will be necessary to start discussion of educators in social work on national level to this issue. Further education of social workers in Slovakia is not regulated nor conceptually formulated. Positive innovations have to be done also through political decisions on the part of the national Ministry of Labor, Social Affairs and Family. Alumni program is perspective on enhancement in the field of education and further education of social workers and at the same time is perspective for strengthening of social worker status in working life.

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Milan Schavel St. Elizabeth UniversityCollege Health and Social Work in Bratislava E-mail: schavelm@stonline.sk

Miloslav Hettes St. Elizabeth UniversityCollege Health and Social Work in Bratislava E-mail: mhettes@gmail.com

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EXPECTED FERTILITY, MARRIAGE AND RELIGIOSITY IN SLOVAKIA


Jozef Matulnk, St. Elisabeth University __________________________________________________________________________________________ ABSTRACT The purpose of the study was to examine the relationship between expected fertility, attitudes towards the life-long marriage and religiosity. The findings of a survey based on representative random sample of 2020 inhabitants of Slovakia aged from 18 to 60 are presented. Results indicate a positive relationship between expected fertility and attitudes towards the life-long marriage. The differences in expected fertility between married, divorced and single living people are pointed out. The negative influence of the acceptance of extra-marital sexual relations on expected fertility is considered. The four dimensions of the religiosity: the ritualistic dimension, the ideological dimension, the experiential dimension and the intellectual dimension, are analyzed. The positive impact of religiosity on expected fertility is discussed. _________________________________________________________________________________________

Jozef Matulnik St. Elisabeth University of Health and Social Sciences Bratislava, Slovakia Email: matulnik@vssvalzbety.sk

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ORGANISATION AND MANAGEMENT OF ANTIMALNUTRITION PROGRAMMES IN KENYA


Vladimir Krcmery, St. Elisabeth University Dadline Kisundi, St. Elisabeth University Jaroslava Sokolov, St. Elisabeth University Victor Namulanda, St. Elisabeth University Ann Nageudo, St. Elisabeth University Nada Kulkov, St. Elisabeth University Daria Pechov, St. Elisabeth University Mario Janovi, St. Elisabeth University Alexandra Mamov, St. Elisabeth University Petra Stulerova, St. Elisabeth University Anna Porazikova, St. Elisabeth University Sona Revicka, St. Elisabeth University Steven J. Szydlowsky, University of Scranton Daniel J. West, University of Scranton Petra Mikolasova, St. Elisabeth University

ABSTRACT Malnutrition is emerging problem in tropic. In additional increasing number of tropical disease is related to undernutrition. Currently, about 2 billion population is suffering on food and water depression. Therefore we activate our ten years experience from our antimulnutrition program in Kenya*.

INTRODUCTION One of millennium United Nations and World Health Organisation goals are to secure nutrition at least for children needs. Another development goal is to secure drinking water for about 2 mil children and women. About 100 million households have not asses to drinking water and about 500 million have access only to one meal per day. Millennium goals urge government on NGOs to activate within 2015 and 2025 full nutrition for children, resulting to at least one warm meal for mothers and at least 2 meals per day for children needs. PATIENTS AND METHODS St. Elisabeth University since 2002 started in cooperation with existing first anti-malnutrition in Nairobi (since 1999) development of tree antimalnutrition clinics in Lunga Lunga slum (St. Charles Lwanga), second one in the third largest slum in the world in Kibera (1.2 mil. inhabitants) and third Mary Immaculate clinic in Nairobi. Patients flow (mother and children) varied 20 60 per week. In addition, active surveillance and visits in those three slums has been organised on daily basis by PhD students and MSC students of social work on Mary Immaculata and St. Charles Lwanda and St. Vincent clinics in Nairobi. RESULTS Organisation and number of cases/malnutrition pairs is in the Table 1. While measuring the basic anthropometric parameters of children, we have observed about 85% response rates among starving children under 5 years of age.

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Country

Location Nairobi Kibera

Staff 1 2 2 1 2 2

Patients/week (pairs) 20 30 60 20 30 60

Kenya

Nairobi MIC Nairobi Lunga Lunga Mtwapa Muhoroni Malindi

Table 1: Overview of antimalnutrition tropical programs CONCLUSION Successful fight against starving and malnutrition includes strategies on the both local community and international level enrolling academia and NGO. Of 10 millennium goals two directly involve commitments against famine, malnutrition and storage of drinking water. Experience from community and university programme from Kenya are presented to demonstrate joint communication of governmental and NGO academia based approach. Note: * Mary Immaculata Clinic, Nairobi, St. Charles Lwange, St. Bakhita, Kibera, Lunga Lunga, SEUC Tropical University Program Vladimr Krmry Professor St. Elizabeth University of Health & Social work Bratislava, Slovakia tropicteam@gmail.com Dadline Kisundi St. Elisabeth University Jaroslava Sokolov St. Elisabeth University Victor Namulanda St. Elisabeth University Ann Nageudo St. Elisabeth University Nada Kulkov St. Elisabeth University Daria Pechov St. Elisabeth University Business and Health Administration Association Annual Conference 2012

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Mario Janovi St. Elisabeth University Alexandra Mamov St. Elisabeth University Petra Stulerova St. Elisabeth University Anna Porazikova St. Elisabeth University Sona Revicka St. Elisabeth University Steven J. Szydlowski Assistant Professor Graduate Health Administration Program Director The University of Scranton Scranton, PA 18510 E-mail: sjs14@scranton.edu Daniel J. West, Jr. Professor & Chairman Department of Health Administration & Human Resources Panuska College of Professional Studies The University of Scranton Scranton, PA 18510 Email: westd1@scranton.edu Petra Mikolasova St. Elisabeth University

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MANAGEMENT OF EPIDEMIC FAILURE IN AFRICAN HORN: EXPERIENCE FROM ETHIOPIA


Marian Karvaj, St. Elisabeth University Petra Mikolasova, St. Elisabeth University Gertruda Mikolasova, St. Elisabeth University Kristina Pauerova, St. Elisabeth University Jaroslava Sokolova, St. Elisabeth University Vladimir Krcmery, St. Elisabeth University Steven J. Szydlowsky, University of Scranton Nada Kulkov, St. Elisabeth University _____________________________________________________________________________________________ ABSTRACT Famine in African Horn represents serious political, economic, health catastrophe with global impact. The aim of this short communication is to prevent an example of community based antimalnutrition intervention on one of most affected country Ethiopia*. _____________________________________________________________________________________________ INTRODUCTION African Horn is subject of famine epidemics such as Sahel belt for 50 years. However, within last ten years this crisis have been accumulated in Ethiopia, Sudan, Somalia and Kenya and has been declared by WHO and World Food Programme (WFP) as Emergency (Grade 1). Only concentrate action of international community, local government, NGO, politic subject and church can avoid hunger related to genocide in this area. Etiology of famine in African Horn is multifactorial: drought, global warming, climatic change, civil wars, political instability, corruption, bureaucracy of NGO, local government and international community including World bank, Global fund, WFP, Unicef and WHO. PATIENTS AND METHODS Hospital of Bl. Mother Theresa is runed by missionaries of charity in Kibre Mengist in south Ethiopia in Amasa region about 200 km from Kenyan borders and Tuchana region.. Daily patients there are about 70 for the OPD (outpatient department) and 20 for inpatient service. Antimalnutrition programme includes about 40 women and 60 children/ week. RESULTS Within last 5 years we have had at the OPD 2234 mother and 3933 children. Of these amount of children 62,3% had mild, 12,3% had moderate and 35,4% severe malnutrition (Kwashiorkor). Marasmus as the most severe grade was seen in about 10% of children under the age of 5. About 25% mothers did not showed back after receiving the first dose of milk powder for the child. The rest (about 75%) had 2 12 months follow up visit. CONCLUSIONS Ethiopia is, together with South Sudan, Kenya and Somalia, mostly affected with famine and malnutrition epidemic. Daily about 1600 children in those one countries die directly of hunger. Only rapid action of both local and international community can stop this tragedy and restore agriculture economy, education and healthcare systems with support of NGO, World Bank, WFP, Universities and WHO for at least next 10 years.

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REFERENCES Keverenge, D.K. (2007). Social and nursing aspects of malnutrition and communicable disease (1st. ed.). MPC Publishing House Nairobi. Public health risk assessment and interventions-The Horn of Africa: Drought and famine crisis (2011). Retrieved from http://www.who.int/diseasecontrol_emergencies/publications/who_hse_gar_dce_2011_3/en/. Note: * Bl. Mother Theresa Hospital, Kibre Mengist, Missionaries of charity, Kibre Mengist, Ethiopia

Marian Karvaj St. Elisabeth University Petra Mikolasova St. Elisabeth University Gertruda Mikolasova St. Elisabeth University Kristina Pauerova St. Elisabeth University Jaroslava Sokolova St. Elisabeth University Vladimr Krmry Professor St. Elizabeth University of Health & Social work Bratislava, Slovakia tropicteam@gmail.com Steven J. Szydlowski Assistant Professor Graduate Health Administration Program Director The University of Scranton Scranton, PA 18510 E-mail: sjs14@scranton.edu Nada Kulkov St. Elisabeth University

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COMMUNITY BASED INTERVENTIONS AGAINST PROTEINO-CALORY MALNUTRITION: EXAMPLES FROM PROGRAMME GOAT IN SUDAN, RWANDA AND BURUNDI
Milan Schavel, St. Elizabeth University Lucia Paskova, St. Elisabeth University Eva Misikova, St. Elisabeth University Michal Krcmery, St. Elisabeth University Alexandra Mamova, St. Elisabeth University Margareta Kacanyova, St. Elisabeth University Petra Mikulasova, St. Elisabeth University Renata Machalkova, St. Elisabeth University Ivan Duraj, St. Elisabeth University Andrea Bajcarova, St. Elisabeth University George Benca, St. Elisabeth University Jaroslava Sokolova, St. Elisabeth University Nada Kulkova, St. Elisabeth University Vladimir Krcmery, St. Elisabeth University John Mutuku-Muli, St. Elisabeth University Andrej Matel, St. Elisabeth University Ivan Bartosovic, St. Elizabeth University

ABSTRACT Rwanda and Burundi suffered from genocide (1995) and civil war (1999 2005) within last years which resulted to economic poverty with severe social consequences. The aim of this communication is to present 3 years of antimalnutrition strategies to ensure protein-caloric nutrition to pre-school and school children in those two Central Africa countries*.

INTRODUCTION Two of ten millennium goals appeared by Word Health Organisation and United Nations for 2000 2025. The first include antimalnutrition strategies securing at least one food portion per day to all school children, and the second to give at least one warm meal per day to children under 5 years of age. In addition, another millennium goal emphasis to serve access drinking water and basic health care to children and mothers. The aim of this communication is to present 3 years strategies to combat protein-caloric malnutrition in pre-school and school children in Burundi and Rwanda. PATIENTS AND METHODS We have performed a single strategy (GOAT strategy of Global Organisation Against Threat of Hunger and Disease). This simple strategy consists of feeding the population with 100 g of meat (goat meat) which prevents main diseases protecting the children organism against protein-caloric malnutrition. 70 children in Coudi (Rwanda), 30 in Gordim (Sudan), 80 in Mihango (Burundi) and 40 in Kibeho (Rwanda) children has been enrolled, receiving 100 g of baked or smoked goat meat weekly. Mainly (up to 75%) of children never recieved meat before, and were eating only potatoes, brad, sukuzma, chapati and fruits (Children under the age of 2 years).

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RESULTS After implementation of the GOATstrategy, most children should decreased frequency of (i) respiratory, (ii) diarrhoea and their weight increased for more than 5% (82%) and increasing income of vitamins sluble in fat and omega-3-unsaturated fatty acid led not only to improved nutrition status and also substational decrease of episodes of respiratory infections, urinary tract infections and gastrointestinal tract infections and tuberculosis.

Location Buramiro (St. Vincent) Coudi (St. Sarah) Gordim (St. Fatima) Kibeho (Les 40 martyres du Buta)

Year of start 2011 2010 2009 2010

No of children 70 50 42 65

Staff No 2 1 1 2

Table 1: Overview of inhabitants CONCLUSION Simple community strategy based on purchasing, donating, portioning, cooking and portioning of 1 goat per 50 children weekly, improved nutritional and health status and protected children in school and pre-school age in Rwanda and Burundi. Note: * St. Elisabeth University project in Rutovu and Murago; St. Sarah Salkazy Hospital, Rutovu; Lady of Fatima Hospital Gordim Sudan REFERENCES Keverenge, D.K. (2007). Social and nursing aspects of malnutrition and communicable disease (1st. ed.). MPC Publishing House Nairobi. Global Health Observatory. Retrieved from http://www.who.int/gho/publications/en/index.html

Milan Schavel St. Elisabeth University Lucia Paskova St. Elisabeth University Eva Misikova St. Elisabeth University Michal Krcmery St. Elisabeth University Alexandra Mamova St. Elisabeth University Business and Health Administration Association Annual Conference 2012

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Margareta Kacanyova St. Elisabeth University Petra Mikulasova St. Elisabeth University Renata Machalkova St. Elisabeth University Ivan Duraj St. Elisabeth University Andrea Bajcarova St. Elisabeth University George Benca St. Elisabeth University Jaroslava Sokolova St. Elisabeth University Nada Kulkova St. Elisabeth University Vladimr Krmry Professor St. Elizabeth University of Health & Social work Bratislava, Slovakia tropicteam@gmail.com John Mutuku-Muli St. Elisabeth University Andrej Matel St. Elisabeth University Ivan Bartosovic St. Elizabeth University

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SOCIAL SERVICE MANAGEMENT FOR HOMELESS PEOPLE IN CAPITAL CITY OF SLOVAKIA AND THEIR SURROUNDING
Andrej Matel, St. Elisabeth University Jozef Zuffa, St. Elisabeth University Tibor Roman, St. Elisabeth University Maria Romanova, St. Elisabeth University Jaroslava Polonova, St. Elisabeth University Robert Kovac, St. Elisabeth University Terezia Dudasova, St. Elisabeth University Maria Stepanovska, St. Elisabeth University Peter Kadlecik, St. Elisabeth University

ABSTRACT Homelessness can be described as a form of extreme poverty and social exclusion, but just a little attention has been paid to its elimination. St. Elizabeth University in Bratislava has been conducting a research focused on the management of social services for people without a regular dwelling in Bratislava, the capital city and its surrounding. Special attention is paid to case management and organizational management with the aim to improve effective multidisciplinary and interagency cooperation, networking of services and improving the management of their quality. Keywords: Case management, homeless people, organizations management, social services.

INTRODUCTION In 2006 a specific model of resolving homelessness issue in the capital city Bratislava was developed by the group of ten non-profit organizations that systematically work with people without regular dwelling. Its integral part is a systematic approach but not effectively working management was identified as one of the weaknesses. The aim of the paper is to introduce some partial results of the research focused on management exploration in selected centers (institutions) of social services for people without homes in the capital city and its surrounding. METHODS Research sample consisted of centers (institutions) providing social services for people without regular dwelling in Bratislava and its surrounding that were established by or have a close cooperation with St. Elizabeth University in Bratislava and they have a key position in resolving the issue of homelessness. They are: a) Shelter Mea Culpa; b) Against the tide (Proti prdu) streetwork, counseling and management of selling streetwork paper Nota bene; c) De Paul Slovakia shelter, hostel; 2. Malacky: shelter Bethany; 3. Dolna Krupa: shelter Josephinum; 4. Holic: shelter Emauzy; 5. Skalica: shelter Road. In the aforementioned centers (institutions) teachers, students and graduate students from St. Elizabeth University in Bratislava work as social workers, social counselors, street workers, case managers and directors. In the research a qualitative methodology was used. The methods were: participating observation and structured interview. RESULTS In current pilot stage of the research results in the area of case management are being processed. Out of them we have selected multidisciplinary and inter-professional help to homeless women who have experienced domestic violence. Partial research sample consisted of 95 women from two centers: Emauza and Bethany. Table Business and Health Administration Association Annual Conference 2012

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no. 1 shows the cooperation of social workers within the case management with professionals from different areas and other helping centers (institutions) in 16 types of generated categories.

Table 1: The Cooperation of Social Workers Kind of professional help/other professionals/other helping institution Legal counseling (client itself) Legal counseling (because of children) Psychological counseling Psychiatrist Alcohol treatment services Physician Police Civil service (social, financial welfare) Civil service (social protection of children) Municipally office Other NGO Children's home or re-education Social insurance company Housing department Help with employment Financial benefit (from private businessman) Clients using that particular help (%) 36 33 30 14 2 6 13 51 21 35 44 3 13 15 26 2

Research results from other institutions (centers) and areas of management will be known in February 2012. Out of partial results it is clear that leading employers (managers) in social services for homeless people in Slovakia have got three main priorities: 1. 2. 3. Development and promoting of knowledge regarding the importance of setting the quality standards and their implementation. Long lasting and multiple sources financial guarantee. Managing conflicts resolution among clients, employees and between these two groups. CONCLUSION From the research result it is clear that progress towards the multidisciplinary and interagency approach, from the point of the individual professions and the institutions, is rather unsatisfactory. In general there are several topical challenges in management of organizations providing social services for people without regular dwelling: common networking and lobbying in cases of legislative changes; educating and preparing their own project managers that would be able to apply for European grants; to be able and to know how to set the processes in organizations in the way that they meet the quality criteria required by laws and regulations; long term participation in promoting status of social workers through competent marketing contribution of social services for the whole society.

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REFERENCES Matel, A., Olah, M., Schavel, M. (2011). Selected chapters form social work methods I. Bratislava: St. Elizabeth University, 2011. 214 p. ISBN 978-80-8132-027-9. Matel, A., Schavel, M. et al. (2011). Applied social pathology in social work. Bratislava: St. Elizabeth University, 2011. 442 p. ISBN 978-80-8132-009-5.

Andrej Matel St. Elizabeth University College of Health and Social Work Bratislava and University of Trnava Trnava Sputnikova 37, 821 02 Bratislava, Slovakia Andrej.matel@gmail.com Jozef Zuffa St. Elizabeth University College of Health and Social Work Bratislava and University of Trnava Trnava Sputnikova 37, 821 02 Bratislava, Slovakia Tibor Roman St. Elizabeth University College of Health and Social Work Bratislava and University of Trnava Trnava Sputnikova 37, 821 02 Bratislava, Slovakia Maria Romanova St. Elizabeth University College of Health and Social Work Bratislava and University of Trnava Trnava Sputnikova 37, 821 02 Bratislava, Slovakia Jaroslava Polonova St. Elizabeth University College of Health and Social Work Bratislava and University of Trnava Trnava Sputnikova 37, 821 02 Bratislava, Slovakia Robert Kovac St. Elizabeth University College of Health and Social Work Bratislava and University of Trnava Trnava Sputnikova 37, 821 02 Bratislava, Slovakia Terezia Dudasova St. Elizabeth University College of Health and Social Work Bratislava and University of Trnava Trnava Sputnikova 37, 821 02 Bratislava, Slovakia Maria Stepanovska St. Elizabeth University College of Health and Social Work Bratislava and University of Trnava Trnava Sputnikova 37, 821 02 Bratislava, Slovakia Peter Kadlecik St. Elizabeth University College of Health and Social Work Bratislava and University of Trnava Trnava Sputnikova 37, 821 02 Bratislava, Slovakia

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TRACK HEALTHCARE AND HOSPITAL ADMINISTRATION

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CUSTOMERS: HEALTHCARE VS. TRADITIONAL


M. Scott Stegall, Clayton State University Thomas McIlwain, Clayton State University Peter Fitzpatrick, Clayton State University _________________________________________________________________________________________ ABSTRACT Traditionally business administration views healthcare administration as a subset within its professional scope of practice. This presentation is part of a series that challenges this traditional view and focuses on the logic of healthcare administration as a separate profession. Part of that argument is associated with the differences between the healthcare customer and the traditional view of customer. Specifically, the traditional customer is viewed as an individual or organization that has the right to purchase, the financial control over the means to purchase and an ability to judge the quality of the purchase. However, rarely in healthcare do all three dimensions overlap one individual or organization such that the one entity can be called the cust omer. In this presentation, the customer is defined as one or more entities (individuals or organizations) that collectively provide and control the assets used in the purchase or exchange for a product/service/experience who also possess the right to make the purchase/exchange and who is knowledgeable (or at least responsible for the knowledge) of the quantity and quality obtained by the purchase /exchange. For example, marketers for candy bars, cars and hair styling can focus upon individual customers who control both the desire to buy and fi nancial resources to complete the transaction. A customer focus is simplified in this model in that the focus is on individual entitiespotential individual buyers. In the healthcare sector, especially with traditional community hospitals with local comp etition, the idea that the customer is the patient does not match cleanly with reality. Very few patients control both payment and the decision from which hospital services are to be rendered. Most potential patients are either employees or family me mbers of an employee that earns as a work benefit health insurance. If the organization provides options in health insurance, often these programs will cover a limited number of local physicians and hospitals. Additionally, individual physicians may have privileges to admit patients in only one hospital or just prefers to admit to one hospital versus another in the community. More explicitly, consider that the concept of customer fits cleanly on the individual entity of kid when the customer is buying a candy bar. However, the customer concept for the hospital is spread across multiple entities, not one. These include, directly or indirectly, the human resource department buying health insurance options for its employees, the health insurance company including particular hospitals and physicians in its coverage offering, the physician choosing to practice in a hospital and the patient that selects the place of employment, the particular insurance offered, and the physician and hospitals from the package. In this presentation the implications of this multiple entity healthcare customer on the education of professional healthcare managers and leaders is discussed. In particular, the differential impact of this concept as applied to healthcare marketing, healthcare economics and finance and healthcare quality improvement are discussed. Finally, the multiple entity customer is shown to be one of several key environmental realities that demonstrate how health administration graduates work in organizations radically different across several key dimensions from organizations where the majority of business school graduates will be employed. _____________________________________________________________________________________________

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M. Scott Stegall, MHSA, Ph.D., Associate Professor Health Care Management, College of Business 2000 Clayton State Blvd. Clayton State University Morrow, GA 30260 Phone: (678) 466-4650 FAX 678-466-4669 Email: scottstegall@clayton.edu

Thomas F. McIlwain, MPH, Ph.D., Professor Director, MHA Program Health Care Management, College of Business 2000 Clayton State Blvd. Clayton State University Morrow, GA 30260 Phone: (678) 466-4931 Email: thomasmcilwain@clayton.edu

Peter G. Fitzpatrick, Ed.D., R.Ph., Professor Department Head Health Care Management, College of Business 2000 Clayton State Blvd. Clayton State University Morrow, GA 30260

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HOSPITALS AND HEALTHCARE SYSTEMS THE NEED TO REDUCE ERRORS AND MISTAKES
Robert J. Spinelli, University of Scranton

ABSTRACT Whether we call it human error or process error, hospital mistakes and medical errors are having a negative impact on hospital performance and patient care. This is a multifaceted problem within the hospital setting and can be labeled as medication error, surgical error, miscalculation or just sheer carelessness. Whatever the root causes, the impact of these events has a detrimental impact on the lives of patients receiving medical treatment. There are many and various reasons why these errors occur. Effective administrative decisions are needed to implement measures in minimizing mistakes and finding appropriate solutions to maintain excellent patient safety and proper patient care.

Robert J. Spinelli, DBA Assistant Professor Department of Health Administration and Human Resources The University of Scranton 423 McGurrin Hall, Scranton, PA 18510 spinellir2@scranton.edu

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GOVERNANCE ISSUES IN THE TRANSITION TO ACCOUNTABLE CARE: A CASE STUDY OF SILVER CROSS HOSPITAL
Stephen G. Morrissette, University of St. Francis _____________________________________________________________________________________________ ABSTRACT A combination of recent developments in healthcare reform legislation and dynamics in the private payer marketplace has created increased impetus towards clinical integration. One structure, accountable care organizations (ACOs) are featured prominently in recent legislation. Clinical integration and ACOs present significant shared-governance challenges that must be understood and addressed by hospital boards of trustees. Governance issues include: equity participation/structure, governance/control structures, regulatory/legal compliance, risk management, etc. This paper outlines these governance issues using a case study of Silver Cross Hospital as it created the governance structure for its ACO. _____________________________________________________________________________________________

Stephen G. Morrissette, PhD Associate Professor College of Business University of St. Francis 500 Wilcox Street Joliet, IL 60435

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ESSENTIAL DIFFERENCES: HEALTHCARE VS. BUSINESS ADMINISTRATION


M. Scott Stegall, Clayton State University Thomas McIlwain Clayton State University Peter Fitzpatrick, Clayton State University _____________________________________________________________________________________________ ABSTRACT Traditionally business administration views healthcare administration as a subset within its professional scope of practice. In this presentation general systems theory is utilize to illustrate the viewpoint that business administration is different from the profession of healthcare administration just as veterinary medicine differs from the medical practices of allopathic and osteopathic physicians. Veterinarians must deal with a multiplicity of species while physicians only focus on humans, arguably the most complex specie. Differences in the entities treated leads to essential differences in the practices of veterinarians and physicians thus the student practitioner of each profession must obtain different educational experiences in training, knowledge, understanding, general philosophy and values. And while the two administrative professions share a common study of disciplines such as organization behavior, finance, statistics and accounting, this commonality parallels both veterinarians and physicians studying germ theory, microbiology and pharmacology. But how does one claim that it is the healthcare administration profession that is analogous to physicians and requiring its own profession due to complexity? The elevated complexity of healthcare organizations is recognized by no less an authority than Peter Drucker in his statement in the February 2002 Harvard Business Review that hospitals are altogether the most complex human organization ever devised... This presentation builds on this perceived difference using the general systems model of inputs, transformation, outputs with feedback in an open environment to classify the essential differences between well educated healthcare administrators vs. business administrators. Many of the differences in the nature of the work of healthcare administrators are documented elsewhere, however, these lists are often populated by symptoms rather than core causes leading to debates on treatments rather appreciation of essential differences that must be understood prior to treatment. To illustrate this point, note, for example, how it is the understanding of the essential differences between viral and bacterial infections that leads to the effective treatments of the disease causing agent that then leads to the reduction of a fever. The same philosophy is at work when quality improvement methodologies emphasize working on the process generating the problem and not the symptoms. The general systems model focuses our attention on the underlying processes rather than lists of competencies that focus on treating symptoms. In this presentation the essential differences between a mass production organization and a community hospital are examined. From a general systems prospective, these differences include customer complexity (single vs. multiple entity), output type (products/services vs. experiences), status of primary production profession (input) (employee vs. independent business operator), and the transformation process itself (machine bureaucracy vs. professional bureaucracy) operating in environments differing in complexity in both dynamics and regulatory intensity. Both organizational sociology and health services research identify healthcare organizations as something different from traditional business organizations. It only makes sense that the training, education, wisdom and overall philosophy of the development of healthcare management professionals would be parallel but different from business administration. To cross those parallel lines is to degrade the effectiveness of the application of scientific knowledge and understanding. The bottom line of this presentation is healthcare administration is and must remain a separate profession from traditional business administration if our society expects superior performance in that economic sector.

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Scott Stegall, MHSA, Ph.D., Associate Professor Health Care Management, College of Business 2000 Clayton State Blvd. Clayton State University Morrow, GA 30260 Phone: (678) 466-4650 FAX 678-466-4669 Email: scottstegall@clayton.edu

Thomas F. McIlwain, MPH, Ph.D., Professor Director, MHA Program Health Care Management, College of Business 2000 Clayton State Blvd. Clayton State University Morrow, GA 30260 Phone: (678) 466-4931 Email: thomasmcilwain@clayton.edu

Peter G. Fitzpatrick, Ed.D., R.Ph., Professor Department Head Health Care Management, College of Business 2000 Clayton State Blvd. Clayton State University Morrow, GA 30260 Phone: (678) 466-4933 Email: peterfitzpatrick@clayton.edu

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VACCINATION TRENDS FOR PUBLIC AND PRIVATE SECTORS


Suzette Hershman, University of Evansville William B. Stroube, University of Evansville

ABSTRACT A new federal mandate will soon go into effect banning any child with insurance from receiving free immunization shots from the health department. This paper uses the state of Indiana as an example for examining issues related to this mandate. The impact upon health care organizations and consumers is discussed.

INTRODUCTION The state of Indiana is pursing fundamental changes in the delivery and administration of children and adolescent vaccines in the state. A new federal mandate will soon go into effect banning any child with insurance from receiving free immunization shots from the health department. Many parents and private sector physician practices tend to use their countys clinic as a means to escape the high costs of the shots, (Gardner, 2011). These costs may be defined as out-of-pocket expense from the patient perspective or the actual costs to purchase the vaccine from the physician perspective. Indiana counties began to implement this change with notice effective July 1, 2011. However, due to great concerns from providers across the state this date was quickly moved to January 1, 2012 to allow a smooth transition for back to school vaccine requirements. The topic brings to the forefront financial challenges for both the insured family and the private sector physician practice. While providers feel the best medical home for administration and tracking of the childhood vaccination record is the physician practice, they often times refer their patients to local health departments. Physicians may refer patients to receive vaccines when the patient has coverage yet a significant self-pay portion of the bill will remain or when insurance reimbursement doesnt cover the manufacturers cost of the vaccine. The state change for the provider is a growing concern as vaccine costs continue to rise and the insurance companies and employers are passing on more shared costs to the insured. This pass back is done through the employee benefit coverage via co-pays, higher deductibles and co-insurance all leaving the private practice physician to subsidize the lack of state and federal funding and payer coverage to collect the patient due portion of the non-covered costs. This issue may result in financial negative variances for the provider while the practice is purchasing the inventory of the vaccines and paying the overhead to store and administer; however, patients cannot afford to pay the balance due even though they have coverage. Some required vaccinations can cost up to $600.00, a cost that can add up very fast for families with multiple children, the insurance companies used to do a good job of paying for immunizations but thats changing now, or if they do pay its a small portion so parents have been turning to the health department to cut down costs. The main issue is the Vaccination for Children (VFC) was never designed to provide vaccine f or children with full insurance coverage, (Gardner, 2011). The goals of physicians, the National Vaccine Advisory Committee (NVAC), and state and federal stakeholders is to create optimal approaches to vaccine financing in both the public and private sectors (NVAC, 2009).

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CURRENT STATUS STATE OF INDIANA Earlier this year, the Indiana State Department of Health Commissioner provided local health departments with guidelines for the use of publicly funded vaccines, advising them to provide those vaccines only to underinsured and uninsured individuals beginning July 1, 2011. The intent of the policy was to help assure that publicly funded vaccines remained available for the underinsured population throughout the year and to comply with the strict guidelines set forth by the Centers for Disease Control and Prevention (CDC). The ISDH then delayed the policy change to January 1, 2012 for the back to school immunization push, (Larkin, 2011). Some recent articles and news reports throughout the state include: Indiana to stop providing low-cost vaccines to children with medical insurance in July. Indiana will no longer be offering free vaccines for children that are currently covered through some form of medical insurance. State officials say that the move will relieve some of the financial burden weighing on families. The costs of providing free vaccines for children have been trickling down to families for several years. Now parents will have to rely on their insurance companies and local pediatricians to obtain the necessary immunizations for their children, (Vagus, 2011).

As indicated in the above article, parents will have to rely on their insurance companies and pediatricians to obtain the necessary immunizations, is stating the issue of conflict. As a public health provider does the (ISDH) have responsibility to our community to assure all children are vaccinated without putting the financial burden on the provider? How will parents rely on their insurance companies? The controversial decision has received harsh criticism from both medical professionals and parents. Several insurance companies have voiced their concerns regarding the issue, saying the new law may mean a significant number of children may not get immunized, which puts them at risk of serious illnesses, (Vagus, 2011).

The same article also indicates how insurance companies do not see this as their issue to resolve. Health care professionals have suggested the state legislators consider a new law that would require all insurance companies in Indiana to cover immunizations. If legislation would take place, does coverage for the patient mean costs are covered for the provider? As we so often avoid in debate in our political system, access to coverage doesnt mean access to care. Often times, access doesnt mean the physician can provide the service because the coverage may still not cover their costs as learned from the funded Medicaid system of coverage. ISDH states if we dont guard the public funds and simply provide the m to all children, we will run out early and those who truly need the coverage, those who are uninsured and underinsured, will not be able to get vaccinations, (Indychannel, 2011). Board of Health, Greene County, Indiana Notice publicly states Funding for the VFC program is now being affected by these changes. The new requirements closely examine Health Insurance Programs that cover vaccines. The intention is to not leave children without vaccine protection, but distribute vaccine costs to insurance policies that include Coverage of Vaccines. The notice also states, those patients with insurance that covers all vaccines, or have high deductibles and co-pays such as 80/20 will need to go to their own physician/health care provider, GCBH (2011).

RELATED ISSUES AND IMPACT ON PROVIDERS Physicians who provide vaccines to children and adolescents report dissatisfaction with the reimbursement levels and increasing financial strain from immunizations. Although large-scale withdrawal of immunization providers does not seem to be imminent, efforts to address root causes of financial pressures should be undertaken.

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The above article Primary Care Physician Perspectives on Reimbursement Related to Vaccinations is consistent with our local Indiana market. As resulted in the abstract of research, the response rate was 49% of pediatricians and family physicians had delayed purchase of specific vaccines for financial reasons and 53% has experienced decreased profit margin from immunizations in the last three years. Twenty-one percent of respondents strongly disagreed that reimbursement for vaccine purchase is adequate, (Freed, et al., 2008). Tables 1 and 2 below list data collected by the authors. Data are coded to maintain the confidentiality of the sources. While the data collection does not represent a statistically valid sample, the authors feel that these data are representative of the Midwestern region of the United States. Table 1 is a compensation analysis for eight pediatricians for a seven-month period compared to the same period prior year indicates. On average a -13.34% compensation decrease was observed. Table 1: Vaccination compensation for eight pediatricians in the Midwestern US market. Physician A B C D E F G H January July 2011 $ 63,006 108,178 174,968 145,151 150,484 151,324 159,319 153,799 January July 2010 $ 98,572 136,638 205,323 167,192 169,795 161,374 165,758 154,420 Variance $ -35,566 -28,459 -30,355 -22,041 -19,310 -10,050 -6,438 -621.00 % Variance -36.08% -20.83% -14.78% -13.18% -11.37% -6.23% -3.88% -0.40%

Vaccine costs along with labor costs are the highest overhead expense allocation in a pediatricians office. While the decrease in compensation may not be 100% attributed to increase costs of vaccines and changes in insurance coverage, it illustrates the continued financial pressures on the private sector physician. The CDC and ISDH policy change may increase the financial subsidy that physicians must provide if insured patients cannot pay their portion of the balance after insurance to cover the costs of the vaccines. Furthermore, shifting the out-ofpocket costs of the patient responsibility to be paid by the provider. The cost of healthcare is creeping above 19% of the GDP at the same time employers are shifting more of the cost for coverage to the patient or insured. Medical practices are experiencing significant increases in patient due accounts receivable at the same time the CDC and ISDH have implemented this policy change for immunizations. There is a wide range of prices paid by physician practices for the same vaccine product and the reimbursement for vaccines and administration fee by payers. This variation highlights the need for individual practices to understand their own costs and reimbursement and to seek opportunities to reduce costs and increase reimbursements, (Freed, et al., 2008). Table 2: Reimbursement in dollars by selected payers in the Midwestern US market. Description HPV Gardasil MMR Pneumococcal Varicella DTAP Rotavirus Hepatitis B Prevnar Payer A $142.50 148.00 128.00 92.00 89.00 115.15 26.62 93.00 Payer B $140.00 147.00 125.00 89.00 70.72 102.50 40.00 105.03 Payer C $156.89 160.00 130.35 102.83 92.22 122.85 25.54 100.51 Payer D $129.80 105.00 148.60 98.10 69.30 101.20 29.06 114.58

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Cost shifting from the public sector to the private sector for vaccine services continues to cause concern because government programs generally pay less, both for the vaccine itself and for administrative costs. It is not unreasonable to anticipate some variation in a free market; however, it remains essential that the United States maintains its great public health success in childhood immunization through a delivery network that is financially stable and efficient, (Rosenberg, 2009). In a survey conducted to assess the Net financial Gain or Loss from Vaccination in Pediatric Practices found more than one half of the respondents broke even or suffered financial losses from vaccinating patients. The greater proportions of Medicaid enrolled patients served, the greater the financial loss was noted. On average, private insurance vaccine administration reimbursements did not cover administration costs unless a child received greater than three at one visit, (Coleman, et al., 2009). FUTURE ISSUES AND CONCLUSIONS Many community physicians are referring patients with adequate health insurance to local health departments for vaccinations that are intended only for residents who are without insurance or who are under insured and unable to pay for the immunizations. Misapplications of these state and federally funded vaccinations will lead to premature depletion of vaccination supplies in the local health departments, (ISMA, 2011). Its understood why local health departments are advocating that community physicians provide vaccinations to their insured patients. Dr. Larkin, states appropriately using both private and public resources will best assure broader community immunizations and therefore a safer and better-protected environment, (Larkin, 2011). The future issue to be understood is the correlation between insured patients with coverage and the costs of the vaccines for the private sector. The NVAC (2009) recommendations include some future considerations of: VFC program should be extended to include access for VFC eligible underinsured children and adolescents receiving immunizations in the public health department clinics and thus should not limit access only at federally qualified health centers. Supporting vaccine Delivery in the Medical Home by improving business practices in the provider office. The AMA relative value scale update committee should review its relative value unit coding to ensure it reflects accurately the non-vaccine costs of vaccination. CMS should update the maximum allowable Medicaid administration reimbursement amounts for each state and should include all appropriate non-vaccine related costs and determined in current studies. The efforts should be coordinated with AMA review of relative value unit coding. Insurers and health care purchasers should develop reimbursement policies for vaccinations that are based on methodologically sound cost studies of efficient practices. These costs studies should factor in all costs associated with vaccine administration, purchasing, handling, storage, labor, and patient and parent education.

While the state and federal goal is to ensure immunizations for pediatric patient population and to maintain public health, the financial trend and cost shifting is in the hands of the physician to provide the majority of their young patients with vaccinations. A survey of research by Berman (2008) reveals that payments throughout the country for immunizing children do not fully cover the associated costs. Secondly, the survey suggests access in rural areas is already eroding as increasing numbers of family physicians decide not to provide vaccines. Also, findings showed one in five family physicians were seriously considering whether to stop providing all recommended vaccines to privately insured children. The trend to keep the insured patient in the physician practice in place of the health department may be sustained financially if the overhead of the vaccine administration and costs can be reimbursed at 17 % to 28% above the purchase price of the vaccine, (Berman, 2008). Immunization reimbursement is a complex issue involving multiple stakeholders. Resolution of these issues is critical in maintaining the health of individuals and society as a whole.

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REFERENCES Berman, S. (2008). Is Our Vaccine System at Risk for a Future "Meltdown? Pediatrics, 122 (6), 1372 -1373. Coleman, M.S., Megan, C.L., John, E., & Lance R. (2009). Net Financial Gain or Loss From Vaccination in Pediatric Medical Practices. Retrieved 13 August 2011 from http://pediatrics.aappublications.org/content/124/Supplement_5/S472.full. Freed, G. L., Cowan, A. E., & Clark, S. J. (2008). Primary Care Physicians Perspectives on Reimbursement for Childhood Immunizations. American Academy of Pediatrics. Retrieved 13 August 2011 from http://pediatrics.aappublications.org/content/122/6/1319.abstract. Gardner, D. (2011). Some Children Will Be Banned from Health Dept. Shots. Retrieved 13 August 2011 from http://tristatehomepage.com. GCBH (2011), Greene County Board of Health. Retrieved 13 August 2011 from http://www.wrv.k12.in.us/index.php?option=com_docman&task=cat_view&gid=57&Itemid=48. Indychannel (2011). State Health Dept. to Cut Low-Cost Vaccines. The Indychannel.com. Chanel 6 News, 8 June 2011. Accessed, 13 Aug. 2011. <http://www.theindychannel.com/news/28174139/detail.html. Larkin, G. (2011). ASDH Issues New Vaccine Policy. News & Publications. ISMA, 13 June 2011. Retrieved 12 August 2011 from http://www.ismanet.org/news/RRSArticle336.aspx. NVAC (2009). Financing Vaccination of Children and Adolescents: National Vaccine Advisory Committee Recommendations (2009). Journal of the American Academy of Pediatrics, S558, 558-559. Rosenberg, A. B. (2009). Vaccination in the United States: Payer Perspective on the Working Group and Its Recommendations. Pediatrics.aappublications.org. WellPoint, Medical Policy, Technology Assessment and Credentialing Programs, 25 Aug. 2009. Retrieved 13 August 2011 from http://pediatrics.aappublications.org/content/124/Supplement_5/S472.full. Vagus, S. (2011). Indiana to Stop Providing Low-cost Vaccines to Children with Medical Insurance in July. Liveinsurancenews.com. Live Insurance News, 28 June 2011. Retrieved 13 August 2011 from http://www.liveinsurancenews.com.

Suzette Hershman University of Evansville Health Services Administration Program 1800 Lincoln Avenue Evansville, IN 47722

William B. Stroube University of Evansville Health Services Administration Program 1800 Lincoln Avenue Evansville, IN 47722 E-mail:bs52@evansville.edu

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A COMPARATIVE ANALYSIS OF HEALTHCARE SYSTEMS: USA AND SWEDEN


Christopher A. Loftus, University of Evansville William B. Stroube, University of Evansville

ABSTRACT This paper examines the health care systems in the United States and Sweden and compares selected inputs and outcomes. Specific issues are analyzed with emphasis on future financial implications.

INTRODUCTION For decades Sweden has been often referred to as having one of the best health care systems in the world. One confirmation is the health of the people. Sweden has one of the longest life expectancies in the world, which is one frequently used indicator for the health of a population. Among the countries in the Organization for Economic Cooperation and Development (OECD) Sweden had a life expectancy at birth of 81.4 years in 2009. This was two years above the average life expectancy of 79.5 years among all OECD countries (OECD, 2011a). However, life expectancy in the United States was almost one and a half years less, at 78.2 years, than the OECD average in 2009 (OECD, 2011b). Americans often relate spending the most on health care to having the best health care in the world. If this is the case, then why are Americans not living longer and healthier lives? Can Americans learn something from Sweden's system by taking a deeper look? STRUCTURE Sweden's health care system is largely decentralized and consists of 21 county councils and 290 municipalities. Each county council is responsible for the health care of the residents within that area. Sweden has a National Health Service (NHS) system, which is a system that is dominantly financed by taxes. Each of these county councils levies their own taxes on the residents within their region. These income taxes account for approximately 70% of the health care costs. National subsidies cover approximately 20% of the costs while any health services that are provided to the elderly or the disabled are financed mainly by the local municipal taxes (Glenngrd, et al., 2005). STATISTICAL COMPARISON County council taxes play a significant role in financing the health care so it is important to note, that 45.8% of the 2010 Gross Domestic Product (GDP) for Sweden was received from tax revenues, while the US accounts 24.8% of its GDP from tax revenues (CTPA, 2011). With this information it is essential to see how much the government is reinvesting into the health care system as well. The GDP in Sweden in 2011 was $458 billion as compared to $14.6 trillion for the USA. The total population in Sweden in 2011 was 9.4 million compared to 311 million for the USA (TA, 2011). Therefore, for 2011 per capita GDP in Sweden was $48,723 whereas it was $46,945 in the USA. Yet, in 2009 the US was still reinvesting approximately 17.4% of our GDP to total healthcare costs. Sweden on the other hand, has annually hovered around the same percentage with approximately 10.0% of its GDP into health care, which is slightly above the OECD average of 9.5%. This amounts to $7,960 per person in the US as opposed to $3,722 per person in Sweden (OECD, 2011a). If the US is spending so much money, it would be expected that it would surpass other countries with its health service and rank among the world's best. It is equally important to examine resource inputs and outcomes for the health system. For example, the US had 2.4 physicians per 1,000 people in 2009. Whereas Sweden had 3.7 physicians per 1,000 people in 2008, which is above the OECD 2009 average of 3.1. Sweden also had 11.0 nurses per 1,000 people while the US had 10.8 per 1,000 people in 2009. Both of these exceed the OECD average of 8.4 in Business and Health Administration Association Annual Conference 2012

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2009. The infant mortality rate is often utilized as an indicator of the quality of a health care system. In 2009 in Sweden there were 2.5 deaths per 1,000 live births which was the second lowest among all OECD countries. The US in 2008 had 6.5 deaths per 1,000 live births, which is above the 2009 OECD average of 4.4. The US had 25.9 MRI machines per 1 million people as compared to the OECD average of 12 and 34.3 CT scanners per million as compared to the OECD average of 22.1. Both countries have had success in recent decades in reducing daily smoking rates among adults as Sweden's was at 14.3% in 2009 and the USA's was at 16.1%. An additional area of comparison is the obesity rate. In 2009 the US had a 27.7% obesity rate while Sweden reported an 11.2% obesity rate, as compared to the OECD average of 15.1% (OECD, 2011a, 2011b). These factors foreshadow a troubling future for American health care if the US continues to reinvest so much of their GDP into health care while obtaining worse results than OECD countries. Sweden on the other hand is spending less and receiving better outcomes from their care. Table 1: Country Comparison Categories GDP Population GDP per capita GDP to Healthcare Healthcare Spending per capita Sweden $458 billion 9.4 million $48,723 10.0% $3,722 United States $14.6 trillion 311 million $46,945 17.4% $7,960

OUT-OF-POCKET COSTS IN SWEDEN For any office visit in Sweden the out-of-pocket cost can range from 100 SEK (~$15) to see a General Practitioner to 300 SEK (~$45) to see a specialist. The exact out-of-pocket cost is determined by each county council independently. However, there is an undifferentiated ceiling of 900 SEK ($137) that any patient pays in a 12-month period. Every patient can keep a high cost card and track their out -of-pocket payments and the dates on which those payments were made. Each patient starts their 12-month period from their first visit to the physician. These fees account for 2.3% of the county council's total revenue. It is important to note that children and young adults age 19 and younger are not required to pay any of these fees and receive free coverage (Glenngrd, et al., 2005). PHARMACEUTICALS The central government in Sweden has the exclusive right to conduct retail trade in drugs. They gave this responsibility to the National Cooperation of Swedish Pharmacies (LFN). The ceiling for pharmaceutical drug costs is separate from all other health services. As opposed to other out-of-pocket fees, which are set by the county councils, the LFN determines the co-payment for prescribed drugs and these are the same throughout the country. In Sweden a patient must pay the full cost for prescribed drugs, up to 900 SEK ($137). After this point the patient will pay less as the government subsidies will gradually cover bigger percentages of the cost. Within a 12-month period the capped ceiling co-payment is 1800 SEK ($274) (Glenngrd, et al., 2005). DENTAL SERVICES All dental services are free of charge for children and adolescents through 19 years of age. Anyone 20 years of age and older will have dental care paid for through financial subsidies. Each of the subsidies is determined by the central government as well as many capped ceiling protection plans for those groups of people such as the elderly and disabled. Patients typically pay the difference between the actual cost of the dental procedure and what the subsidy will cover. Every patient is placed on a rating scale of either group A, B, or C with A being the best and C being the worst determined by dentists. Subsidies cover more of the cost if the patient is in group A than it will if the patient is in group C as an incentive to encourage good dental hygiene. Patients can also choose to pay a monthly premium or pay per visit. Patients are also only recommended to come in for yearly cleanings as opposed to cleanings every 6 months recommended in the US (Ekman, 2011). Business and Health Administration Association Annual Conference 2012

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PRIVATE INSURANCE County Councils and municipalities are the chief provider of public health care in Sweden covering roughly 90% of services. However, approximately 10% of health care is serviced by private providers. Most of the hospitals are operated by the county councils. Also, the majority of physicians are employed by the county councils. There are a small number of private hospitals and private primary care physicians. However, they must function under contract with the county councils where they pay a contribution to the NHS system. Private insurance is available to Swedish residents, but in 2007 it only covered approximately 3% of the Swedish population. This number has been on the rise in recent years as more employers are offering private insurance to their employees. One of the main reasons for the attractiveness of this model is the advantage of getting around waiting lists that can be problematic in Sweden for elective procedures. The longest lists typically are for orthopedic and plastic surgery. With private insurance, patients can jump these waiting lists. They can also get quick access to a specialist as opposed to having to go through a general practitioner first and then being referred to a specialist. A guideline known as the 0-7-90-90 rule is used to determine how long the process for an elective procedure can take. This guarantee states that any patient should have immediate contact with health care system, see a general practitioner within 7 days, consult a specialist within 90 days, and receive treatment within 90 days after being diagnosed. If this guarantee is not met the county council must set up treatment for the patient in another county council. Patients can look for care in other county councils, but the majority of people stay within their own county council because country councils do not have to provide care to people living outside of their region. Waiting lists in other county councils can be just as long if not longer in other county councils ((Glenngrd, et al., 2005). CONCLUSIONS Currently, 17.4% of the US GDP is devoted to health care. This nearly doubles the OECD average of 9.5%. As the US population begins to age and costs continue to increase, the sustainability of the US healthcare system is in jeopardy. The US must consider the future consequences towards the healthcare of its people if the current rate of spending continues. At this point the healthcare outcomes from that spending have not matched the positive results of other OECD countries that are spending far less. As the US enters into its next healthcare phase it must find a model where quantity meets quality. Sweden and other countries can provide the US with insight and alternate approaches to addressing a wide range of current issues. REFERENCES Ekman, S. (2011). Personal Interview conducted in Sweden and United States, August 2011. CTPA (2011). Centre for Tax Policy and Administration. OECD Tax Revenue Statistics: Table A. Total Tax Revenue as percentage of GDP. Retrieved 10 October 2011 from http://www.oecd.org/document/60/0,3746,en_2649_34533_1942460_1_1_1_1,00.html. Glenngrd, A.H., Hjalte, F., Svensson, M., Anell, A., & Bankauskaite, V. (2005). Health Systems in Transition: Sweden. Copenhagen, WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies, 2005. Retrieved 10 October 2011 from http://www.euro.who.int/__data/assets/pdf_file/0010/96409/E88669.pdf. OECD (2011a). OECD Health Data 2011: How Does Sweden Compare. Retrieved 8 October 2011 from http://www.oecd.org/dataoecd/46/6/38980334.pdf. OECD, (2011b), OECD Health Data 2011: How Does the United States Compare. Retrieved 8 October. 2011 from http://www.oecd.org/dataoecd/46/2/38980580.pdf. TA (2011). Trading Economics. Retrieved 21 October 2011 from http://www.tradingeconomics.com/.

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Christopher A. Loftus University of Evansville Health Services Administration Program 1800 Lincoln Avenue Evansville, IN 47722

William B. Stroube University of Evansville Health Services Administration Program 1800 Lincoln Avenue Evansville, IN 47722 E-mail:bs52@evansville.edu

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DRUG TESTING IN PAIN MANAGEMENT PRACTICE


Ahmet Ozzie Ozturk, Marshall University _____________________________________________________________________________________________ ABSTRACT Chronic disease management is a difficult and expensive enterprise in medical practice. In face of an aging population more and more patients require chronic palliative care, which is disease management without an expected cure. A particular subgroup of such patients requiring palliative care is patients under Chronic Opioid Therapy (COT). Since pain is a purely subjective symptom, monitoring is difficult and critical, especially when prescribing opioids and other controlled psychotropic drugs that have both addictive potential and liability for diversion. In todays America prescription drug abuse and diversion is a present and ever increasing reality. Every clinician and healthcare administrator has an obligation to assess the risks of prescribing and/or dispensing opioids form their pain management clinic, and monitor the drug use closely. Drug testing, especially urine drug testing, seems to be the most objective and reliable tool to monitor for proper use of opioid and other controlled drugs in the pain management setting. This presentation points out to the importance of drug testing in pain management setting, reviews the different modalities of testing, and explains to pros and cons in detail for various drugs. In conclusion, we believe that from an administrative standpoint, drug testing should be an integral part of a pain management practice.

Ahmet Ozzie Ozturk, MD, MS Clinical Professor, Marshall University School of Medicine Department of Neuroscience MS, Health Care Administration Director, CHH Regional Pain Management Center 1623 13th Avenue, Huntington, West Virginia 25701 Phone: (304) 526-2243 Fax: (304) 526-2220 E-mail: Ahmet.Ozturk@chhi.org E-mail: sahrn.ozturk@gmail.com

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AVIAN AND PANDEMIC INFLUENZA (API) BEYOND CONTROLIT IS PREVENTION!


Muhiuddin Haider, University of Maryland Jared Frank, University of Maryland

ABSTRACT Recently, the world at large has seen a measurable increase in the spread and diagnosis of Highly Pathogenic Avian Influenza (HPAI) H5N1. At this time, HPAI H5N1 is of particular concern due to its extreme virulence among wild bird and domestic poultry populations, especially because of its spread through the movement of infected bird populations. Additionally, through aerosol transmission and physical contact with infected fecal matter and bodily fluids such as blood and saliva, HPAI has shown potential for human infection. To date, avian influenza has taken countless lives, both avian and human, cost billions of dollars, through necessary control and prevention measures, to numerous governments and organizations, and now threatens to become a global pandemic. The current public health approach to avian influenza focuses on control and management after an outbreak has already occurred. Unfortunately, during the time following an outbreak, recent research has found problems with issues such as the control of diseased bird/poultry populations, the sanitary removal of the diseased carcasses of deceased birds/poultry, and, most importantly, the treatment of Avian Influenza among infected humans. Through various focus groups and observational studies, researchers have also found lapses in the training and outreach provided to those individuals most at risk of exposure and contamination by HPAI H5N1. New prevention-oriented measures, including the research of new vaccinations, the further development of health regulations and standards, a strong focus on the One Health Initiative, and improved training programs and awareness campaigns, which provide information to the public through television, radio, and even social networks (as available), should be utilized to address the issues associated with avian influenza, especially bird-to-human transmission.

WHAT IS AVIAN INFLUENZA? Throughout the development of civilization, researchers have continuously discovered the means to prevent, treat, and/or control diseases that have plagued mankind. However, there are still many diseases, both those recently presented among human populations and some that have adversely affected health outcomes for years without effective treatment, that have yet to be successfully addressed and eradicated. Specifically, the zoonotic disease known as avian influenza (AI), has caused upwards of tens of millions of deaths among domestic poultry and wild bird populations globally. An even more problematic fact is that numerous regions have seen scattered outbreaks, some with dozens of deaths recorded, among human populations. At the moment, the disease is spreading west from Asia, traveling through the Middle East, and creeping slowly towards Europe in spite of measures implemented by governments and various world health agencies to control such outbreaks. Avian influenza, otherwise known as avian flu or bird flu, is an influenza type A virus. Although there are a variety of sub-types of this particular disease, due to the many combinations of the two components that comprise the virus, haemagglutinin (H) and neuraminidase (N), H5N1 is the most well known sub-type as a result of its past and current virulence among both avian and human populations. As for the components of the virus, haemagglutinin is a protein found on the surface of influenza viruses which is responsible for binding the virus to the cell that is being infected; neuraminidase is also found on the surface of influenza viruses (FAO, 2011). In addition, when discussing the disease itself, there are two types of avian influenza known as low pathogenic avian influenza (LPAI) and highly pathogenic avian influenza (HPAI). While prevalent in many regions, LPAI poses very little danger to birds and almost zero threat to human populations (Haider, Frank, & Noreen, 2010, p. 323). However, HPAI, the category in which H5N1 falls, has a much higher capacity for causing disease than LPAI. As mentioned, HPAI H5N1 is very deadly among birds and can be equally dangerous among humans once transmitted.

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HISTORY AND TRANSMISSION Over the course of human experience with avian influenza, as is the case with many other diseases and/or illnesses, researchers have heavily documented all instances and factors surrounding outbreaks of the disease. Outbreaks among animals, transmission to humans, and negative effects on the environment have been recorded as to their duration, scale, and the total number of resulting cases and subsequent deaths among birds and humans. In addition to these measureable aspects of outbreaks, researchers have also kept a comprehensive timeline of every case of animal and human infection as reported by countries across the world. From the initial isolation of the H5N1 virus in 1996 in the Guangdong Province of China to the recent outbreak of H5N1 in the Banteay Meanchey Province of Cambodia (September 12, 2011), the World Health Organization (WHO) has compiled a timeline, entitled H5N1 avian influenza: Timeline of major events, which consists of all the significant points in history to date regarding avian influenza (WHO, 2011). As mentioned, avian influenza affects both domestic poultry and wild bird populations in many countries. Outbreaks, due to transmission between these various populations, can occur in the wild, at commercial farms and personal farms, and at live bird markets. Although everyone is at varying degrees of risk of contracting avian influenza, there are particular actions that result in higher chances of infection for certain individuals than others. As aforementioned, those who keep or sell poultry are among those at risk of bird-to-human transmission of avian influenza. Specifically, some of the factors that contribute to spread of HPAI from birds to humans include slaughtering poultry and preparing the meat in the home, direct contact with sick or infected birds, and the consumption of infected poultry (Haider & Applebaum, 2011, p. 20). Although the threat of AI is spreading rapidly outwards from Asia, a large threat remains in many regions of the continent. Not only are farmers and poultry workers contracting the disease through improper handling and cleansing of poultry, but, due to low hygiene conditions and close quarters, the disease continues to spread unchecked throughout domestic poultry and wild bird populations. If one domesticated bird has the strain, it can spread to other birds in the flock quickly, well before culling or other measures of containment can be effectively implemented. CURRENT STATUS & FUTURE RISK Presently, there is an increased risk of infection for those improperly handling diseased poultry or coming into contact with infected fluids or meat, thereby contracting the disease through animal-to-human transmission. However, the virus has not yet mutated into a form that has high potential for human-to-human transmission, though current research has hinted at the future possibility of a mutation resulting in a strain with such potential. Regardless, as realized through recent data on the transmission of the disease from animals to humans and its incidence and prevalence in human populations, researchers have found that the lack of up-to-date practices and the utilization of inadequate methods continue to put people at risk of contracting the disease. In an effort to decrease the risk of transmission, prevention, through methods such as education and focused training sessions, can play a significant role in informing populations about avian influenza. Especially in developing countries where avian influenza has had the greatest impact, individuals and communities can be trained on the proper handling of poultry, the temperature at which meat should be cooked to prevent infection, and to minimize contact with the feathers, intestines, blood, saliva, and droppings of diseased or dead birds. Further, because avian influenza affects both poultry and humans, a multi-sector approach is necessary to manage the disease. As a major part of this multi-sector approach, avian influenza is best addressed through a One Health perspective, otherwise known as the One Health Initiative, which considers human, animal, and eco-system health to be inextricably linked. In the case of avian influenza, the health of the poultry directly impacts and is impacted by humans and the local eco-system. This paper will further examine this interconnected web of health from the One Health perspective, emphasizing some important gaps that are not adequately addressed in avian influenza control measures. EFFECT OF AVIAN INFLUENZA WORLDWIDE Along with the increasing numbers of deaths within domestic poultry and wild bird populations throughout numerous countries in the Middle East, Africa, and Asia, human deaths have also steadily continued to occur in spite of measures designed to control the spread of this disease. In fact, there are fifteen (15) countries that have reported

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human cases and/or deaths from HPAI H5N1. These countries are ordered from highest to lowest number of human cases/deaths through August 2, 2011 in the following table: Table 1: Countries with HPAI H5N1 Human Cases & Deaths Country of Impact Human Cases Human Deaths

Indonesia 178 146 Egypt 144 48 Vietnam 119 59 China 40 26 Thailand 25 17 Cambodia 16 14 Turkey 12 4 Azerbaijan 8 5 Bangladesh 3 0 Iraq 3 2 Pakistan 3 1 Lao Peoples Democratic 2 2 Republic Djibouti 1 0 Myanmar 1 0 Nigeria 1 1 Data obtained from World Health Organization (WHO, 2011) As you can see in Table 1, avian influenza has had a substantial impact on human populations in Southeast Asia (i.e. Indonesia and Vietnam) and an equally large effect in Northern Africa (i.e. Eygpt). Further, instances of the disease in such countries as Turkey, Iraq, Djibouti, and Nigeria are indicating a potential trend in the spread of the disease further east through countries in both the Middle East and Africa. This potential trend may be further indicated by the outbreaks of HPAI H5N1 among birds in countries including Israel, Japan, Republic of Korea, Mongolia, and the Palestinian Autonomous Territories [West Bank] (FAO, 2011). Should measures not be taken, as mentioned above, AI may continue to spread along this path through commonly utilized transportation routes for poultry, potentially threatening new, unsuspecting populations. In their mid-year review of avian influenza in 2011, the FAO found that within countries in Asia and AfricaThe Peoples Republic of China in East Asia, Vietnam in the Greater Mekong sub -region, Indonesia in Southeast Asia, Bangladesh and India in the Indo-Gangetic Plain, and Egypt in North AfricaH5N1 HPAI remains entrenched, and these countries are considered endemic for the disease (FAO, 2011, p. ix). Three countries, Bangladesh in South Asia, Indonesia in South East Asia, and Egypt in the Middle East, have been increasingly representative of areas that have focused heavily on control methods, which should focus on the benefits of prevention. In fact, as recently as June 22, 2011, The Ministry of Health of Egypt reported a human case of H5N1, which was confirmed by the Egyptian sub-national laboratory for Influenza in Aswan and the Central Public Health Laboratories in Cairo, a National Influenza Centre of the WHO Global Influenza Surveillance Network (WHO, 2011). In this instance, the individual developed symptoms, which were recognized, and they were placed in the care of a nearby hospital. While the individual received medical care, through treatment with oseltamivir, otherwise known as tamiflu, which slows the spread of the influenza virus between cells, there was a nine day delay between the development of symptoms and treatment, with death following a day after the first treatment. Unfortunately, it appears that in this case, as present in many communities that have little to no access to education or current medical facilities, that the symptoms were recognized much too late, the treatment was given long after symptoms were presented, and the exposure incident had not been fully discerned. Indonesia is another country which has been heavily impacted by HPAI H5N1. As the country with the most recorded human cases and deaths from avian influenza, this has been a very important area in terms of control and preventing disease. Unfortunately, problems such as the complex and weakly regulated structure of the poultry Business and Health Administration Association Annual Conference 2012

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sector has hampered the control and prevention of avian influenza in Indonesia (FAO, 2011, p. 66). After years of trying to control outbreaks on a case-by-case basis, the FAO along with the Ministry of Agriculture of Indonesia and private sector market-traders have begun to team up to implement prevention-oriented measures. A specific example includes initiating a cleaning and disinfection program for poultry transport vehicles at collector yards (FAO, 2011). Instead of having to cull large numbers of poultry to control the spread of the disease and subsequently losing money, preventative measures are beginning to be recognized as both necessary and economical. In case of an outbreak, regardless of any preventative measures implemented, the FAO Emergency Centre for Transboundary Animal Diseases Avian Influenza Programme has provided funding to help the government of Indonesia to implement a host of avian influenza prevention, surveillance, response, control, and research and communication activities nationwide (FAO, 2010). Bangladesh is also seen as a hotspot for avian influenza. To date, there has been much done by the international community in the way of supporting the government of Bangladesh to control any outbreaks of HPAI H5N1. In order to further emphasize the global impact of HPAI H5N1, the map below gives a global geographic representation of the spread of AI over the past eight years:

Figure 1. Areas with confirmed human cases of H5N1 avian influenza since 2003*

As seen on the map, the areas colored in red on the map are those areas with confirmed human cases of H5N1 avian influenza since 2003, as of the date May 6, 2011 (WHO, 2011). The number of deaths attributed to the disease among humans within each country at this particular point in time has also been provided. While the above tables and figures have examined the distribution of cases and deaths by country, the following table gives a total of the same information for the years 2003 through the present:

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Figure 2. HPAI H5N1 Cases & Deaths Based on this graph, following a rapid increase in the number of human cases and deaths over the first few years of AIs reemergence, the numbers seem to have since declined. However, regardless of any decline in HPAI H5N1 human cases and deaths, the fact remains that, as reported by the WHO as of August 2, 2011, there have been approximately 566 human cases of avian influenza globally, with 332 total deaths (WHO, 2011). CONTROL OF AVIAN INFLUENZA In an effort to deal with outbreaks of AI, health organizations, governments, and local and state agencies within numerous countries have been working to develop and implement control measures to prevent further loss due to the disease. Currently, there is no treatment for avian influenza among humans beyond treating the symptoms, such as a cough, fever, or trouble breathing, associated with the disease. Unfortunately, animals that become infected with the disease are not so treatable. In fact, control me asures such as rapid culling, extensive quarantines, and sanitary measures have been taken (Haider et al., 2010, p. 324). Additional methods for control include the rapid removal of the fecal matter, blood, and other bodily fluids from diseased/infected birds so as to prevent runoff. These measures, however, are not considered truly effective as the quarantined birds often die, the culling must encompass some not yet diseased birds because they may carry the virus and infect others, and any sanitary measures taken may not encompass all areas where the outbreak occurred. However, the FAO has reported that good husbandry, proper nutrition, and broad spectrum antibiotics may reduce losses from secondary infections (FAO, 2011). Along with an examination of the methods for controlling an outbreak, it is also important to study the programs currently in place within countries that commonly experience outbreaks. The FAO has recognized that implementation of various control measures based around early detect ion and stamping out, appears to have reduced the number of cases but the virus has not been eliminated (FAO, 2011, p. 51). Concerning potential issues with control, the FAO has recognized various constraints for disease control and responses (FAO, 2011, p. 55): The requirement of a government order before culling delays early response The quality of post-outbreak disposal, cleaning and disinfection is substandard The location of commercial farms in densely populated areas makes movement control of people and animals difficult Borders are long and porous The source of infection is unknown Tracing infection forward or backward is difficult On the other side of the argument, however, it is noted that these control measures have resulted in a decrease in the time required for detection, laboratory testing, and culling (i.e. stamping out) after infection. Business and Health Administration Association Annual Conference 2012

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Regardless, the focus on avian influenza has seen a shift in methods towards a preventative approach. Currently, regulations are being developed, such as the Animal Slaughter and Meat Quality Control Act of 2010, and education and training is being provided to help ensure faster diagnosis of the disease so control measures can be taken to prevent spread of the infection. As of 2007, the Third Global UNSIC-World Bank (pg. 67) Progress Report found overall improvement in the ability of numerous countries to respond to HPAI outbreaks by way of new surveillance techniques, updated laboratory systems, and an increased capacity of health systems, though varying by region, to handle potential and real threats to human health. However, this same report found multiple issues such as an insufficient joint working of animal and human health surveillance and response networks and lack of significant tran slation into behavior change among individuals and communities of the increasing awareness of the threat posed by HPAI H5N1 (UNSIC & World Bank, 2008, p. 67). With proven measures of control already in place, future efforts must now be placed on the development, build up, and implementation of prevention-oriented measures. COSTS OF CONTROL Since the outbreak of highly pathogenic avian influenza (HPAI) H5N1 in 1996 and the subsequent outbreaks across the world, billions of dollars have been pledged and globally distributed by numerous countries in an effort to control and prevent the rapid spread of this disease. As noted by the United Nations (UN) System Influenza Coordinator & World Bank, in their document, Responses to Avian Influenza and State of Pandemic Readiness, the rapid spread of HPAI has resulted in significant socioeconomic losses, numerous human deaths, and the potential threat of a human pandemic influenza (UNSIC & World Bank, 2008, p. 8). There have been many advances in control measures such as the development of surveillance techniques, updating health care facilities, such as hospitals, laboratories, and clinics, and improving upon health systems and outbreak response networks. In fact, the ability of a country to carry out effective disease management in cases of an outbreak is highly dependent upon such constructs as capacity building, the training of workers and volunteers and provision of commodity supplies, and infrastructure development. Further, logistics management focuses on issues pertinent to implementing disease management strategies such as space and equipment availability, staffing and human resource skills, supplies of relevant commodities, recordkeeping and reporting, and transportation (Haider & Applebaum, 2011, p. 9). Additionally, there is an ongoing need for the provision of clean water and cleaning supplies, such as sprayers, detergents, masks, and gloves, especially in live bird markets, and ongoing surveillance/monitoring. As expected, however, there are high costs associated with infrastructure development, especially in (low income) developing countries, and regular training of staff and volunteers to carry out an effective outbreak response and successfully implement biosecurity measures. Though government, and international, assistance is often provided in cases of an outbreak, it is incumbent upon each country to develop, fund, and implement their own disease management programs. As an example, the United States Agency for International Developments (USAID) Stamping Out Pandemic and Avian Influenza (STOP AI) provides assistance, such as through training and public-private partnership development, in order to better prepare countries for responding to and recovering from HPAI H5N1 outbreaks. Along with providing technical assistance, STOP AI aims to mobilize public and private sector partners as well as NGOs to implement systematic and sustained behavioral changes that will result in measureable improvements in biosecurity (Haider & Applebaum, 2011, p. 6). However, such collaborative efforts are often limited by issues including opposing political views and the time involved concerning the political process, private sector motivation (i.e. direct benefit), public sector oversight and regulation, and cost-sharing. Going forward, it is important to note that efforts involving capacity building, logistics management, and communication for behavior change are not only measures used to manage (control) and/or eradicate avian influenza in live bird populations, but can play a significant part in outbreak, and subsequently disease, prevention (Haider & Applebaum, 2011, p 8). As noted above, while there are numerous methods for controlling the spread of influenza, the costs associated with control of an outbreak, such as rapid mobilization of a global health response, mass production of treatments and other health services, and related efforts, are very high. However, a focus on prevention has shown a decrease in the overall cost associated with disease. Concerning past experience with multiple outbreaks of influenza, though not on the scale of a potential outbreak of avian influenza at the level of human-to-human transmission, the WHO recommends annual immunization of at -risk persons as the best and most cost-effective Business and Health Administration Association Annual Conference 2012

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strategy for reducing influenza-related morbidity and mortality (WHO, 2011). Similarly, on a more basic level, the benefits received and costs avoided as a result of strong hygiene practices can not be overlooked. Of these practices, hand hygiene and surface cleaning are among the simplest and most cost-effective ways to prevent transmission of the highly pathogenic avian influenza virus (WHO, 2011). CONTROL & PREVENTION Although control and prevention appear to be two different methods for addressing the same problem, it should be noted that researchers, agencies, and governments can approach AI successfully utilizing measures from both areas simultaneously. In fact, the FAO Emergency Centre for Transboundary Animal Diseases (ECTAD) produced a document in January 2007 called Protect Poultry Protect People: Basic advice for stopping the spread of avian influenza. This document provides a quick, but thorough, review of current prevention and control measures when dealing with potential and real cases of avian influenza among wild birds, domestic poultry, and humans, and how transmission may be prevented between animal-to-animal and animal-to-human (ECTAD, 2007). Further, the figure below examines measures of control and prevention and the overlap between both approaches.

Figure 3. Control vs. Prevention: Compare & Contrast

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PREVENTION OF AVIAN INFLUENZA Although control and prevention both have a role in dealing with avian influenza, the majority of the focus should be placed on prevention. While control aims to prevent further spread of a disease in a region in which an outbreak has already occurred, prevention seeks to address potential vulnerabilities ahead of time in order to prevent an outbreak from occurring in the first place. As seen by the examination of past and present control measures utilized for handling avian influenza outbreaks, it is necessary to implement new strategies to address the issues faced as a result of this disease. Recent research has shown that it is possible to utilize resources more strategically by adopting a prevention-centered approach, especially in those areas currently at a high risk of an outbreak of avian influenza. In fact, to date there have been lapses in training and outreach, inadequate education, and poor dissemination of health information. Researchers have also noted that overall, knowledge is necessary, but NOT sufficient to produce behavior change. Perceptions, motivation, skills, and factors in the social environment play important roles (Glanz & Rimer, 1995). Therefore, education program and interventions going forward should incorporate comprehensive health education with related behavior change methods so that individuals are not only knowledgeable about what needs to be changed, but they can also have the self efficacy to carry out the healthy behaviors. As it pertains to defining a countrys risk status, all countries are at varying levels of risk of avian influenza due to reasons including improper procedures and lack of food and agriculture standards. High risk areas may be defined as those that are currently experiencing or have already experienced an outbreak. Similar to the manner in which control measures are currently being implemented to combat avian influenza, potential preventative strategies can also be implemented and then analyzed as to their effectiveness. If successful interventions can be found to produce significant results, the intent would then be to widely disseminate these measures in other high risk areas, areas considered to be at low risk (those which have had limited outbreaks of the disease), and even in those regions that have had no previous experience with avian influenza to prevent the possibility of a future outbreak. The prevention of avian influenza can be defined as hindering both the outbreak and spread of the disease. As seen by the various preventative measures to be examined, there will be a focus placed on the Social Ecological Model of Prevention, developed by the Centers for Disease Control and Prevention (CDC), which aims for better health outcomes through a tiered approach, at the individual, community, and societal levels, for identifying areas for prevention activities. This model can be best characterized as an upstream approach where, as one moves upstream, one makes their way to larger streams, which then lead to rivers, and ultimately, to the source of the problem. This is a proactive, systemic approach, though fairly complex, which better enables researchers to get to the core of the problem. The overall aim is to reduce morbidity and mortality rates. By preventing an outbreak before it occurs, resources can be directed toward broader improvements in sanitation and hygiene practices that will positively affect not only avian influenza control efforts, but those of many other communicable diseases. Education and Training Sessions One of the main prevention oriented efforts currently in place in many countries and utilized by world organizations is the mass utilization of education programs through awareness campaigns and focused training sessions. The idea behind the use of education programs, whether at the individual, group, or community level, is to provide information on handling the spread of avian influenza, especially regarding how the outbreak of the disease can be prevented in the first place. Research indicates that the aforementioned awareness campaigns, including targeted training sessions and health information dissemination, should aim to prevent avian influenza by focusing on a variety of aspects including how to: Maintain a sanitary environment Maintain the overall health of poultry/livestock on the farm Properly handle diseased birds Properly dispose of the diseased bodies of dead birds Properly cleanse birds/poultry and cook the meat appropriately before consumption

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Transport poultry/livestock under conditions which prevent the spread of disease in case of an outbreak

While these methods are very helpful, there are additional measures that may be taken by farmers and commercial businesses to prevent virus transmission, and resulting issues, among their poultry and other at risk populations. These additional methods include meeting the regulations and standards set forth by local, state, and federal governments and the provision of vaccinations. The manner in which education is provided is crucial and depends on the audience of interest. The primary way in which information should be disseminated, which could reach a wider audience and in a more cost effective manner, is through awareness campaigns (media) by way of television, radio, and social networks, where available. Through these methods, information can be provided on sanitation and outbreak control measures, new policies and regulations, and vaccine dissemination. For a more direct approach, community oriented training sessions would educate the population at a more personal level and potentially result in greater behavior change as the community works together to ensure prevention. Key limitations of these methods include availability, especially in the developing countries, and cost. When considering these widespread education programs, the focus should primarily be on training farmers since flu transmission occurs primarily during bird/poultry handling and cleansing process. If the lay population comes into contact with avian flu, the interventions then become control-oriented. However, in addition to farmers, training sessions and education-oriented campaigns should target both men and women, especially the wives of the farmers. Although the most likely recipients of this information would be [male] farmers, recent focus groups among women in Pakistan find that, to ensure a faster spread of awareness of Avian Influenza throughout the various regions, training sessions and related health education programs should focus on incorporating both genders (Haider, Frank, & Noreen, 2010, p. 329). As Haider et al. discovered, after conducting focus groups with two groups of women in Pakistan, many of whom had husbands whose occupation was farming and/or had knowledge about avian influenza through their husbands going regularly to live bird markets, it was apparent that there was a lack of education within the various communities in the region of study. As a result of this study, more training sessions should be scheduled, and the information covered should be more extensive, especially regarding the transmission of the virus and the most recent preventative measures (Haider et al., 2010, p. 332). Vaccinations The utilization of educational outreach and training sessions covers one aspect of the prevention-centered approach. However, an integral part of these awareness and information driven campaigns is the focus on spreading awareness of current Avian Influenza vaccination measures. Specifically, the method of vaccination has been proven to be an effective tool for preventing disease by enabling resistance, thereby reducing the chance of becoming infected during an outbreak. Similarly, vaccination of poultry and humans helps to control disease in both populations by stalling or stopping the spread of the disease in question. In fact, in developing countries, vaccination programmes in avian species have been recommended recently, however it will require concurrent management of local husbandry practices and industry compliance to eradicate the disease rather than the establishment of an endemic situation (Capua, 2007, p. 5645). While developed countries have had lower levels of risk of an outbreak of avian influenza, as indicated by both the lack of animal and human cases and deaths from the disease and the architecture currently in place, including regulations and standards, health education programs, and health services, many of these countries are not taking any chances. In developed countries vaccination is being used as a means of increasing resistance of susceptible animals to reduce the risk of introduction from the reservoir host or to reduce secondary spread in densely populated poultry areas (Capua, 2007, p. 5645). Officials, researchers, and businessmen/farmers, are aware that control measures such as depopulation through massive culling is not feasible when both food supplies and economic stability are at risk of upset due to the spread of disease. By focusing on vaccinations, the health and safety of domestic poultry can be maintained as long as the efficacy of the vaccine is constantly monitored, infected birds are managed appropriately to prevent infection of healthy populations, and most importantly, regulations and standards are met and exceeded such that HPAI H5N1 is prevented from gaining a foothold in any region. Of course, some major questions still need to be answered concerning the utilization of vaccines. As mentioned above, the current and future effectiveness of vaccine use is reliant on monitoring and continuous study. Another potential problem is the question of whether the vaccine will be developed, produced, and distributed by a government organization or private entities, specifically who will be Business and Health Administration Association Annual Conference 2012

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responsible for the provision of the vaccine. Finally, an issue that still needs to be addressed is that regardless of the research showing prevention to be far less expensive than control, the mass production and distribution of vaccines is very costly for both the developer/manufacturer and the individual businesses and farmers aiming to prevent any outbreaks of the disease by vaccinating themselves and their populations of livestock. A more in-depth analysis of cost control measures and the additional resources necessary for successful implementation of vaccine campaigns is especially warranted. Regulations Another important aspect of prevention is the development of regulations. These regulations should foremost address sanitation and hygiene among live bird markets and commercial businesses in an effort to prevent and control future outbreaks. By setting forth responsibilities for the applicable parties to follow, governments aim to maintain the safety, well-being, and overall health of a population. As an example, for areas such as the United States which have had no first-hand experience with avian influenza, the United States Department of Agriculture (USDA), in an interim rule, prohibited the import of wild birds/poultry and poultry products (i.e. meat) from any and all regions where a subtype of HPAI, such as H5N1, exists. Unlike in developed countries, which have a modicum of control over outbreaks of avian influenza and related diseases due to health regulations and significant oversight of the food production industry, developing countries have a different set of concerns. Specifically, regulations that should receive focus in these countries include those that better protect the food protection process such as processes for handling and transporting poultry products and registering the farms responsible for both of these tasks. Currently, the FAO, as part of their Animal Production and Health Paper, Approaches to controlling, preventing, and eliminating H5N1 Highly Pathogenic Avian Influenza in endemic countries, notes key areas, specifically biosecurity measures, which need to be addressed through regulations for the small commercial businesses and personal farms that are found throughout those countries affected by avian influenza. The regulations should address the fact that (FAO, 2011): Live bird markets need to be improved Poultry slaughter houses need to be modernized Decontamination procedures are not sufficiently monitored Infrastructure in poultry production needs to be upgraded including building poultry processing plants Limited integration of small-scale farming into larger corporate farming enterprises Animal Slaughter and Quality Control Act will be revised but uncertainty around its implementation Existing regulations are not well executed or enforced.

Sanitation is one of the most important aspects of maintaining the health of a large animal population in close quarters, which in this case refers to domestic poultry. Infrastructure, specifically poultry slaughter houses and live bird markets, needs to be updated in terms of procedures, tools, and oversight. Furthermore, in case of an outbreak, there should also be a standardisation of reporting procedures for outbreaks of disease to in ternationally accepted standards (The World Bank, 2006). The World Bank notes that the development of an operational manual would not be unwarranted, one that addresses 1) how to react in the event an outbreak occurs, 2) which individuals, organizations, and/or entities are responsible for certain tasks to control further outbreak or response to human infections, and 3) how will coordination be handled. By ensuring the health of the environment and sanitary living conditions for the poultry under care, especially through well thought out, approved regulations, there is a better chance that the H5N1 virus may be resisted and/or the spread and impact of the virus is decreased. One Health The above mentioned prevention strategies are key components of preventing the outbreak and spread of Avian Influenza. However, these efforts need to be utilized together in order to increase their effectiveness. Specifically, these prevention strategies should be incorporated into the One Health Initiative. This initiative, which is carried out in collaboration by many agencies including the American Medical Association (AMA), the CDC, and the USDA, is dedicated to improving the lives of all specieshuman and animalthrough the integration of human medicine, veterinary medicine and environmental science (One Health Initiative, 2011). As shown by the Business and Health Administration Association Annual Conference 2012

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vision statement, the One Health Initiative is based on the premise that the health of humans, animals, and the ecosystem (environmental health) as a whole are linked, whereby a detrimental effect on the health outcomes of one could have negative outcomes for that of another. In order to truly push Avian Influenza prevention measures into the realm of One Health, some components need to be addressed. A major component to be expanded upon, as mentioned above, is comprised of a dual focus on both human and animal health research, such as through the development of new vaccinations and antiviral drugs, including the promotion of alternative administration measures to make widespread vaccination feasible within each population. Another component of interest is the improvement upon these methods and the addition of new human health behavior interventions focused at the individual, community, and population levels. Furthermore, enhanced wildlife surveillance techniques along with additional funding for such endeavors would serve to prevent the spread of infection along migratory paths. As noted, the migration of wild birds can quickly and efficiently spread disease from one region to the next if the proper steps are not taken immediately, assuming an availability of the appropriate resources. Another key issue addressed by the One Health Initiative is the increased involvement of animal health professionals, including veterinarians, alongside those physicians, scientists, etc. focused on human health. Finally, as discussed under the methods for prevention and control of the disease, there should be more of an emphasis placed on ecosystem health. This includes such aspects as proper disposal of carcasses to maintain clean water supplies, sanitary living conditions for humans and animals, and sustainable production of poultry. Efforts to support a prevention-centered approach to pandemic Avian Influenza, particularly HPAI H5N1, can be used to strengthen a nation's public health infrastructure, which will ultimately result in greater public health and security gains than any reactionary response could possibly hope to address. While the necessity has previously been to control and mitigate outbreaks once they have occurred, we are in a strategic position to move towards a more sustainable focus on prevention. It is time to seize the opportunity to get ahead of the threat and to focus resources on stopping outbreaks before they occur. Success can no longer be measured strictly by the control of outbreaks and minimization of the associated human cases and deaths, but by the ability of each and every country to save the lives of animals and humans alike through an effective, efficient, prevention-centered approach. DETERMINATION / CONCLUSION Instead of containment, through quarantine and culling, or other control measures including utilization of antibiotics in treatment of symptoms, methods of a preventative nature should be used. By preventing future outbreaks, not only will deaths among both humans and animals be prevented, but the economic burden of many countries and health organizations can be reduced. However, without sufficient education, awareness campaigns, and focused training sessions, including the promotion of behavior change, many individuals will remain unaware of sanitary ways to handle and transport poultry and how to properly cook meat. Similarly, vaccination campaigns for both animals and humans can prevent at-risk populations from contracting the disease through animal-to-animal or animal-to-human transmission. The development of regulations will also serve to set standards that must be met concerning quality of health and the provision of a sanitary environment. By acting upon the aforementioned methods to prevent disease, especially as part of the One Health Initiative, by focusing on animal, human, and environmental health in all aspects of addressing avian influenza, the end of this disease can indeed be brought about. Following the successful implementation of a prevention-centered approach, a major goal is making prevention sustainable. Key goals following the utilization of preventative measures include the retention of lessons learned from the training provided, the continuation of processes in place, and the adherence to rules and regulations. Specifically, training programs should be maintained going forward, especially in cases where H5N1 appears to have been nearly eradicated. Health education programs should be continued and expanded upon regarding AI response and prevention information, and the education given should be as up-to-date as possible. As far as regulations are concerned, butchers and farmers who prepare their own meat should be continually educated and farms and slaughter houses should be continuously inspected for sanitation and proper disposal. Hygiene regulations should be increased and there should be properly enforced penalties for those who violate proper hygiene in regards to handling infected poultry along with incentives for those who maintain/exceed standards. Furthermore, assistance should be provided to the governments to potentially help those who rely on poultry as a source of income so that they do not need to sell infected meat in desperation and will dispose of it properly without worrying about losing a significant amount of money, thus ensuring adherence to the regulations set forth. In the end, the need for clinical management of H5N1 may be decreased and potentially eliminated by managing H5N1 Business and Health Administration Association Annual Conference 2012

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ahead of an outbreak, especially through a focus on live birds. Each country should ensure they are working on increasing awareness and informing the population of the significance of the disease, especially through working with the government to implement more programs, providing public service announcements, and particularly by education villages/communities. As weve seen, when outbreaks occur, countries want to control and respond on an emergency basis, thus using more resources than would have been necessary had the outbreak been prevented. By taking a proactive, instead of a reactive, approach towards avian influenza, countries will see less utilization of essential resources, create more awareness and a better educated populace, and ultimately better control and prevent the spread of avian influenza. Note: The authors recognize the assistance of Zandra H. Andre. REFERENCES Capua, I. & Marangon, S. (2007). Control and prevention of avian influenza in an evolving scenario. Vaccine. 25(30), 56455652. FAO. 2011. Approaches to controlling, preventing and eliminating H5N1 Highly Pathogenic Avian Influenza in endemic countries. Animal Production and Health Paper. 171, Rome. FAO Emergency Centre for Transboundary Animal Diseases (ECTAD). (2007, January). Protect people - protect poultry: Basic advice for stopping the spread of avian influenza. Retrieved from http://www.fao.org/docs/eims/upload//207623/FAO_HPAI_messages.pdf. Food and Agriculture Organization of the United Nations (FAO). (2010). FAO at work 2009-2010: Growing food for nine billion. Retrieved from http://www.fao.org/docrep/013/am023e/am023e00.pdf. Food and Agriculture Organization of the United Nations (FAO). (2011). Avian influenza: Background. Retrieved from http://www.fao.org/avianflu/en/background.html. Food and Agriculture Organization of the United Nations (FAO). (2011). Avian influenza in 2011: Mid-year review. Retrieved from http://www.fao.org/avianflu/en/news/ai_review.html. Glanz, K., & Rimer, B. K. (1995). Theory at a Glance: a Guide for Health Promotion Practice . NIH Pub # 97-3896, Bethesda, MD: National Cancer Institute. Haider, M., Frank, J., & Noreen, S. (2010). Analysis of avian influenza with special focus on Pakistan. Journal of Health Communication. 15(3), 322-333. Haider, M. & Applebaum, B. (2011). Disease Management of Avian Influenza H5N1 in Bangladesh: A Focus on Maintaining Healthy Live Birds. In Health Management. Croatia: InTech Open Access Publisher. Noreen, S. (2008). Report on level of knowledge of rural women about Avian Influenza through focus group discussion (pp. 118). Peshawar, Pakistan: Ministry of Agriculture, Livestock, and Cooperative Department, Government of NWFP. One Health Initiative. (2011). One health initiative: Mission statement. Retrieved from http://www.onehealthinitiative.com/mission.php. The World Bank. (2006, May). World Bank will support Bangladeshs avian flu program. Retrieved from http://www.worldbank.org.bd/WBSITE/EXTERNAL/COUNTRIES/SOUTHASIAEXT/BANGLADESHEXTN/0,,c ontentMDK:20936997~pagePK:141137~piPK:141127~theSitePK:295760,00.html. UN System Influenza Coordinator & World Bank. 2008. Responses to avian influenza and state of pandemic readiness. Fourth Global Progress Report. New York. Business and Health Administration Association Annual Conference 2012

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World Health Organization (WHO). (2010, May 6). Areas with confirmed human cases of H5N1 avian influenza since 2003*. Retrieved from http://reliefweb.int/sites/reliefweb.int/files/resources/A724B3AD85DDDF2C852577230060879A-map.pdf World Health Organization (WHO). (2011). Avian influenza: food safety issues. Retrieved from http://www.who.int/foodsafety/micro/avian/en/index1.html World Health Organization (WHO). (2011, September 12). H5N1 avian influenza: Timeline of major events. Retrieved from http://www.who.int/influenza/human_animal_interface/avian_influenza/H5N1_avian_influenza_update.pdf World Health Organization (WHO). (2011, August 2). Global alert and response (GAR): Cumulative number of confirmed human cases of avian influenza A (H5N1) reported to WHO. Retrieved from http://www.who.int/influenza/human_animal_interface/EN_GIP_LatestCumulativeNumberH5N1cases.pdf.

Muhiuddin Haider School of Public Health, University of Maryland College Park, Maryland, USA E-mail: mhaider@umd.edu Jared Frank School of Public Health, University of Maryland College Park, Maryland, USA

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ESTABLISHING AN EFFECTIVE AND COMPREHENSIVE PALLIATIVE CARE PROGRAM IN AN ACUTE HOSPITAL SETTING
Ebony A. Smalls, Clayton State University _____________________________________________________________________________________________ ABSTRACT Born from the hospice movement, the growth of palliative care programs are increasing in the United States. Due to the stigma of hospice and the culture of medical science, these programs are not optimally utilized in the United States. Through patient education and a diverse team, an effective palliative care program can enhance patient care, decrease unnecessary usage of health care, and improve the financial outlook of healthcare institutions. This paper clearly distinguishes the difference between hospice and palliative care, discusses barriers for utilization, ways to implement palliative care programs, and the necessity for having patient specific programs in hospital settings.

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INTRODUCTION In the 1990s, palliative care was born from the hospice movement to fulfill the unmet needs of patients in early chronic disease states. From 2000 to 2003, the number of palliative care services rapidly increased in the United States from 15% to 25% in acute care hospitals (Hanson, Usher, Spragens, & Bernard 1997) and by 2006, Hospice and Palliative Medicine was accredited as a medical specialty (Cherney 2009). Most equate palliative care with hospice, but the primary distinction between the two is when utilization of services can occur. Hospice is restricted to a six month patient life expectancy and cannot be implemented along with curative care. According to the World Health Organization, palliative care is a philosophy . . . and an organized, highly structured system for delivering care expanding traditional disease -model medical treatments(Cherney 2009). Palliative interventions address the physical, psychological, social, emotional and spiritual needs of patients and families suffering from chronic illnesses. An effective palliative care program can enhance patient care, education, and satisfaction; improve symptom control and pain management; decrease unnecessary usage of health care; and improve the financial outlook of healthcare institutions (Rodriguez, Barnato, & Arnold 2007.). Several care models exist ranging from a full complement of supportive services concentrated in a single palliative care inpatient unit to a palliative care case management system with the level of support varying among institutions. All models reduce costs and utilization of resources prior to death (Hanson et al.), however, no matter the format utilized, the best model practiced should be flexible, discussable and individualized based on the patients desires (Barazetti, Borreani, Miccinesi, & Toscani 2010.). A comprehensive palliative care program includes specially trained medical and nursing professionals, social workers, spiritual leaders, and professionals in nutrition, rehabilitation services, pharmacy, and other disciplines required based on the individual needs of the patient (Kelley & Meier 2010). There are several barriers that must first be overcome before implementation of a successful palliative care program can begin. First, medical staff and patients must be educated in the services offered through palliative programs to overcome the stigma associated with end-of-life care. Second, medical staff must be encouraged to utilize palliative care services that are available. Utilization of palliative care services Management of palliative care patients can be time consuming; therefore utilization of palliative care services can ease the burden of primary care practitioners. The ideal health system would provide a seamless transition between primary care and palliative care with care of the patient shared between the two services (Schnieder, Mitchell, and Murray). In Australia, a needs-based palliative care delivery system ensures the patient Business and Health Administration Association Annual Conference 2012

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receives the appropriate level of care at the appropriate time (Schnieder, Mitchell, and Murray 2010). In Great Britain, a general practice-based system routinely identifies terminally ill patients and develops individualized care plans (Schnieder, Mitchell, & Murray 2010). Increased exposure to palliative care can increase the likelihood of physicians implementing the service within the patients care plans. One way to increase exposure is to increase the presence and visibility of the palliative care program in the hospital facility as a reminder of services offered to patients and families (Ahluwalia & Fried 2009). Palliative care services include: Assessment and management of psychiatric disorders Obtaining advanced directives/DNR orders Addressing ethical issues Referrals to hospice, home care, and other placements Completion of individualized comprehensive care plans Pain consultation/symptom management Psychosocial support A palliative care consultation should include (Ciemens, Blum, Nunley, Lasher, & Newman 2007): Evaluation and discussion of patient goals of care Identification of a healthcare proxy Completion of symptom assessment Review of current treatment plan Recommendations for any changes in treatment Referrals to social services and spiritual support Review of advanced directives with patient and family Palliative care consults can be utilized concurrently with curative care, therefore, consults should be instituted as early as initial diagnosis of any life-limiting chronic illness. Early implementation of palliative care services can address symptom control, psychological and social issues, improve communication between patients, families, and medical staff (Rodriguez, Barnato, & Arnold 2007), improve quality of life and allow for a smoother transition to hospice care (Hui, Elsayem, & De la Cruz 2010). When palliative care is offered early in a disease state, families can become familiar with available resources, communication about death can begin and the patient and families are given the opportunity to discuss goals of care with physicians and medical staff (Grant, Elk, Ferrel, Morrison, von Gunten 2009). Although death is a constant presence in healthcare, medical staff experience difficulty discussing the subject with their patients. Early introduction of palliative care eases the discomfort of having to discuss end-of-life choices with a patient who is not yet facing imminent death. Palliative care consultation can provide a way to encourage physicians to be frank and tell the truth about patient diagnosis and promote patient rights (Miller, Williams, English, & Keyserling 2002). The promotion of palliative care has to overcome the curative concept of medicine. Physicians have different perspectives on terminal illness. Most physicians are taught to treat until death is near and certain, however death is unpredictable. The decision to minimize aggressive treatment is usually made after a round of unnecessary treatment is given in spite of patient discomfort and cost. As a disease progresses, the patient may decide to cease certain forms of therapy, therefore, physicians must be prepared to respect patient preferences for minimal treatment if that is the desire of the patient and family. It is often the case that medical staff are unclear with the conflicting role definitions between healthcare providers (Schneider, Mitchell, & Murray 2010). EDUCATION Staff Education Palliative services can enhance patient care through facilitation of education for medical staff on utilization of palliative care services. Health care professionals must be educated on the benefits and concept of palliative care coupled with curative care (Hui et al.). Training in symptom control, communication, counseling and bereavement Business and Health Administration Association Annual Conference 2012

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support is frequently requested by medical staff (Becker, Momm, Deilbert, Zander, Gigl, & Wagner 2010). This can be accomplished through various programs including discussion panels, mass media, integration of materials into educational curriculum, national meetings, certification/recertification requirements, online courses, and individual readings. Below is a list of educational opportunities for medical personnel to increase their knowledge base of palliative care: The End-of-Life Nursing Education Consortium (ELNEC) is a national education initiative dedicated to improving end-of-life care in the United States. A train-the-trainer approach is utilized to educate participants in palliative and end-of-life care. The curriculum is delivered by national nurse leaders and includes modules (Grant et al.). The Education for Physicians on End-of-life Care (EPEC) Curriculum also utilizes a train-the-trainer approach to assist physicians in reaching a level of competence to effectively manage end-of-life care (Grant et al.). The Center to Advance Palliative Care (CAPC) has nine palliative care programs across the country that provide intensive, hands-on training to hospital and hospice teams involved in establishing or managing palliative care programs (Grant et al.).

Patient Education Palliative care can enhance patient care through better patient education in understanding of individual disease diagnosis and prognosis. Patients should be involved in all decisions concerning their treatments. A palliative care consult gives the opportunity for medical staff to provide a thorough explanation of the complete range of curative and palliative treatment options available for the benefit of developing a patient-driven care plan. This explanation should include information about life-sustaining treatments and patients should be informed of their right to express their individual preference regarding the use of these treatments. When patients are thoroughly informed about their disease states, they are able to make educated decisions about their treatment plan; they are able to communicate treatment preferences; and, physicians are able to provide more appropriate care that better suits the needs of patients resulting in a reduction of inappropriate use of life-sustaining treatments. Facilitation of Communication Communication is an important element of care. Effective communication can significantly affect clinical outcomes (Rodin, Zimmerman, Mayer, Howell, Katz, & Sussman 2009). Communication builds and maintains relationships for the purpose of transmitting information, providing support, and negotiating treatment decisions. It should be truthful, clear, and concise and given in an environment in which patients feel free to express themselves and ask questions. Techniques that may help to improve understanding, recall, and patient satisfaction include taping consultations, providing informational tapes, sending letters summarizing the consultation, and inclusion of a support person during the clinical visit (Rodin et al.). An article printed in the Australian Family Physician journal presented the acronym PREPARED as a guide to help facilitate end-of-life discussions: Prepare for the discussion Relate to the person Elicit patient and caregiver preferences Provide information Acknowledge emotions and concerns Realistic hope Document

A palliative care program involving multidisciplinary teams can improve continuity of care and facilitate communication and improve continuity of care.

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Caregiver Support The act of caring for a loved one with a chronic illness can be challenging. Responsibilities are multifaceted and the process can have negative effects on the caregivers health. They are not only dealing with the actual physical act of caring for the family member, but also the grief associated with their loved ones chronic illness and impending death. It is just as important to identify and address the needs of informal caregivers before and after the patients death and provide psychosocial support . Caregivers often are not educated in how to provide physical care for patients and often times have physical illnesses themselves that have an impact on their ability to properly care for the patient (Schneider, Lueckmann, Kuehne, Klindtworth, Behmann 2010). A palliative care consult can better meet patients needs and relieve some of the burden of primary caregivers (Grant et al.). Cultural Considerations Providing appropriate end-of-life care in a diverse community requires health care professionals to be culturally aware while practicing cultural sensitivity and competence. One of the most important elements of a comprehensive palliative care program is the acknowledgement of personal, social, religious, and cultural values and beliefs of patients and families and how they affect their choices. It is important to identify, respect and not judge the differences among patients. It is important to understand that medicine is in itself its own culture with its own language that may conflict with belief systems and values of patients. An article in the Australian Family Physician journal lists the following requirements for successful understanding of culturally appropriate palliative care (Clark & Phillips 2010): The disclosure and consent preferences of the patient The degree to which individual versus family decision making is preferred Specific privacy issues The meaning assigned to the disease and its symptoms The patient and their familys attitudes toward medications and nutrition, preferred en d of life rituals, and customs and spiritual and/or religious preferences

Evaluation of Palliative Care Programs With the rapid growth of palliative care programs, concern for quality of care is an issue. Programs can be evaluated through clinical audit to measure quality. Clinical audit evaluates how well the program performs; sets a target for performance level; decides how improvements will be made, enacting these improvements, and measuring to see of target goals were met (Selman & Harding 2010). Evaluating the outcomes of palliative care: Allows for improvement of patient and family care holistically and individually. Allows collection of evidence on the impact of care on the patient and family and the effectiveness of the palliative care program in its goals. Allows assessment and improvement of quality of care Sets precedence for evidence based practices Provides a standard for quality care no matter who, where, or how care is delivered (Selman and Harding). SUMMARY According to CBS News, Medicare spent approximately $50 billion dollars on health care expenses for patients in the last two months of life (CBS News 2010). 25 percent of Medicare spending is a result of the five percent of patients who are in the last stages of life (Petasnick 2011). Developing a comprehensive palliative care program can decrease utilization of unnecessary healthcare by allowing patients to make informed decisions about what treatment they desire to implement in their healthcare plans. This in turn will lead to a reduction in spending on needless tests and treatments that are contributing to the increase in healthcare costs.

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REFERENCES Ahluwalia, S., & Fried, T. (2009). Physician factors associated with outpatient palliative care referral. Palliative medicine 23 (7), 608-615. Barazzett, G., Borreani, C., Miccinesi, G., & Toscani, F. (2010). What best practice could be in Palliative Care: an analysis of statements on practice and ethics expressed by the main Health Organizations. BMC Palliative Care 9 (1). Barnato, A,. Anthony, D., Skinner, J., Gallagher, P., & Fisher, E. (2009). Racial and ethnic differences in preferences for end-of-life treatment. Society of General Internal Medicine. 24 (6), 695-701. Becker, G., Momm, F., Deilbert, P., Zander, C., Gigl, A., & Wagner. B., et.al. (2010). Planning training seminars in palliative care: A cross sectional survey on the preferences of general practitioners and nurses in Austria. MBC Medical Education 10 (43). Behmann, M., Luckmann, S., & Schneider, N. (2009). Palliative care in Germany from a public health perspective: Qualitative expert interviews. BMI Research Notes. Bloomer, M., Tan, H., & Lee, S. (2010). End of life care: The importance of advance care planning. Australian Family Physician 39 (10), 734-737. Borgonovi, E., (2004). Economic aspects in prolonged life sustainable treatments. NeuroRehabilitation, 19, 367371. Brueckner, T., Schumacher, M., & Schneider, N. (2009). Palliative care for older peopleexploring the views of doctors and nurses from different fields in Germany. BMC Palliative Care. Camhi, S., Mercado, A., Morrison, S., Qungling, D., Platt, D., & August, G., et.al. (2009 ). Deciding in the dark: Advance directives and continuation of treatment in chronic critical illness. Critical Care Medicine 37 (3), 919-925. Casadio, M., Biasco, G., Abernethy, A., Bonazzi, V., Pannuti, R., & Pannuti, F. (2010). BMC Palliative Care 9 (12). CBS News (2010). The Cost of Dying. Cherny, N. (2009). Stigma associated with Palliative Care. American Cancer Society. Ciemins, E., Blum, L., Nunley, M., Lasher, A., & Newman, J. (2007). The economic and clinical impact of an inpatient palliative care consultation services: A multifaceted approach. Journal of Palliative Medicine 10 (6), 13471355. Clark, K., Phillips, J. (2010). End of life care: The importance of culture and ethnicity. Australian Family Physician. 39 (4), 210-213. Dale, J., Petrova, M., & Munday, D., et al. (2009). A national facilitation project to improve primary palliative care: Impact of the Gold Standards Framework on process and self-ratings of quality. Quality and Safety in Healthcare, 18, 174-180. Emanuel, L., & Scandrett, K. (2010). Decisions at the end of life: have we come of age? BMC Medicine, 8 (57).

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Enguidanos, S., Housen, P., Goldstein, R., Vesper, E., Allen, J., & Braun, W. (2009). Physician and Nurse Perceptions of a New Inpatient Palliative Care Consultation Project: Implications for Education and Training. Journal of Palliative Medicine, 12 (12), 1137-1142. Grant, M., Elk, R., Ferrel, B., Morrison, R.S., von Gunten, C. (2009). Current status of palliative care clinical implementation, education, and research. CA: A Cancer Journal for Clinicians, 59, 327- 335. Hanson, L., Tulsky, J., & Danis, M. (1997). Can clinical interventions change care at the end of life? Annals of Internal Medicine. 126, 381-388. Hanson, L, Usher, B., Spragens, L, & Bernard, S. (2008). Clinical and economic impact of palliative care consultation. Journal of Pain and Symptom Management. 35 (4), 340-346. Hudson, P., Remedios, C., Thomas, K. (2010). A systematic review of psychosocial interventions for family careers of palliative care patients. BMC Palliative Care, 9 (17). Hui, D., Elsayem, A., & De la Cruz, M., et al. (2010). Availability and integration of palliative care at US cancer centers. Journal of the American Medical Association. 303 (11), 1054-1061. Integrating mental health services into hospice settings. (2009). The Palliative Care Psychiatric Program: San Diego Hospice and the Institute for Palliative Medicine, San Diego. Johnson, R., Newby, K., Granger, C., Cook, W., Peterson, E., & Echols, M., et. al. (2010). Differences in level of care at the end of life according to race. American Journal of Critical Care, 19, 335-343. Kelley, A., & Meier, D. (2010). Palliative care a shifting paradigm. New England Journal of Medicine. 363, 781782. Luce, J. (2010). End-of-life decision making in the Intensive Care unit. American Journal Respiratory Critical Care Medicine, 182, 6-11. Millier, G., Wlliams, J., English, D., & Keyserling, J. (2002). Delivering quality care and cost-effectiveness at the end of life: Building on the 20-year success of the Medicare Hospice benefit. National Hospice and Palliative Care Organization. Qaeem, A., Snow, V., Shekelle, P., Casey, D., Cross, T., & Owens, D. (2008). Evidence-based Interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: A clinical practice guideline from the American College of Physicians. Clinical Efficiency Assessment Subcommittee of the American College of Physicians. Petasnick, W. (2011). End-of-life care: The time for a meaningful discussion is now. Journal of Healthcare Management 56 (6), 369 372. Pinheiro, T., DeBenedetto, M., Levtes, M., Giglio, A., & Blasco, P. (2010). Teaching palliative care to residents and medical students. Brazilian Society of Family Medicine, 42 (8), 580-582. Ripamonti, C., Farina, G., & Garassino, M. (2009). Predictive models in palliative care. American Cancer Society. Rodin, G., Zimmerman, C., Mayer, C., Howell, D., Katz, M., & Sussman, J. (2009). Clinician-patient communication: evidence-based recommendations to guide practice in cancer. Current Oncology, 16 (6), 42-49.

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Rodriguez, K., Barnato, A., & Arnold, R. (2007). Perceptions and utilization of palliative care services in acute care hospitals. Journal of Palliative Medicine 10 (1), 99-110. Schneider, N., Lueckmann, S., Kuehne, F., Klindtworth, K., & Behmann, M. (2010). Developing targets for public health initiatives to improve palliative care. BMC Public Health, 10 (222). Schneider, N., Mitchell, G., & Murray, S. (2010). Palliative care in urgent need of recognition and development in general practice: The example of Germany. BMC Family Practice, 11 (66). Selman, L., & Harding, R. (2010). How can we improve outcomes for patients and families under palliative care? Implementing clinical audit for quality improvement in resource limited settings. Indian Journal of Palliative Care, 16 (1), 8-15. Seymour, J., Almack, K., & Kennedy, S. (2010). Implementing advance care planning: A qualitative study of community nurses views and experiences. BMC Palliative Care, 9 (4).

Ebony A. Smalls Clayton State University esmalls@gapreventivehealth.org

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PHYSICIAN BEHAVIORS CRITICAL TO ACCOUNTABLE CARE ORGANIZATIONS (ACO)


Leanne Hedberg Carlson, Viterbo University Lisa Wied, Viterbo University Renee Fraser, Viterbo University _____________________________________________________________________________________________ ABSTRACT Becoming and accountable care organization (ACO) is on the forefront of most health care institutions in the United States and many practitioners and scholars are grappling with how to transition health care organizations to an ACO model. However, most of the focus on this transition is on defining the technical aspects of such a transition. Little research has been conducted that focuses on the social aspects of the ACO model, which is interesting, given that the role of the physician is central to successful integration of such a model. This is also interesting, given that most change efforts fail because of social factors rather than technical factors. This research fills a research gap by exploring the behavior changes that physicians must adopt for ACO to be successful. The methodology used for the study is a survey of primary care physicians and their support staff to identify needed behavior changes.

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Leanne Hedberg Carlson, MBA Administrator and Instructor, Health Care Management Viterbo University 900 Viterbo Drive La Crosse, WI 54669 lmhedbergcarlson@viterbo.edu Lisa Wied Administrative Director 1900 South Avenue La Crosse, WI 54601 (608) 782-7300 ljwied@gundluth.org Renee Fraser Human Resource Manager 1900 South Avenue La Crosse, WI 54601 (608) 782-7300 rdfraser@gundluth.org

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TRACK HEALTH, WELLNESS AND QUALITY OF LIFE

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FITNESS, HEALTH AND PRODUCTIVITY


Mansour Sharifzadeh, California Polytechnic State University

INTRODUCTION As the American workforce increases, so does its waistline. It is estimated that 64% of the adults in the United States are obese with nearly 9 million children age six and older are becoming obese. With obesity come serious health problems such as heart disease, diabetes, hypertension and high blood pressure. Americans are faced with the challenge of trying to manage a higher cost of living that requires them to work more hours. They have to deal with the fact that increase in the hours they work takes time away from their time to cook which leads to unhealthy fast food choices and even less time to exercise. Employers are investing large amounts in the employee fitness program but the value of physical exercise and lifestyle has yet to be established. This paper provides a critique of the applied and experimental research related to the impact of the employee fitness programs in the work-related variables and discusses future research directions. More and more companies either are planning or have developed physical fitness programs for their employees. In United States approximately 55,000 companies are involved in employee fitness and they promote physical activities. The scope of employee fitness programs ranges from the company paying for memberships at a private fitness clubs to complete on- site fitness facilities. These programs cost from $2000 to millions. Organizations that support these programs consider them as an inexpensive benefit that produces the following returns: 1) increase ability to attract competent employees, 2) improved attitudes and loyalty, and 3) increase empl oyees productivity. The current idea has always been that there is a relationship between fitness and productivity, but is this relationship a reality? The thought that there is a relationship can easily be rationalized without much thought as many jobs do require physical skills. Therefore, if a person is fit, he/she will be able to handle more physically demanding tasks, such as carrying more weight, or working longer and harder without having to take as many breaks. However, in todays job market, most jobs require little or no physical exertion. Therefore fitness and productivity are not really related. For instance in an office job, would an athlete be any more productive than one who is overweight, or even obese? When productivity is measured, it can be measured in both absenteeism and presentism. Absenteeism is the loss of productivity due to absence, while presentism is the loss of productivity while present. Presenteeism is a better measure of pure productivity as it measures how productive someone is while they are working, opposed to the loss of productivity from vacations, sick days, and lateness. The majority of scholarly articles hold the belief that there is a relationship between fitness and productivity. If fitness could be increased through some type of fitness program, there would be a noticeable increase in productivity. Other articles suggest that there is a relationship between fitness and productivity, yet only in the extreme cases. While other articles suggest that a relationship may exist, but it cannot be proven without more research. REVIEW OF THE LITERATURE Adhop Der-Karabetian, University of La Verne and Norma Gebharbp, General Dynamics conducted a study to measure job satisfaction, body image, and sick days for those who exercised and those who did not. They selected two groups from a large Southern California company. The first group participated in a physical fitness program for six months. The three variables: job satisfaction, body image, and sick days were measured at the start of this program and six months later. The second group was used as a control group, to make sure no major external factors affected the variables. They found that after the six month time the employees who participated in the fitness program had a higher job satisfaction and body image, and had less sick days than the control group. They then suggested that every company should focus on employee fitness since it reduces absenteeism (sick days), and increases morale of the employees which will increase productivity. (Der-Karabetian and Gebharbps, Effect of Physical Fitness Program in the Workplace, Journal of Business and Psychology)

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Mills PR, Kessler RC, Cooper J, Sullican S wrote in their article Impart of a Health Promotion Program on Employee Health Risks and Work Productivity that being part of a companys fitness program increased productivity levels. This survey consisted of a variable group (n=266) and a control group (n=1242). The variable group was placed in a multi-component health promotion program which showed participants their health risks, personalized health improvement plan, literature, and lectures focused on health improvement. Using the World Health Organization health and work performance questionnaire they concluded that those enrolled in the multi-component health promotion program reduced their health risks by 0.45, lowered their monthly absenteeism days by 0.36, and had a mean increase on the work performance scale of 0.79. These results suggest that implementing a multicomponent health promotion program which would increase the fitness levels of its participants, would also make noticeable differences in health risks and productivity. Wayne N. Burton MD, Katherine T. McCalister EdD, Chin-Yu Chen PhD, Dee W. Edington PhD conducted a study in which they survey both people enrolled (n=854) and not enrolled in the companies fitness center (n=4543), and asked questions based on their productivity in the workplace. They concluded that those employees who were not participating in their companys fitness program reported higher loss of productivity due to time management, physical difficulty of the work, limitations of amount they could output, and overall loss of productivity than the same race, age, gender, work location comparables who were enrolled in their companys fitness center. (The Association of Health Status, Worksite Fitness Center Participation, and Two Measures of Productivity) Christopher P. Neck and Kenneth H. Cooper believe that the higher ones fitness is, the higher their productivity would be. They mention in their article The fit executive: Exercise and diet guidelines for enhancing performance, many studies which show that fitness and work productivity are related. In one study by Frew, D. R. & Brunning that measured improved productivity and job satisfaction with the enrollment in an employee exercise program. Commercial real estate stock brokers who participated in an aerobics program for 12 weeks had higher sales than their comparable brokers during and after the 12 weeks aerobic program. Another study which looked at 56 college professors, noticed that the physically active professors were able to retain information better, as well experience slower decline in memory with age. (Research Quarterly For Exercise and Sport, 64(2):144-151). Paul L. Lloyd, Lloyd & Associates and Sandra L. Foster, Success at Work suggests that there is a relationship between fitness and productivity only when fitness is extremely low. For example someone who is extremely obese, or someone who had severe diabetes, or even someone who had heart disease needs to worry about loss of productivity, yet someone who is slightly overweight, or is not fit will experience no loss of productivity. They suggest that lack of fitness is a major health risk and it could affect workplace productivity. Garland Y. DeNelsky and Michael G. McKee tried to predict the job performance of individuals based on an assessment which included fitness. They had a sample of 32 government employees, who they gave a health assessment which predicted their individual job performance as above average, average, or below average. Their results showed that 71% of those who received an above average or average score on the assessment performed at an above average, or average level. Sixty percents of those who received a below average score on their assessment performed at below average level. This assessment was able to predict performance better than just plain chance, yet this study does not provide enough support to the claim that fitness affects productivity, as psychologists used the health assessment to determine whether each person was a motivated person, which does affect productivity. (Journal of Applied Psychology Vol. 53, No. 6 Prediction of Job Performance from Assessment Reports: Use of a modified Q-sort technique to expand predictor and criterion variance) Allen, Harris PhD wrote in the Journal of Occupational & Environmental Medicine about his study on whether health affected productivity. He created a Health Risk Appraisal which examined health in the context of work, mental health, and demand from personal life. He had 17,821 respondents to his Work Limitation Questionnaire and his study confirmed that there are two types of productivity loss due to health conditions: Presenteeism and Absenteeism as discussed earlier. His study showed that health is one of eight factors that affect productivity. The others include: Work-Life Balance, Personal Life Impact, Stress, Financial Concerns, Job Characteristics, Employee Characteristics, and Company Characteristics. Although health does affect productivity the other seven factors together impact productivity five times as much as health. This study confirms that health and fitness has some impact on productivity, yet health is not the primary determinant of productivity. Business and Health Administration Association Annual Conference 2012

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Bernaards, Claire M. PhD; Proper, Karin I. PhD; Hildebrandt, Vincent H. PhD, MD wrote in the Journal of Occupational & Environmental Medicine about their study on how physical activity, cardio-respiratory fitness, and body mass index affects work productivity, and absence due to sickness in employees who do office work. All their participants had neck, arm and hand pain within the six months before the study. The productivity was measured using the Health and Performance Questionnaire. They concluded that the amount of physical activity and cardiorespiratory fitness did not have an effect on work performance or sick absences, yet however obese male workers did have significantly lower productivity levels than lean workers. Loren E Falkenberg, wrote in his article, Employee Fitness Programs: Their Impact on the Employee and the Organization, that there is not enough evidence to show that fitness increases workplace productivity at all. Falkenbergs agrees that higher fitness levels do benefit your body and mind in many positive ways. It has been proven that those who are fit have less depression, less stress, and less anxiety than their comparable who are not fit. There is sufficient evidence to show that fitness significantly lowers the absenteeism (Cox, Shephard & Corey 1981) (Bertera 1990). Yet the only reasoning for this drop in absenteeism that can be suggested is that fitness makes one healthier. However although fitness is good for you, and might make you healthier, it has never been shown to affect presenteeism (which is productivity while working.) With all the current studies that have been conducted, there still does not seem to be enough support to show that there is a strong relationship between fitness and productivity. Although the relationship can be pinpointed through small surveys and studies, other external factors such as personal differences, motivation, differences in jobs and stress could very well affect both productivity and fitness. This would make both fitness and productivity the effect of some external cause, opposed to the theory that changes in fitness cause changes in productivity. DEFINITIONS Body mass index is a statistical measure of the weight of a person scaled according to height. BMI is useful for population measure, not for diagnosing individuals. The formula was invented between the 1830s and 1850s. The body mass index can be found in two different ways. The formula for measuring the BMI is body weight divided by the square of the height. The relationship between BMI and health is that medical professionals use the BMI test to determine if a person is physically active or inactive. Then based on their results they can determine if their current weight is healthy for them. When an individuals BMI is below 18.5 it commonly means the person is underweight (when a person BMI is below 17.5 they are considered to be classified as anorexic). When the BMI is between 18.5 and 25 it means the person is at their optimal weight. The BMI of above 25 shows that the person is overweight, and when a persons BMI is 30 or above it allows them to believe the person is obese (when BMI is 40 they call it morbidly obese). If the BMI were above or below the optimal zone it would reflect the current health as being good or not good. Productivity is the measure of output from a production process per unit of input. The emphasis is on quantitative output and sometimes on input. Productivity accounts for monetary values of what is being produced and the cost of inputs being used. The formula used to determine the productivity is: Total productivity equals output quantity divided by input quantity. There are a variety of methods to determine the productivity. A common way of increasing productivity is by using computers and machines to perform more tasks for the company. The company will increase productivity because they wo nt have to pay employees to do the work that the computer or machines are completing. The average person uses the word productivity to describe the effectiveness and ability to obtain goals for the day or a set time period. Productivity is important to management because their job is to be sure that productivity increases or stays constant. The management team has the job of making sure that workers are working effectively and that they are doing their job. Fitness is comprised of general fitness and specific fitness and is defined as the capacity to carry out the days activities without undue fatigue. It is the measure of the bodys ability to function efficiently and effectively in work and leisure activities, to be healthy, and to resist emergency situations. There are different levels of fitness that must be incorporated to be considered fit. The following are taken into consideration: cardiovascular, strength, muscular endurance, flexibility, and body composition. Also, the mental or emotional health as well as the age or bone structure of the individual should be taken into consideration. If a person is active on a daily basis and has Business and Health Administration Association Annual Conference 2012

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good eating habits, that could help maintain their fitness. People that are fit can be overweight or fat. However, most people that are obese arent fit at all. Most people that are fit are not overweight and are conscience of their physical appearance and their health too. Health is defined as optimal functioning with freedom from disease and abnormality. It is a state of complete physical, mental, social well-being and not merely the absence of disease or infirmity. A sick person can be fit depending on the sickness. If a person is ill with a disease or disorder they maybe fit in other areas just not in the particular area that they are sick. A person can be productive and unhealthy. Being healthy might be a beneficial to be productive but isnt a necessity. For example Steve Job the founder of APPLE INC. was very productive during his major illness. Although he was sick he still was working and being productive RESULT OF THE FITNESS AND PRODUCTIVITY SURVEY The purpose of this research paper was to show that there is no correlation between fitness and productivity. A questionnaire was developed with 17 questions. The first set of questions measured BMI, the body mass index. The next set of questions measuring fitness and health and the last set of questions measured productivity. Questionnaires were sent to 1765 Cal Poly College of business alumni. A total of 355 responded to the questionnaire, but only 328 of them were complete.

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The majority of the respondents were male, accounting for more than half of the responses totaling to 59.3%. The response from the female population surveyed accounted for only 40.7% of the surveys returned. The total number of responses with all the questions completed was 339 surveys. Only two surveys were returned with one or more incomplete answers. Respondent were mostly in their 30s. The youngest one was 22 and the oldest was 74 years old. The second highest category were respondent who were in their 20s and then those who were in their 5os.The following table shows the category of the respondent based on their age. 63 were in 20s 182 were in 30s 59 were in 40s 23 were in 50s 6 were in 60s 2 were in 70s

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As far as how many times they typically exercise, a high percentage of the survey respondents, 43.3%, stated that they exercised an average of 2-3 times a week. The next highest portion of respondents, 27.0%, stated that they typically exercised 0-1 times a week. This percentage is close to the portion of respondents, 24.9%, who stated that they exercised 4-5 times a week. There was only a small portion of respondents, 4.2%, who stated that in a week they exercised 6-7 times a week. And the smallest portion of respondents, 0.6%, stated that they would work out as much as 8 times or more within a week.

All of the survey respondents stated that they participated in some form of exercise on a weekly basis. The chart above illustrates a break down of how long they actually engage in the exercise of their choice. The most significant percent, 27.4 %, stated that their work out was approximately 45-60 min, including warm-up and cooldown. The second largest percent, 22.6%, stated that their entire workout was as long as 60 min+. Next, 18.7 % of Business and Health Administration Association Annual Conference 2012

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the respondents stated that the length of their workout was 30-45min. The second smallest portion of respondents, 16.3%, stated that the duration of the workout was 15-30 min, while the smallest portion of the respondents, .5%, stated that their entire workout was only 0-15min. Despite the fact that the survey revealed that 30.8% of the respondents engaged in their choice of exercise for 30 min or less, it also revealed that an overwhelming 50.5% engaged in some form of exercise for 45 min or more.

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While the previous survey question revealed the amount of time the respondents engaged in some form of exercise, this question revealed the respondents perceived exertion and physical signs of their effort. The majority of the respondents, 34.7%, stated their perceived exertion was strong and during exercise they experienced sweating and could talk without much difficulty. The second largest portion of respondents, 30.0%, stated that they felt their physical exertion to be moderate, causing their body to become warm on a cold day and producing a slight sweat on a warm day. The next largest portion of respondents, 16.3%, stated they perceived their physical exertion to be quite strong, which causes them to sweat heavily and experience great difficulty when talking. Approximately 7.1% of the respondents stated that they perceived their physical exertion be very minimal, and at times, to be completely unperceivable. An even smaller portion of the respondents, 5.6 %, stated that they perceived their physical exertion to be weak with a minimal feeling of motion. However, there was a small amount of respondents, 5.0%, who stated that they perceived level of physical exertion was extremely strong and felt that they were at the brink of near exhaustion when engaged in some form of exercise. The smallest portion of respondents, 1.2%, marked down their perceived level of physical exertion to be other, or not adequately described by the categories provided. Please look back to the options in question 7. How many times in the last week did you achieve an exercise rating of option c or higher? Answer Options a. 0 Times b. 1-2 Times c. 3-5 Times d. 5+ Times Response Percent 16.3% 49.3% 30.9% 3.6% answered question skipped question Response Count 55 166 104 12 337 4

The respondents were asked to reflect how many times they believed their perceived exertion and physical signs attributed to work out to fall somewhere between moderate to extremely strong during their workout sessions in the previous week. A majority of the survey respondents, 49.3%, stated that they perceived their exertion and physical signs to be moderate to extremely strong during 1-2 of their workouts. The next highest percentage of Business and Health Administration Association Annual Conference 2012

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respondents, 30.9%, stated that they would rate their perceived exertion between moderate and extremely strong during 3-5 of their workout sessions, while the smaller portion of respondents, 3.6 %, believed their perceived physical exertion to be moderate to extremely strong during 5 or more of their workout sessions. There were also a significant number of the respondents, 16.3%, who stated their perceived physical exertion level fell below moderate during any of their workout sessions. To what extend do you believe that known health issues (e.g. blood pressure, coronary issues, diabetes, etc.) affect your performance on the job? Answer Options a. Health issues have no adverse effects on my work performance b. Very minor health issue impact my work performance c. Minor health issues impact my work performance d. Some health issues impact my work performance e. Health issues have major impacts on my work performance Response Percent 36.5% 13.5% 10.5% 21.9% 17.7% answered question skipped question Response Count 122 45 35 73 59 334 7

A large portion of the respondents, 36.5%, stated that known health issues have no adverse effects on their work performance. The next largest portion of respondents, 21.9%, stated that some of the health issues that they are aware of impact their work performance in some way. The next most significant portion of respondents, 17.7%, stated that known health issues have a major impact on their work performance. The second smallest portion of respondents, 13.5%, stated that very minor known health issues impact their work performance, while the smallest portion of respondents, 10.5%, stated that very minor known health issues impact their work performance in one way or another.

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A large portion of the respondents, 42.4%, stated they would rate their current health to be very good. The next largest portion of respondents, 33.0%, stated they would rate their current health to be good. Out of the respondents left, 14.0% stated that they would rate their current health as excellent, 9.2% stated they would rate it as being fair while the smallest portion of respondents, 1.2%, stated they would rate it to be poor.

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This survey question asked the respondents to reflect on their current metal health. The largest portion of respondents, 41.1%, of the respondents stated they would rate their current mental health to be very good. The next highest portion of respondents, 30.1%, rated their current mental health to be excellent. Another marked portion of respondents, 22.0%, rated their current mental health to be good. Out of the portion of respondents left, 6.0% stated they would rate their mental health to be fair, while only 0.9% rated their current mental health to be poor.

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The respondents were asked if they have ever smoked. A rather large portion of the respondents, 74.0%, stated that they have never smoked. The next highest portion of respondents, 20.6%, stated that they had smoked at one time in their lives but have quit. The remaining portion of respondents, 5.4%, stated that they currently smoke. The survey question asked the respondents to choose a category that best describes their line of work. A large portion of respondents, 26.6%, stated that they work in computer information related jobs. The next largest portion of respondents, 20.3%, stated that they work in accountant or financial related jobs. The other large portion of respondents, 19.9%, stated that their jobs are related to marketing and sales. Of the respondents that are left, 10.6% stated they work in executive, administrator or senior manager positions, 9.0% work in human resources, clerical or administrative positions, 4.7% work are educators, 4.7% are in real estate or insurance type positions, and 4.3% are involved in production and manufacturing positions.

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The following questions asked the respondents to reflect on their performance at their work in the past 4 weeks. When asked how often their performance was higher than most of the workers at their work, 57.7% of the respondents stated most of the time. And when asked how often their performance was lower than most of the workers at their work, 54.7% of the respondents stated barely any time. The next question asked the respondents how often they were not working during the time they were supposed to be working. A large portion, 52.0%, of the respondents stated barely any time. The respondents were then asked how often they found themselves not working as carefully as they should and 51.8% of the respondents stated barely any time. The next question asked the respondents to reflect on how often the quality of their work was lower than what it should have been. A large portion of the respondents, 57.2%, stated barely any time. The last question asked the respondents how often they did not concentrate enough on their work, and 50.2% stated barely any time.

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This survey questions asked the respondents to rate the typical performance of most of the workers in their workplace on a scale of 0-10 where 0 is the worst possible rating, and 10 is the best possible rating. A large portion of the respondents, 51.2%, rated their co-workers performance at 6 -7. The next largest portion of respondents, 34.8%, stated that they would rate their co-workers performance at 8 -9. Of the remaining respondents, 10.4% rated their co-workers performance at 4-5, 1.8% rated it at 2-3, 1.2% rated it at 10, and the smallest portion of respondents, 0.6% rated it at 0-1.

This survey question asked the respondents to rate their own normal job performance in the last three years by following the same scale used to rate their co-workers performance. The largest portion of respondents, 73.8%, rated their personal job performance at 8-9. The next largest portion of respondents, 12.3%, rated their performance at 6-7. Of the remaining respondents, 10.2% rated their job performance over the last three years at 10, 3.0% at 4-5, 0.3% at 2-3 and 0.3% at 0-1. Business and Health Administration Association Annual Conference 2012

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The first part of the chart represents that average scores of the survey respondents BMI, fitness, health, a combination of these three elements, as well as the average sore of their productivity. The Respondents average BMI level was 1.23, their average fitness level was 3.43, their average health level was 6.51, and their average score of productivity was 13.52. The next part of the chart shows the average score of productivity by level of BMI, fitness and health. Respondents, whose level of body fat percentage, fitness and health were low, obtained scores of 13.52 and 13.5. Respondents, whose level of body fat percentage, fitness and health were medium, obtained scores of 13.37, 13.5, and 13.46. And the respondents, whose level of body fat percentage, fitness and health were high, obtained scores of 13.63, 13.55 and 13.62. The next portion of the chart shows the body fat percentage of the respondents. The largest portion of respondents, for men, 26-37%, and women, 31-41%, had a description of body fat percentage of being overweight. An even more significant portion the female respondents, 41% or more, had a body fat percentage that was at the obese level, as well as 37% or more of the male respondents. Of the female respondents, 13-21% had a body fat percentage of an athlete; 21-25% had a fit body fat percentage, while 25-31% had a percentage that was acceptable. Of the male respondents, 5-13% had a body fat percentage of the athletic level, 13-17% had a fit body fit percentage, and 17-26% had an acceptable body fat percentage.
BMI average Fitness average Health average Average score of fitness+health+BMI Average score of productivity

1.231788079

3.435761589

1.84602649

6.513576159

13.52317881

Average score of productivity by level of BMI fitness and health

Level low medium high

Body fat percentage 13.47569444 13.63235294

Fitness 13.52173913 13.50735294 13.55241935

Health 13.5 13.46694215 13.625

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Body fat percentage Women <10% 1013% 1321% 2125% 2531% 31-41% 41%+ Men <2% 2-5% 513% 1317% 1726% 26-37% 37%+ Score 0 1 1.5 2 1.5 1 0 Level low low medium medium medium high high

Description Essential fat Athletes Fitness Acceptable Overweight Obese Fitness

Score <3 >3 and <5.6 >5.6 Health Score Not fit Medium fit Very fit

Score <1.25 >1.25 and <3 >3

Not healthy Medium healthy Very healthy

SUMMARY AND CONCLUSION The idea of a direct relationship between fitness and productivity has made the companies to spend billions to improve employees fitness. The idea of a relationship can easily be recognized without much thought as many jobs do require physical skills. However, in todays job market when most jobs require little or no physical exertio n, are fitness and productivity really related? The majority of the scholarly articles hold the belief that there is a relationship between fitness and productivity. If fitness could be increased through some type of fitness program, that would be a noticeable increase in productivity. Other articles suggest that there is a relationship between fitness and productivity, yet only in extreme cases. While other articles suggest that a relationship may exist, but it cannot be proved without more research. Questionnaires were sent to 1765 Cal Poly College of business alumni. A total of 355 responded to the questionnaire, but 328 of them were complete. The majority of the respondents were male, accounting for more than half of the responses totaling to 59.3%. As far as how many times they typically exercise, a high percentage of the survey respondents, 43.3%, stated that they exercised an average of 2-3 times a week. All of the survey respondents stated that they participated in some form of exercise on a weekly basis. The 34.7 of the respondents stated their perceived exertion was strong and during exercise they experienced sweating and could talk without Business and Health Administration Association Annual Conference 2012

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much difficulty. A majority of the survey respondents, 49.3%, stated that they perceived their exertion and physical signs to be moderate to extremely strong during 1-2 of their workouts. A large portion of the respondents, 36.5%, stated that known health issues have no adverse effects on their work performance. A 42.4% of the respondents stated they would rate their current health to be very good. The 41.1% of respondents stated they would rate their current mental health to be very good. The respondents were asked if they have ever smoked. A large portion of the respondents, 74.0%, stated that they have never smoked. When asked how often their performance was higher than most of the workers at their work, 57.7% of the respondents stated most of the time. After applying a set of statistical modeling and analyzes, the result showed no significant correlations between the productivity of those who are fit and have a correct BMI and those who are not fit and their BMI is higher or lower than it should be.

Mansour Sharifzadeh Professor of Management Cal Poly State University Pomona College of Business Pomona, Ca 91768 E-mail: msharifzadeh@csupomona.edu

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VIEWPOINTS ON ELECTIVE COSMETIC SURGERY: AN INITIAL INQUIRY INTO CONSUMPTION PRACTICES FROM A MARKETING PERSPECTIVE
Kirk Moore, New Mexico State University INTRODUCTION The elective cosmetic surgery literature has been dominated by the medical and psychiatric disciplines. This has led to an over emphasis on cosmetic surgery in terms of mental illness and medical issues. There has been research of cosmetic surgery in the social sciences (sociology, anthropology, feminist study) where the focus has been on the consumer as a victim of the media and society or, much like the medical literature, in terms of mental illness. Researchers are beginning to explore the use of elective surgery in a different light. This paper is an initial inquiry into elective surgery as a consumption practice. Elective cosmetic surgery can be studied in marketing terms. Through interviews with medical professionals and lay people, the author is in the first stage of developing the idea of elective cosmetic surgery as a multi-headed hydra marketing phenomena. The author also explores the subjective nature of products. BACKGROUND LITERATURE REVIEW The literature in the academic marketing world is a bit thin concerning elective cosmetic surgery. The articles were found on Business Source Premier using various search terms encompassing elective cosmetic surgery. Seltman and Nayar studied the semantic differences between various word pairs, including cosmetic and aesthetic, in the context of naming clinics (Seltman and Nayar 1998). They found that cosmetic had some negative reactions, but was readily identifiable to the target market (Seltman and Nayar 1998). Sayre related her experience of having a facelift, including the choice to have a facelift and post-facelift feelings (Sayre 1999). Sayre did include the commonly held belief that the choice to have facelifts is driven by societal demands about the looks of women, including the impact of a hostile media (Sayre 1999). Mowen, Longoria and Sallee, in their article identify traits of individuals who have a propensity for tanning and undergoing cosmetic surgery (Mowen, Longoria, and Sallee 2009). The article supports the idea that emotional instability correlates with undergoing cosmetic surgery ((Mowen, Longoria, and Sallee 2009). Besides these three papers, nothing much seems to have been done within the academic marketing literature. The medical literature has dealt extensively with the psychiatric implications, but that is outside the scope of this paper. The study of the body has been extensively covered in the sociology, feminist, philosophical, psychology, and anthropology literature. For this extended abstract, the aut hors concern is to note that the study of elective cosmetic surgery as a luxury does not seem to have been covered within the marketing literature. INITIAL METHOD At the beginning of any inquiry, qualitative or quantitative, it is important to determine if the subject has any room for discovery of new theory and also if the proposed study has any merit. For this initial foray into the realm of elective cosmetic surgery and the idea of luxury, informal discussions with medical personnel, academic colleagues, and lay persons were conducted. These discussions were unstructured. The beginning to the discussions was started with various forms of the question or statement, is elective cosmetic surgery a luxury? The discussions were not recorded. The discussants were informed of the researchers intent to begin studying the idea of luxury and its relation to elective cosmetic surgery. Of interest is that discussants understood the term elective cosmetic surgery without having requested a definition. From the discussions, it was clear that the discussants understood the difference between elective cosmetic surgery and other forms of plastic surgery. In terms of determining if the subject, elective cosmetic surgery and luxury, has any room for theory development and having any merit, the discussants proved to be interested in talking about the subject. They were Business and Health Administration Association Annual Conference 2012

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more than willing to talk about and think about the subject. The interest from fellow academics also proved that this is an area that needs to be looked into, from an academic business and marketing perspective. DISCUSSIONS The bulk of the informal discussions were conducted in November and December of 2011. Incorporated into these discussions is also a lifetime of listening to people discuss elective cosmetic surgery. The following section will look at three different groups: lay people, academic colleagues, and medical personnel. These groupings, while developing organically, seem to be natural divisions in dealing with the subject at hand. Lay people seem to have two separate groups. Those that have or are going to have elective cosmetic surgery and those that have not had nor are planning to have elective cosmetic surgery. Those that have had or are planning to have cosmetic surgery, on the whole, seem to view elective cosmetic surgery, not as a luxury, but as a necessity. The different groups of would be or actual elective cosmetic surgery patients needs to be studied in much more detail. When talking to lay people who have not had and are not planning to have elective cosmetic surgery, there seemed to be no doubt that elective cosmetic surgery is luxury. A simple yes was the answer to the initial question, is elective cosmetic surgery a luxury? Further differentiation between the two groups needs to be explored. While academic colleagues can be viewed as lay people in the context of elective cosmetic surgery, it seemed beneficial to break them out as a separate group. This separate grouping allows for the determination of whether or not the area is academically interesting and whether it should be pursued in an academic inquiry. The discussions with academic colleagues focused more on whether or not research on the subject of elective cosmetic surgery and luxury had any merit and had any interest for the academic community. The overall response was that this area of research had something of interest for the academic community. After discussing the potential in studying elective cosmetic surgery as a marketing concept while at the same time testing the meaning of luxury, it became obvious that this subject of study has value in being researched. The medical personnel had a slightly different view of the subject of elective cosmetic surgery. There was a feeling that elective cosmetic surgery, while being elective, as opposed to as being necessary for health reasons, may not be a luxury. A plastic surgeon provided a threefold way to look at elective cosmetic surgery. Depending on the patient and the type of elective cosmetic surgery being done, the procedure could be seen as a luxury, a quality of life/business decision, or as a form of psychiatric problem expression. At the same time, an inactive nurse, who had dealings with elective cosmetic surgery patients, witnessed patients who had had facial surgery. Those surgeries, to her, were an expression of cultural coming of age rituals. The viewpoints of medical personnel seemed to differ from the other two groups in that there was more breadth of interpretation in what elective cosmetic surgery meant and its relation to luxury. CONCLUSION The initial process of determining whether or not to study the subject at hand seems to suggest that there is indeed something to be studied here. The literature in the academic marketing literature is a bit thin in both the elective cosmetic surgery arena and the luxury area, which suggests space to explore both concepts. The discussions with all three groups suggested an overall interest in the subject. The plastic surgeon, in particular, was enthusiastic about the study of his field as a business and marketing phenomenon. Out of these discussions, several areas of further research appeared. First off is that the vision of what a luxury is seems to be highly subjective (Berry discussed at length the relativity of luxuries in Berry 1994). One persons necessity is anothers want. This idea is of great interest, given that luxury is us ually discussed in terms of luxury brands by practitioners, which suggests that marketers view luxury as an absolute, as opposed to subjective, concept. Also of interest from the discussion with the plastic surgeon, is the idea that different kinds of surgeries attract different types of patients. The specific product, in this case the specific elective procedure, may determine whether or not it is viewed as a luxury. From the forgoing information, there emerged a number of avenues of research. Of potential help for the medical profession may be the determining a typology of procedures and whether or not they can be viewed as Business and Health Administration Association Annual Conference 2012

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luxuries. If a given procedure is in fact a luxury, then surgeons may be missing out on potential profits. Also, a typology might help in determining expectations of patients and help surgeons with customer service issues and patient selection processes. Basic survey research should be able to help elucidate the construct of luxury in the context of elective cosmetic surgery. Ideally, the research will help both the academic world in exploring a vital subject area, while at the same time improving outcomes for the medical profession.

REFERENCES Berry, Christopher. (1994). The Idea of Luxury: A Conceptual and Historical Framework, Cambridge, England: Cambridge University Press. Mowen, John C., Adelina Longoria, and Amy Sallee. (2009). Burning and Cutting: Identifying the Traits of Individuals with an Enduring Propensity to Tan and to Undergo Cosmetic Surgery. Journal of Consumer Behavior 8, 238-251. Sayre, S. (1999). Facelift Forensics: A Personal Narrative of Aesthetic Cosmetic Surgery. Advances in Consumer Research, 26, 178-183. Seltman, Kent, & Veena R. Nayar (1998). Good Names: Market Research Reveals Semantic Differences in Common Health Care Names. Marketing Health Care Services, 5(12).

Kirk Moore New Mexico State University E-mail: dr.moore.for.hire@gmail.com

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NATIONAL CULTURE, HUMAN DEVELOPMENT, AND ENVIRONMENTAL HEALTH: A CROSS NATIONAL ANALYSIS
Avinandan Mukherjee, Montclair State University Naz Onel, Montclair State University

ABSTRACT There is a considerable scarcity in the literature on environmental performance of the countries that would affect the human health directly and the mechanism between national culture, human development, and environmental health. This study aims at constructing a model to examine the effects of cultural values and human development on environmental health by incorporating different variables from Human Development Index, Hofstedes Cultural Dimensions, and Environmental Performance Index. The main objective of the study is to empirically test the effects of different components of national culture and human development on environmental health performance of countries. Multiple linear regression models were employed to test the hypotheses on a sample of 67 countries. Empirical results conclude that combined effects of national culture and human development on environmental health show only significant effects of human development components. These findings provide theoretical and managerial implications of cultural values and ethical behavior in general and environmental management in particular.

INTRODUCTION Human health is determined by a broad variety of external and internal factors. These factors include individual behaviors, genetic inheritance, quality and accessibility of healthcare, and the wide-ranging external environment such as the quality of water, air, and living conditions (Hernandez and Blazer, 2006). Today, the significant and detrimental effects of environmental factors on human health are accepted by many (Iles, 1997). In fact, in many parts of the world, it is easy to see environmental factors, such as pollution, decline, and loss of biological diversity, and degradation, being increasingly responsible for ill-health of the world population (WHO, 1997; UNDP, 1998). In many cases, destroyed habitats negatively affect the quality of living conditions of human communities. For instance, millions of people are exposed to unnecessary physical and chemical hazards in their living environment and work place constantly. According to Blaint (1999), more than one billion people are lacking access to safe drinking water, and more than three billion peoples accessed water lacks minimally acceptable sanitation requirements. Every year, four million infants and children die as a result of diarrheal diseases, largely caused by contaminated food or water. At any given moment, 267 million people are suffering from malaria, again caused by environmental factors. Every year, two million people die from it. Devastating intestinal parasites affect hundreds of millions of people each year. Tuberculosis causes deaths of three million people every year, and any given time 20 million are affected by it. Hundreds of millions suffer from sicknesses caused by poor nutrition (Yassi et al., 2001; Moeller, 2005). More than 210 million malnourished children are drastically susceptible to infections, mainly as a cause of land degradation. Many communities live with the danger of wide-spread cholera as a result of lacking safe drinking and household water. All these and many more negative impacts of deteriorated environmental goods on peoples lives lead us to infer that the health of millions of people around the world highly depends on their access to unaltered environmental goods such as clean air and uncontaminated water. In fact today, a wide range of domestic as well as international bodies, such as the World Bank, World Health Organization (WHO), and United Nations (UN), recognizes the associations between environmental conditions and human health (Iles, 1997). According to the World Health Organization, environmental health mean s those aspects of the human health and disease that are determined by factors in the environment. It addresses all the external factors ( e.g. physical, chemical, and biological) to an individual and all the related factors impacting behaviors of this individual.

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Environmental health includes the evaluation and control of these external factors that can potentially affect the humans health (WHO, 2011). Previous studies related to environmental conditions in the literature generally focused on the environment in general. Most of these studies have showed that economic development and environmental degradation of a country are connected closely (e.g., Grafton and Knowles, 2004; Husted, 2005; Mendelsohn, 1994). Husted (2005), on the other hand, highlighted the importance of national culture on environmental performance of the countries. In his study, he hypothesized and verified correlated relationship between environmental performance and national culture. Husted adopted Vitell et al.s (1993) proposition regarding the influence of national culture on ethical decision-making based on the typology of Hofstede (1980). Husted (2005) developed the logic regarding how national culture of a country could affect environmental conditions of that country. Similar study from Peng and Lin (2009) discussed the potential effect of national culture on moral behavior at the analytical level of a country and gave the environmental outcomes as national cultures consequences. Also, according to Park, Russel, and Lee (2007), the willpower, determination, and capability to protect the environment from harmful actions are influenced by many intra-country socio-cultural factors. If the communities shaped by people with more culturally conscious of environmental conditions, high environmental sustainability can be maintained more easily. Furthermore, in these kinds of communities, it would be much easier and quicker to restore the environmental health if damages occur. This scenario tells us that by shaping the attitudes and perceptions, national culture influences the acts of individuals in terms of utilizing their environments and natural resources. Although scholars have argued that national culture and economic development are important factors of determining the level of the environmental performance (e.g., Husted, 2005; Park et al., 2007; Peng and Lin, 2009), none of these studies in the literature has tried to compare and evaluate the relationship of national culture and economic and social development on environmental health. Herein lays the importance of empirically determining the significance of national culture on environmental health conditions. The purpose of the present paper is to provide some modest first steps in the search for greater understanding of the statistical relationship between elements of culture, human development, and environmental health. To the best of our knowledge, this is the first paper to demonstrate an overall statistical relationship between three sets of environmental health, human development, and cultural variables. A quantitative analysis of culture is not an easy task, mainly because culture is itself a complex concept. In this paper, we take Hofstedes work (1980, 1983, 1991, 1997, and 2001) as a base and employ four dimensions of culture. In addition, we include Human Development Index variables as well as environmental health variables to complete the statistical analyses. Given its theoretical significance and practical relevance, the mechanism linking cultural values, human development, such as educational and living standards development, and environmental health ( i.e. impacts on human health) deserves systematic and in depth analysis. Specifically, this study attempts to answer the following research questions: (1) Does national culture of the countries affect environmental health of a country? (2) Do certain human development components have an effect on environmental health of the countries? In the following section, we first review the literature to develop a set of hypotheses, and then test the hypotheses on a sample of 67 countries. Finally, we discuss the findings and conclude the article by suggesting new directions for future studies. LITERATURE REVIEW AND HYPOTHESIS CONSTRUCTION In this research study, we are interested in exploring the relationships between national culture, human development dimensions and environmental health. To the best of our knowledge, there is no similar study dealing with this issue, only a few studies deduce the relationship between national culture and general environmental performance by the definitions of Hofstedes four cultural dimensions. From the authors focused on general environmental performance and cultural factors, Husted (2005) proved that three of the four cultural dimensions, masculinity, individualism, and power distance are significantly connected with environmental performance. However, Park et al. (2007) were only able to find power distance and masculinity as significant factors in effecting environmental performance across countries. Similarly, more recent study by Peng and Lin (2009) showed that the same factors, power distance and masculinity, to be the most effective and consistent predictors of environmental performance of a country. Even though Ringov and Zollo (2007) also found the same cultural dimensions to be significant in environmental performance, their focus mostly involved corporate level environmental activities and performance and not the country level performance. Although these studies proved that various cultural dimensions

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could affect the environmental performance of the nations, none of them examined the relationship considering the environmental health specifically, which defined as a sub-division of the environmental performance. National culture In this section, we build a model for environmental health and its cultural antecedents based on the crosscultural management literature. Although culture is defined by many in different ways, most accepted definitions consider culture to consist of shared beliefs, values, knowledge, and goals that guide people s actions (Milton, 1997; Hofstede, 2001). The description by Newman and Nollen (1996) define national culture as the values, beliefs and assumptions learned in early childhood that distinguish one group of people from another (p. 754). Hofstede (1991) defines culture as the collective programming of the mind which distinguishes the members of one category of people from another" (p. 5). In this study, we are mainly interested in understanding how specific cultural values/dimensions of a country impact environmental health of that country. By using IBM employees as the studys subjects, Hofstede (2001) developed four main work -related dimensions that could characterize various cultures around the globe. These dimensions are: (1) High versus Low Risk Avoidance (UAI), (2) Collectivism versus Individualism (IND), (3) High versus Low Power Distance (PDI), (4) Masculine versus Feminine (MAS). These four dimensions of culture have been widely accepted and found very effective by researchers who try to explain different socio-economic trends in various cultural settings (e.g., Hofstede and Bond, 1984; Kogut and Singh, 1988; Shane, 1992; Nakata and Sivakumar, 1996; Lu et al., 1999; Singhapakdi et al., 1999; Christie et al., 2003; Park et al., 2007). In this study, we adopt a similar approach by examining the impact of Hofstedes national culture framework on national environmental health performance in a cross-country setting. Individualismcollectivism The first cultural dimension, individualism/collectivism, looks at the functioning of the society in the context of interpersonal relationships as well as achievements from individualistic and collectivistic standpoint. In individualistic societies, individuals take responsibility mainly considering their own benefits and those of their immediate families (Hofstede, 1980; Triandis, 1995; Ringov and Zollo, 2007). If a society is highly individualistic, the importance of the individual in the society and individual rights become significantly influential. On the other hand, if the society has low individualistic nature, the personal rights become less important and benefits to the society as a whole become more influential. These societies typically can be defined as collectivistic. In these societies, individuals can take responsibilities for the other members of the group they belong to, such as extended families and friends (Hofstede, 1991). There is a considerable close tie between these individuals in collectivist societies. Because of this connectedness and placed importance to the shared interests in these communities, we can expect collectivistic societies to exhibit higher levels of environmental consciousness. In fact, Park et al. (2007) support this idea and state that the environmental sustainability could be sustained with higher levels in collectivistic societies. However, we should also consider the importance of social movements to help sustain environmental protection activities. Individualism/collectivism of countries affect how members of the society function, and this in turn, gives the general picture of the society in terms of how they perceive certain movements. When we look at the environmental movement, we see the emergence as the result of different interest groups activities which are highly dispersed in nature. In general, these activities are not carried out from the centralized associations (Vogel, 1987; Dobson, 1990). It is also very rare to see collectivist societies to congregate for the purpose of improvement of the environment they live in. Contrarily, in individualistic cultures, environmental interest-group activities seem to be greatly diverse and widespread (Katz, Swansons, and Nelson, 2001). In this case, as supported by Husted (2005), if a country has a high individualistic tendency, that country would be expected to have more environmental groups and, as a result, more social as well as institutional capacity to respond to environmental problems. All these should lead to a better environmental health condition for the society that has higher individualism as a cultural dimension. Thus, we expect: Hypothesis 1. The higher the level of individualism of a country, the higher is the environmental health of the country. Business and Health Administration Association Annual Conference 2012

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Power distance This cultural dimension examines the degree of perceived equality among people in a given society. Hofstede (1997, p. 28) defines power distance as "the extent to which the less powerful members of institutions and organizations within a country expect and accept that power is distributed unequally." In high power-distance countries, subordinates are highly dependent on their superiors. There is a strong parallel between high power distance and paternalism (Hofstede, 2001; Husted, 2007). In paternalism, superiors expect loyalty from their subordinates as a return for their favors. If the favors are done to them, then the subordinates need to show loyalty. In this kind of societies, decisions are made on the basis of a balance between favors and loyalty, not the merit. So, if the protection of the environment is crucial for the general health of the society, and if that specific society is characterized by high levels of power distance, then the decision cannot be made solely based on how the results of that decision could be vital for the society. In this case, we can say that even if the environmental conditions are affecting the human health destructively, the decision making regarding the environmental issues would be different in high power distance and low power distance societies. Metz (1991) gives a good example of this assumption in his research paper and examines deforestation program implementations in Nepal in the context of power distance influence. He points out that the power distance dimension may hinder the implementation of the programs in various different ways. According to Husted (2007), if a society has high level of power distance, it causes agents to focus on internal politics of the agencies instead of the problems main technical merits. Furthermore, high power distance societies lack the necessary debate capacity for the better environmental conditions due to the great respect towards authorities. This respect to the higher authorities and resulting weaker capacity for debate usually lead to a weaker private sector responsiveness to social issues in high level of power distance countries (Katz, Swanson, and Nelson 2001; Husted 2005). As Husted (2007) suggests, in the societies that have lower level of power distance, it is much easier to openly discuss social and environmental initiatives and come up with necessary solutions. Furthermore, citizens in these countries are more likely to have equal rights and wealth (Peng and Lin, 2009) to work on and support environmental improvement activities collaboratively. Hence, we would expect that societies with low level of power distance tend to be more protective of the environmental health of the country. Thus; Hypothesis 2. The higher the level of power distance in a country, the lower is the environmental health of the country. Uncertainty avoidance Hofstede (2001, p.161) defines uncertainty avoidance as the extent to which the members of a culture feel threatened by uncertain or unknown situations. Individuals with high uncertainty avoidance are generally concerned with security in life, and generally, they would not tolerate ambiguous situations or deviations from the norms. They feel secure if everything happens the way it always does, without any variations (Hofstede, 1980). Contrarily, individuals with low uncertainty avoidance are perceived to be more tolerant to risks in life and less concerned with security. According to Kale and Barnes (1992), strong resistance to change can be seen in societies with high levels of uncertainty avoidance, while lower resistance to change exists in societies with low uncertainty avoidance. Peng and Lin (2009) explain this by pointing out the close link between change and uncertainty. When there is a change, it would come with its uncertainties. Individuals in high uncertainty avoidance cultures tend to be strict and dogmatic. They feel threatened by unknown situations. If the environmental conditions are deteriorating, this may affect the societys health conditions adversely which could lead to unknown future for the citizens of that society. Hence, it is reasonable to assume that individuals in high uncertainty avoidance cultures would desire to have stable environmental health conditions to avoid risks in their lives. Thus, we expect; Hypothesis 3. The higher the level of uncertainty avoidance of a country, the higher the environmental health of the country. Masculinityfemininity Hofstede (2001) proposed this cultural dimension in terms of the degree society emphasizes (or does not emphasize) the traditional male achievement. According to Hofstede, Masculinity stands for a society in which social gender roles are clearly distinct: Men are supposed to be assertive, tough, and focused on material success; women are supposed to be more modest, tender, and concerned with the quality of life. Femininity stand for a society in which social gender roles overlap: Both men and women are supposed to be modest, tender, and Business and Health Administration Association Annual Conference 2012

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concerned with the quality of life (p. 297). In a society with high level of masculinity, usually there is a higher degree of inequality in terms of genders. Hofstede (1985, p. 348) points out that masculinity is a prefere nce for achievement, heroism, assertiveness, and material success. This explains the materialistic nature of the masculinity cultural dimension. On the other hand, low masculine societies have a lower level of differentiation between genders (Heffernan and Farrell, 2005). These more feminine societies tend to emphasize modesty, social interaction and caring for the vulnerable (Ringov and Zollo, 2007). Since the societies that have highly masculine characteristics place low value on caring for others and quality of life, it can be expected that individuals in these societies tend to care less for the environmental conditions that may affect the members of the community adversely. Tice and Baumeister (2004) suggest that masculinity generally restrains helping behaviors in a society. If the individuals would not be willing to protect each other against environmental degradation, then it can be easily inferred that these communities could face environmental health problems. This leads us to hypothesize that higher levels of masculinity will have a negative impact on environmental responsiveness as well as environmental health conditions. Thus, Hypothesis 4. The higher the level of masculinity of a country, the lower is the environmental health of the country. Human development According to UNDP, human development is considered as more than just the national income increase or fall. UNDP defines it as creating an environment in which people can be productive by reaching their full potential. They can support their lives creatively and meet their needs and interests as the way they aim for. The real wealth of the nations is considered to be the people. Development could be possible if nations are able to expand their citizens choices in their lives that they value the most. Therefore, human development paradigm should be considered much more than just economic growth, indeed one of broadening peoples choices (UNDP, 2011a). These definitions help us to expect high human development to bring better living standards for the communities. For instance, Gorobets (2011) suggests that a high percentage of healthy population can be seen as the principal indicator of sustainable human development. Then, if the living conditions better for the society as a result of high human development, we would expect the health of society and the environment to be enhanced, compared to the low human development societies. UNDP uses composite indices to determine human development of each country. The agency combines educational attainment, health, and income indicators to come up with a composite human development index, named as the HDI (UNDP, 2011b). For this research study, we will use all these three sub-divisions of human development index to evaluate the relationship between human development and environmental health. Educational attainment There is extensive literature regarding the link between education and human health, such as mortality, morbidity, functional limitations and health behaviors. Hernandez (2006) points to the connection between lower educational attainment and inferior health outcomes through the life course of a human being. He gives an example of infant life expectancy. For instance, chance of an infant that born to mother with less education dying before the first birthday is 2.4 times higher than infants born to mothers with more years of education. This association between maternal education and infant mortality has been defined as gradient ( NCHS, 1998). For instance, steep educational gradients are detected for childrens health such as cigarette smoking, obesity, and high lead levels in their blood streams. Also health issues that people face in their midlife are observed to be much higher in low educated group of individuals, including high mortality rates. Finally, in older ages, these individuals face more chronic conditions such as diabetes and hypertension compared to more educated persons (Hernandez, 2006). Of course, we can assume that not all aforementioned health issues could be directly related to the environmental conditions. But if we consider that protecting and improving the environmental health would need a greater worldview that could be emphasized and advanced with educational attainment, we can assume the link between environmental health and higher education. For example, quality of drinking water the communities have access can get affected from the surrounding agricultural and industrial activities as well as domestic use of the resource by individuals. Agricultural fertilizers, pesticides, industrial discharges, and household wastewaters can easily reach to underground aquifers as a result of surface runoff. Unfortunately, this polluted water can be detrimental to human Business and Health Administration Association Annual Conference 2012

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health and cause illness and even death. As an example, approximately two million children die annually from diarrheal diseases caused by unsafe drinking water which defined as the worlds one of the greatest killers (UNICEF, 2007). However, if the individuals in the community are knowledgeable enough to see the connection between the harmful practices they adopt and detrimental health outcomes, they can alter their actions towards conserving the limited resources. So, in addition to acquisition of knowledge and skills that promote health, such as the implementation of healthier behaviors (Cutler and Lleras-Muney, 2006), higher level of schooling can affect the prospects towards the environmental health. Furthermore, lower educational attainment can cause a lack of understanding of the importance that environmental protection could have. Since the population cannot pay the necessary attention to the environment, environmental health can become deteriorated. According to the above perspective, we infer; Hypothesis 5. The higher the level of educational attainment, higher the environmental health of the country. Income Similar to the education variable, there is extensive literature in about a strong relation between income and health. Research has been conducted at both individual and aggregate levels. For instance, comparing the top (>$70,000 in 1984 dollars) income earners to the bottom (<$15,000) income earners revealed that family income was highly correlated to the mortality risk among working-age adults (Duncan et al., 2002). This relationship between income and human health has been also extended to neighborhoods and other geographic areas. Various studies that adopted multilevel designs included quality of neighborhood in their investigations and conceptualized place with income attributes (Kawachi and Berkman, 2003). The results of these studies showed that living in the disadvantaged neighborhood imposes an additional risk to human health. For example, the study conducted by Department of Housing and Urban Development in neighborhood mobility (Moving to Opportunity study, MTO) found that moving from a poor to a wealthier neighborhood improves adults health attributes significantly (Clark, 2008). When Kawachi and Berkman (2003) defined disadvantaged neighborhoods, they also included adverse physical and social environments, such as exposure to more air pollution. These approaches help us to infer that income related adverse environmental health outcomes are possible to observe in low-income neighborhoods. Environmental quality and income often directly related each other, especially when higher income samples are contrasted with lower income samples. Also, environmental quality accepted to be inversely related to various physical (and psychological) health outcomes. In other words, income of the individuals in a society is generally accepted to be highly associated with exposure to a wide variety of environmental quality indicators in the surrounding environment, at home, on the job, in school, as well as in ones neighborhood, which in turn cause negative health effects on individuals (Evans and Kantrowitz, 2002; Cakmak et al., 2006). In fact, numerous studies in the literature focus on the environmental pollutants and income, especially hazardous wastes and air pollution in poor communities. Also, a few case studies suggest the connection between higher levels of contaminated drinking water and low-income societies (Calderon et al. 1993, WHO, 2006). For instance, Ciesielski et al.s (1991) study shows that in North Carolina, migrant farmers with very low income receive water that 44% of it tested to be positive for coliform and 26% for fecal coliform. Same regions comparable farms, on the other hand, had the levels at 0% for both kinds of coliforms. Similarly, Chicano populations living along the U.S./Mexico border that have low level of income are also plagued by polluted drinking water. According to the study by Calderon et al. (1993), approximately 50% of the Chicano population in Texas does not have access to safe drinking water, a condition that is largely assumed to be the reason for the substantial increase in water borne diseases in this population. Clearly, as supported by various studies, there is a significant link between income of the population and health of the communities that is directly related to multiple environmental risks surrounds them. Thus; Hypothesis 6. The higher the level of income of a country, higher the environmental health of the country. Life expectancy Individuals health condition is an important determinant of the living standards and human development. As mentioned earlier, UNDP measures human development by combining indicators of educational attainment, health, and living standards. Therefore, we use health as the last indicator of human development index in this study. Business and Health Administration Association Annual Conference 2012

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This indicator measured with a component life expectancy at birth by UNDP. Life expectancy at birth is defined by OECD as the average number of years a newborn can expect to live i f he or she experienced the age-specific mortality rates prevalent in a particular year (OECD, 2009). According to Mariani et al. (2009), the way individuals value future is highly impacted by their life expectancy. Usually, if they have a higher life expectancy, they would feel more sympathetic to coming generations as well as their own future. Therefore, Mariani et al. (2009) conclude that if someone expects to live longer, that person would be keen to invest more in environmental quality and future generations. In fact, it is reasonable to invest in environmental quality, depending on how much a person expect to live; because every individual would want to have a longer life with a better quality and higher standards. Increased investment in environmental quality eventually will lead to better living conditions and improvement in environmental health. Thus; Hypothesis 7. The higher the level of life expectancy at birth of a country, the higher the environmental health of a country. METHODOLOGY Conceptual model On the basis of the section of literature review and hypothesis construction, the framework of this research is illustrated in Figure 1. In this study, we attempt to explore the relationships among cultural variables, human development, and environmental health. Cultural Dimensions Individualism H1 Power Distance H2 Uncertainty Avoidance H3 MasculinityFemininity H4 Environmental Health

Env. Burden of Disease

Air Pollution (effects on humans) Water (effects on humans)

Human Development Education

H5

H6 Income H7

Life Expectancy at Birth

Figure 1. Model for the combined effects of culture and human development on environmental health. Business and Health Administration Association Annual Conference 2012

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Sample The research sources were from three international surveys: the Hofstede culture study, the UNDP, and the World Economic Forum. The data of cultural dimensions were obtained from the Hofstedes study (1997). The data of environmental performance was taken from the Yale Center for Environmental Law and Policy/Global Leaders of Tomorrow Environmental Task Force of the World Economic Forum. The data of GNP per capita, income, education, and health were collected from the UNDP (2011). We first obtained country-level data of environmental health performance from the Environmental Performance Index (EPI) report (2010) and excluded those cou ntries not included in Hofstedes (1997) country list. Finally, we collected these countrys human index data from UNDP. Measures Dependent variable Environmental Health: Environmental health, as a dependent variable, was measured by the Environmental Health Performance provided by the Environmental Performance Index (EPI). The EPI was developed by the Yale Center for Environmental Law and Policy (YCELP) and the Center for International Earth Science Information Network (CIESIN) of Columbia University, in collaboration with the World Economic Forum and the Joint Research Centre of the European Commission. The index gives each country scores on two key objectives; (1) Environmental Health and (2) Ecosystem Vitality (EPI, 2010). Environmental Health refers to the extent to which deficiencies in water quality, air pollution, and other factors cause health issues and reductions in quality of life. Ecosystem Vitality measures the health of a countrys ecosystem by evaluating such factors as agriculture, biodiversity and habitat, climate change, fisheries, and forestry. The fact that we are interested in the human health consequences related to the environmental conditions, from these two key objectives of the index, we used Environmental Health measures. When measuring the variables, the EPI utilizes a proximity-to-target methodology focused on a core set of environmental outcomes linked to policy goals. The Environmental Performance Index (EPI) in its 2010 report ranked 163 countries on 25 performance indicators that are tracked across ten policy categories covering both environmental public health and ecosystem vitality. Performance indicators used by EPI provide a general picture in terms of how close countries are implement environmental policy goals. In the index, "environmental health" determined by the human health related variables, such as child mortality, indoor air pollution, drinking water, adequate sanitation and urban particulates. Sub-categories of the environmental health are given as: (1) Environmental burden of disease (with 25% weight assigned to it), (2) Air pollution effects on human (12.5%), and (3) Water effects on human (12.5%). Both air and water indicators are also divided into two different groups, for air, they are indoor and outdoor pollutions (each has 6.25% weight), and for water, they are access to water and sanitation (also each has 6.25% weight) (EPI, 2010). Independent variables Culture: The cultural variables of power distance, individualism, masculinity, and uncertainty avoidance were measured using data published by Hofstede (1997) for 67 countries. As mentioned earlier, by using large number of IBM employees as the studys subjects, Hofstede developed these four main work -related dimensions that characterize various cultures around the globe. He surveyed the employees between 1967 and 1973 in more than 70 countries to extract data on their cultural attributes. This work is still widely cited and used by many scholars. Human Development: For the measurement of human development, we used the data provided by the United Nations Development Programme (UNDP). The UNDP provides a Human Development Index (HDI) which is a summary composite index that measures a country's average achievements in three basic aspects of human development: health, knowledge, and income (UNDP, 2011). It was introduced in 1990 as an alternative measurement to conventional methods of measuring national development ( e.g. level of income and rate of economic growth). The HDI combines life expectancy, educational attainment, and income indicators into a composite human development index. For each dimension in the index, the HDI sets a minimum and a maximum value (i.e. goalposts), and then examines where each country stands in terms of distance to these values. The HDI values are expressed as between 0 and 1. Business and Health Administration Association Annual Conference 2012

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Education: The education component of the Human Development Index is measured by two elements, mean years of schooling and expected years of schooling. For mean years of schooling, adults aged 25 years, and for expected years of schooling, children of school going age were taking into account. Mean years of schooling is calculated by considering duration of schooling at each level of education. Expected years of schooling, on the other hand, calculated based on enrolment by age at all levels of education. For expected years of schooling estimation, also population of official school age for each level of education has been considered. In the estimations, normalization has been used by giving a minimum value of zero and maximum value of actual observed maximum value of the indicators from the relevant countries in the time series between 1980 and 2010. This last step provides a combined Education Index value for each country that we used in the study. Health: UNDP measures health by evaluating life expectancy at birth for each country. The life expectancy at birth, or health component, of the HDI is calculated using a 20 years minimum value and 83.2 years maximum value. Similar to the education component, the observed maximum value in the time series (1980-2010) from the countries used as maximum value. Income: The income (or wealth) component of the HDI measured by Gross National Income (GNI) per capita (PPP US$). For this component, the value for minimum income is considered as $163 (PPP) and the maximum is considered as $108,211 (PPP), which both observed in the same time series. By using the logarithm of income, HDI aims to reflect the diminishing significance of income with increasing GNI. DATA ANALYSIS AND DISCUSSION Data analysis A summary of descriptive statistics and correlation matrix for the variables of pooled cross-national data are provided in Table 1. There are significant correlations among dependent variable ENV. HEALTH and independent variables including power distance, individualism, life expectancy, education, and income. Similar to the results of Peng and Lin (2009), we found education to be significantly associated with income, power distance, and individualism. Different than their results, however, we also found education association with life expectancy at birth. Furthermore, the results of the correlation matrix showed a high correlation between individualism and power distance as seen in Peng and Lin (2009), Husted (2005), which also acknowledged by Hofstede (1997). According to Hofstede (1997), if we held economic variable constant, this relationship would disappear. Similar to Peng and Lin (2009), since we included income in the model, we were not need to be concerned about this potential affect. In addition to these correlations, we also found significant associations between power distance and human development variables (i.e. life expectancy, education, and income), and similarly, individualism and each human development variables. Statistical results The regression analysis of the model gave the following results for each variable (Table 2): Individualism: The effect of individualism on environmental health was not significant. This result shows that the countrys individualism level does not have any effect on the countrys level of environmental health. Hence, H1 was not supported. Power Distance: The results of the study did not show any significant effect of power distance on environmental health. Therefore, the H2 was not supported. Uncertainty Avoidance: The statistical analyses showed no significant effect of the level of uncertainty avoidance of a country on the environmental health of that country. Hence, H3 was not supported. Masculinityfemininity: The results of the study showed that the environmental health of a country was not affected by the level of masculinity-femininity of the country. So, the hypotheses H4 was not supported.

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Descriptive Statistics and Correlation Matrix

Variable

PDI

IDV

MAS

UAI

LIFE EXP.

EDUCATION

INCOME

ENV. HEALTH

Mean

SD

PDI

1.000

-0.666**

0.074

0.164

-0.364**

-0.575**

-0.445**

-0.465**

59.746

20.827

IDV MAS

1.000

0.091 1.000

-0.225 0.049

0.415** 0.069

0.669** 0.082

0.597** 0.068

0.545** 0.092

41.746 50.194

23.483 16.941

UAI

1.000

0.160

0.043

0.047

0.122

64.806

22.295

LIFE EXP.

1.000

0.792**

0.878**

0.912**

0.851

0.141

EDUCATION

1.000

0.856**

0.884**

0.689

0.172

INCOME ENV. HEALTH

1.000

0.932**

0.676

0.171

1.000

71.743

21.481

TABLE 1. Descriptive statistics and correlation matrix. **p < 0.01, two-tailed test. N=67

Regression analysis of the combined effects of National Culture and Human Development on Environmental Health R2 = 0.963, F Sig. = 0.000

Hypotheses
H1. Individualism- > Environmental Health

Standardized Beta
-0.041 -0.042 0.035 0.025 0.263 0.421 0.329

p-Value
0.491 0.402 0.365 0.487 0.002 0.000 0.000

Results
Not Supported Not Supported Not Supported Not Supported Supported Supported Supported

H2. Power Distance- > Environmental Health H3. Uncertainty Avoidance- > Environmental Health H4. Masculinity- > Environmental Health H5. Education- > Environmental Health H6. Income- > Environmental Health H7. Life expectancy at birth- > Environmental Health

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Educational Attainment: The first component of human development, educational attainment, had a significant effect on the environmental health with p value of .0.002. Thus, H5 was supported. Income: The effect of income on environmental health was significant. This result shows that when the countrys level of income is high, the country will have higher levels of environmental health. Hence, H7 was supported. Health: As the indicator of health, life expectancy at birth component of the HDI showed a significant effect on environmental health. Thus, H8 was supported. The model was perfectly significant with an R2 value of 0.963 with 0.000 significance (Table 2). Of the independent variable, only HDI components of life expectancy, education, and income showed a significant effect on environmental health. However, none of the cultural dimensions showed a significant effect on environmental health in the model. The p values for cultural variables were: 0.491 for individualism, 0.402 for power distance, 0.365 for uncertainty avoidance, and 0.487 for masculinity. DISCUSSION AND CONCLUSION The study showed that none of the four cultural dimensions of Hofstede (i.e. masculinity, power distance, individualism and uncertainty avoidance) have possible effects on the environmental health of a country when we take into account the effects of human development. The combined effects of human development and culture showed only human development effects on environmental health. Our assumption that there is an association between income, education, and life expectancy, and environmental health was supported by the results of this study. All three UNDP measures of human development, income, health, and education, showed a direct effect on environmental health in the model. Income is associated with exposure to a wide variety of environmental quality indicators in the ambient environment, at home, in school, on the job, and in ones neighborhood (Evans and Kantrowitz, 2002). So as proved by previous studies (e.g., Kawachi and Berkman, 2003; Kling et al., 2004) each incremental rise in income help individuals to improve their surrounding health related conditions. The result also supports the Moving to Opportunity study conducted by the Department of Housing and Urban Development which found that moving from a poor to a wealthier neighborhood was associated with significant improvements in health conditions (Kling et al., 2004). The poor bear a disproportionate burden of exposure to suboptimal, unhealthy environmental conditions. As our study also confirms, we can conclude that income is directly related to environmental health. The results of this study also showed that the education dimension of the human development effects environmental health of a country significantly. Environmental scholars supported the idea that higher education institutions occupy a unique position in that they educate and mold the next genera tion of societys decision-makers (Walton et al., 2000); therefore, formal education considered critical for achieving environmental and ethical awareness, values, attitudes, skills and behavior (Peng and Lin, 2009). Our results also support this assumed relation of educational attainment and environmental health. According to the result of this study, the last measurement of human development, health, or in other words, life expectancy at birth, also showed an effect on environmental health. This was an expected result because if someone expects to live longer, we would anticipate s/he would be willing to invest more in environmental activities. They would be worried for themselves and forthcoming generations because they would value future more than the others. A higher longevity makes people more sympathetic to future generations and/or their future selves (Peng and Lin, 2009). Our results also align with this assumption. If the level of life expectancy at birth of a country is high, the environmental health of that country also expected to be high. Although there is a growing body of research focusing on the relationship between social and cultural factors and health (e.g. Berkman and Kawachi, 2000; Marmot and Wilkinson, 2006), there is a paucity in the literature in terms of studies examine the possible relationship between cultural and social factors and environmental health. We believe this study facilitates a first step towards more detailed and comprehensive examination of the issue for the future.

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While there is rapidly increasing interest in researching and explaining the linkages between different cultural dimensions, human development variables, and environmental health, many obstacles remain. For instance, some environmental degradation has a long latency period, and other degradation occurs on such a scale that it defies foresight and data gathering. Additionally, many risk factors may interact synergistically, making it extremely difficult to predict their effects. All these need consideration when focusing on different environmental outcomes. Furthermore, it is possible that the future research considering different time periods and over time changes can help identify the potential relationship between different national culture dimensions, human development variables and environmental health. The future data may show different results regarding these relationships.

REFERENCES Balint, P.J. (1999). Drinking Water and Sanitation in the Developing World: The Miskito Coast of Honduras and Nicaragua as a Case Study. Journal of Public and International Affairs 10(1), 99-117. Berkman, L., Kawachi, I, (2000). Social Epidemiology. (editors). New York: Oxford University Press; 2000. Cakmak, S., Dales, R.E., and Judek, S. (2006). Respiratory health effects of air pollution gases: modification by education and income. Archives of Environmental & Occupational Health, 61, 5-10. Calderon R, Johnson C, Craun G, Dufour A, Karlin R, Sinks, T. & Valentine, J. (1993). Health risks from contaminated water: Do class and race matter? Toxicol. Ind. Health, 9, 879900. Christie, P. Maria Joseph; Ik-Whan G. Kwon, Philipp A. Stoeberl, and Raymond Baumhart (2003). A cross-cultural comparison of ethical attitudes of business managers: India, Korea and the united States, Journal of Business Ethics 46, 263-287. Cieselski, S., Handzel. T. & Sobsey, M. (1991). The microbiologic quality of drinking water in North Carolina migrant farmer camps. American Journal of Public Health, 81, 762-764. Clark, William A.V. (2008). Reexamining the Moving to Opportunity Study and its Contribution to Changing the Distribution of Poverty and Ethnic Concentration. Demography. 45(3), 515535. Cutler D, Lleras-Muney A. (2006). Education and Health: Evaluating Theories and Evidence . Ann Arbor, MI: National Poverty Center. Dobson, A. (1990). Green Political Thought. London: Harper Collins. Duncan, G.J., Daly, M.C., McDonough, P., & Williams D.R. (2002). Optimal indicators of socioeconomic status for health research. American Journal of Public Health. 92(7), 11511157. EPI (2010). Environmental Performance Index. Yale Center for Environmental Law & Policy, Yale University. Retrieved from <http://epi.yale.edu/> on September 19, 2011. Evans, G.W., & Kantrowitz, E. (2002). Socioeconomic status and health: The potential role of environmental risk exposure. Annual Review of Public Health, 23, 202-231. Gorobets, Alexander (2011). The global systemic crisis and a new vision of sustainable human development. Environment, Development and Sustainability. 13. 4 (Aug 2011), 759-771. Heffernan, T. W., & Farrell, M. (2005).The Impact of Culture on Early International Relationship Development in the Education Sector. Journal of Asia Pacific Marketing, 4(1), 1740.

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Hernandez, L. M. & Blazer, D. G. (2006). Genes, Behavior, and the Social Environment Moving Beyond the Nature/Nurture Debate. Edited by Lyla M Hernandez and Dan G Blazer. Institute of Medicine (US) Committee on Assessing Interactions Among Social, Behavioral, and Genetic Factors in Health. Washington (DC): National Academies Press (US); 2006. Hofstede, G. (1980). Cultures Consequences: International Differences in Work-Related Values. Sage Publications, Beverly Hills, CA. Hofstede, G. (1983).The cultural relativity of organizational practices and theories. Journal of International Business Studies, Fall, 7590. Hofstede, G. (1991). Cultures and organizations: Software of the mind . London: McGraw-Hill. Hofstede, G. (1997). Culture and Organization: Software of the Mind . New York: McGraw Hill. Hofstede, G. (2001). Cultures consequences: Comparing values, behaviors, institutions, and organizations across nations (2nd edition). Beverly Hills: Sage Publications. Hofstede, G. and M. Bond (1984). Hofstedes cultural dimensions: An independent validation using Rokeahs value survey. Journal of Cross-Cultural Psychology, 15, 417-433. Husted, B. W. (2000). The Impact of National Culture on Software Piracy, Journal of Business Ethics, 26(3), 197 211. doi:10.1023/A:1006250203828. Husted, B. W. (2005). Culture and Ecology: A Cross- National Study of the Determinants of Environmental Performance, Management International Review, 45(3), 349371. Iles, A. T. (1997). Health and the Environment: A Human Rights Agenda for the Future. Health and Human Rights, 2(2), 46-61. Kale, S. H., & Barnes, J. W. (1992). Understanding the Domain of Cross-National Buyer-Seller Interactions, Journal of International Business Studies, 23 (First Quarter), 101-132. Katz, J.P., Swanson, D.L., & Nelson, L.K. (2001). Culture-based expectations of corporate citizenship: A proportional framework and comparison of four cultures. International Journal of Organizational Analysis, 9(2), 149-172. Kawachi, I., & Berkman, L.F. (2003). Neighborhoods and Health. New York: Oxford University Press. Kling, J.R., Liebman, J.B., Katz, L.F., Sanbonmatsu, L. (2004). Moving to opportunity and tranquility: Neighborhood effects on adult economic self-sufficiency and health from a randomized housing voucher experiment. 2004. [accessed June 14, 2004]. KSG Working Paper No. RWP04-035. [Online]. Retrieved from http://ssrn.com/abstract=588942 on November 10, 2011. Kogut, B., & Singh, H. (1988). The Effect of National Culture on the Choice of Entry Mode Journal of International Business Studies, 19(3), 411 - 432. Lu, L., Gregory, M. R., & Blodgett, J.G. (1999). The effects of cultural dimensions on ethical decision making in marketing: An exploratory study. Journal of Business Ethics, 18(1), 91-105. Mariani, F., Perez, B., & Raffin, N. (2009). Life Expectancy and the Environment. IZA Discussion Paper No. 4564. Available at SSRN: http://ssrn.com/abstract=1506316. Business and Health Administration Association Annual Conference 2012

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Marmot M.G., & Wilkinson, R.D. (2006). Social Determinants of Health (editors). Oxford, England: Oxford University Press. Mendelsohn, R. (1994). Property rights and tropical deforestation. Oxford Economic Papers, New Series , 46, Special Issue on Environmental Economics (Oct. 1994), 750-756. Metz, J. J. (1991). A Reassessment of the causes and severity of Nepals environmental crisis, World Development, 19(7), 805-820. Milton, K. (1997). Ecologies: Anthropology, culture, and the environment, International Social Science Journal, 49(4), 477-495. Moeller, D.W. (2005). Environmental Health (3rd ed.). Cambridge, MA: Harvard University Press. Retrieved from http://books.google.com/books?hl=en&lr=&id=A4DSAonzJN4C&oi=fnd&pg=PR7&dq=education+%22environme ntal+health%22+relationship&ots=qm82Z7__Mh&sig=GVhm6yQLSZ8hEsJoAre9J7dJ0wA#v=onepage&q&f=fals e on November 12, 2011. Nakata, C., & K. Sivakumar (1996). National culture and new product development: An integrative review. Journal of Marketing, 60, 61-72. NCHS (1998). (National Center for Health Statistics). Health, United States, 1998 with Socioeconomic Status and Health Chartbook. Hyattsville, MD: NCHS. Newman, K.L, & Nollen, S.D. (1996). Culture and congruence: The fit between management practices and national culture. Journal of International Business Studies, 27(4), 754779. OECD (2009). Life expectancy at birth. Definitions and methodology. Retrieved from http://www.oecd.org/dataoecd/22/36/47697608.pdf on November 28, 2011. Park, H. , Russel, C., & Lee, J. (2007). National culture and environmental sustainability: A cross-national analyses. Journal of Economics and Finance, 31(1), 104-121. Peng, Y. S., & Lin, S. S. (2009). National Culture, Economic Development, Population Growth and Environmental Performance: The Mediating Role of Education. Journal of Business Ethics, 90(2), 203-219. Ringov, D., & Zollo, M. (2007). Corporate responsibility from a socio-institutional perspective: The impact of national culture on corporate social performance. Corporate Governance, 7(4), 476-485. Shane, S. (1992). Why do some societies invent more than others? Journal of Business Venturing, 7(1), 29-46. Singhapakdi, A., Rawwas, M. Y. A., Marta, J. K., & Ahmed, M. I. (1999). A cross-cultural study of consumer perceptions about marketing ethics. The Journal of Consumer Marketing, 16(3), 257-272. Tice, D.M., & Baumeister, R.F. (2004). Masculinity inhibits helping in emergencies: personality does predict the bystander effect. Journal of Personality and Social Psychology, 49(2), 420-8. Triandis, H.C. (1995). Individualism and Collectivism. Westview Press, Boulder, CO. UNDP (1998). World Resources Institute, United Nations Environment Programme, United Nations Development Programme, World Bank. A guide to the global environment: environmental change and human health. New York: Oxford University Press; 1998.

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UNDP (2011). UNDP Human Development Index (HDI). Retrieved from http://hdr.undp.org/en/statistics/hdi/ on September 10, 2011. UNDP (2011-a). UNDP Human Development Concept. Rerieved from http://hdr.undp.org/en/humandev/ on September 10, 2011. UNDP (2011-b). UNDP Composite indices HDI and beyond. Retrieved from http://hdr.undp.org/en/humandev/indices/ on September 10, 2011. UNICEF (2007). Millennium Development Goal 4: Reduce Child Mortality. Retrieved from http://www.unicef.org/mdg/mortalitymultimedia/index.html on September 15, 2011. Vitell, S., Nwachukwu, S., & Barnes, J. (1993). The Effects of Culture on Ethical Decision-Making: An Application of Hofstedes Typology.Journal of Business Ethics, 12, 753760. Vogel, D. (1987). The comperative study of environmental policy: A review of the literature, in Dierkes, M./Weiler, H.N./Antal, A.B. (eds.). Comparative Policy Research: Learning from Experience, Aldershot, UK: Gower 1987, 99170. Walton, J., Alabaster, T., & Jones, K. (2000). Environmental Accountability: Whos Kidding Whom?, Environmental Management, 26(5), 515-526. doi: 10.1007/s002670010109. WHO (1997). Health and environment in sustainable development: five years after the Earth Summit. Geneva: World Health Organization;1997. WHO document WHO/EHG/97.12. WHO (2011). World Health Organization, Health Topics. Environmental health. Retrieved from http://www.who.int/topics/environmental_health/en/ on September 12, 2011. Yassi, A., Kjellstrm, T., de Kok, T., & Guidotti, T. (2001). Basic Environmental Health. New York: Oxford University Press.

Avinandan Mukherjee Professor and Chair, Department of Marketing Editor International Journal of Pharmaceutical and Healthcare Marketing Montclair State University School of Business Montclair, NJ 07043, USA Phone: (973) 655-5126; Fax: (973) 655-7673 Email: mukherjeeav@mail.montclair.edu

Naz Onel Ph.D. Student, Environmental Management Earth and Environmental Studies College of Science and Mathematics Doctoral Assistant, Department of Marketing School of Business Montclair State University Montclair, NJ 07043, USA Ph: (973) 655-7037; Fax: (973) 655-7673 Email: onelgarmkhb1@mail.montclair.edu

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IS ELECTIVE COSMETIC SURGERY A LUXURY? APPLYING BERRYS THE IDEA OF LUXURY TO ELECTIVE COSMETIC SURGERY
Charles Kirk Moore, New Mexico State University

INTRODUCTION This paper asks the question of whether or not elective cosmetic surgery is a luxury. The initial framework for assessing the nature of cosmetic surgery is Berrys work The Idea of Luxury. Berrys work succinctly covers the idea of luxury in a conceptual and historical way (Berry 1994). Berry has put forward a four category framework for luxury goods (sustenance, clothing, shelter, and leisure) (Berry 1994). Using Berrys concept of luxury, we can begin to explore what elective cosmetic surgery is and what is not in the constellation of goods and services. BACKGROUND LITERATURE Christopher Berry wrote a book entitled The Idea of Luxury: A Conceptual and Historical Investigation in which he explored the overall idea of luxury (Berry 1994). His overall approach was episodic and looked at various historical periods in an attempt to develop an overarching concept of what luxury is (Berry 1994). Out of this research, he developed the idea that the difference in whether or not a luxury is a luxury is the difference between a necessity and a want (Berry 1994). For Berry, a necessity has an external, objective reality, while a want has a subjective reality (Berry 1994). It is objectively necessary that a person needs water to survive, the person may satisfy that need with a desired, specific product (Berry 1994). While developing the idea of relativity of luxury, he does point out that most people can agree, intuitively, what constitutes a general idea of luxury (Berry 1994). Out of his conceptual discussion, he developed four categories of luxury: sustenance, clothing, shelter, and leisure (Berry 1994). The categories are self-explanatory. Sustenance deals with food, clothing deals with clothes, shelter deals with shelter, and leisure deals with leisure time. Berry states that most things can be shoe horned into one of the four categories (Berry 1994). Depending on the liberality of interpretation of the four categories, this may or may not be the case. Berrys discussions about different historical periods help in understanding luxury as a cultural concept. The historical time period has an effect on what luxuries are and also how to interpret the meaning of luxury. Time, place, and cultural expectations help to determine whether or not something is a luxury. DISCUSSION OF METHOD Given Berrys overarching conceptual framework for luxury, it seems reasonable to try and use this framework to investigate elective cosmetic surgery. This paper applies the framework to determine, under Berrys concept, whether or not elective cosmetic surgery is a luxury. APPLYING FRAMEWORK The four categories, sustenance, clothing, shelter, and leisure, can be applied to elective cosmetic surgery. Under Berrys version of sustenance, i.e. food, does not apply to elective cosmetic surgery. Neither does shelter, elective cosmetic surgery not being a habitable living space. Although, the basic body may be considered a form of shelter, but that seems to be stretching the point. Clothing, too, does not seem to apply, unless skin can be seen as the most basic clothing of all. The last, leisure, might apply to the process of undergoing elective cosmetic surgery, in that there does need to be available free time to undergo a medical procedure. At this point, the different medical procedures that constitute elective cosmetic surgery may make a difference in whether or not the process can be seen Business and Health Administration Association Annual Conference 2012

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as a luxury. Elective cosmetic surgery can cover simple outpatient procedures that take a moment to perform, e.g. Botox injections, all the way to whole body surgical procedures at an exclusive spa, which can take upwards of a month to complete. Therefore, the overall idea of elective cosmetic surgery may need to be broken out into different procedures to better apply Berrys leisure category. The paper further breaks out the different procedures. But as it stands, the overall concept of elective cosmetic surgery does not seem to fit within the leisure category. Looking towards Berrys broader idea of necessity versus want may illuminate the idea of elective cosmetic surgery. Elective cosmetic surgery stands in contrast to reconstructive surgery and surgeries necessary for physical health. In the intuitive meaning between the three, elective cosmetic surgery can be seen as a want as opposed to a medical necessity. However, elective cosmetic surgery can also cover procedures that have an economic/business purpose as well as overall improvement of well-being, which seems to not be covered by the traditional meaning of medically necessary surgeries. This aspect of Berrys concept, as applied to elective cosmetic surgery, highlights the different focuses between that of the traditional heroic medicine framework, the focus of economic man in economic literature, and the focus of the holistic approach to well-being and general life satisfaction. It seems that Berrys framework of luxury proves difficult when applied to the generalized concept of elective cosmetic surgery. CONCLUSION Underneath Berrys framework, as applied to the overall concept of elective cosmetic surgery, elective cosmetic surgery does not appear to be a luxury item, given that elective cosmetic surgery does not fit easily within the four categories, nor does it sit easily within the necessity/want dichotomy. This seems counter-intuitive given the feeling people seem to have concerning elective cosmetic surgery. Berry did note that most people are able to determine things that are considered luxuries (Berry 1994). The tension between the attempted applications of the four categories to elective cosmetic surgery suggests a valuable area of study for both the idea of luxury and the elective cosmetic surgery world.

REFERENCES Berry, C. (1994). The Idea of Luxury: A Conceptual and Historical Framework , Cambridge, England: Cambridge University Press.

Kirk Moore New Mexico State University E-mail: dr.moore.for.hire@gmail.com

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LIFESTYLE DISEASE TRIAD: AN EMPIRICAL COMPARATIVE ASSESSMENT OF THE MACRO LEVEL PREDICTORS OF OBESITY, DIABETES, AND HYPERTENSION ACROSS THE US MSAS
Vivek S. Natarjan, Lamar University Avinandan Mukherjee, Montclair University Kabir Chandra Sen, Lamar University

ABSTRACT Lifestyle diseases such as Obesity, Diabetes and Hypertension are a pressing challenge for health care managers and policy makers alike. These have a major impact on costs and quality of healthcare across the nation. Understanding the drivers of Obesity, Diabetes and Hypertension if therefore of paramount importance. The objective of this study is to understand the key drivers of Obesity, Diabetes and Hypertension. The data included life style variables across the metropolitan statistical areas of the US.

Vivek S. Natarajan Assistant Professor of Marketing, Lamar University, Beaumont, TX-77710 USA Phone: 409-880-8643 vivek.natarajan@lamar.edu

Avinandan Mukherjee Chairman and Professor of Marketing School of Business Montclair State University Montclair, NJ 07043, USA. Phone: 973-655-5126 mukherjeeav@mail.montclair.edu

Kabir Chandra Sen Chairman and Professor of Marketing, Lamar University, Beaumont, TX-77710 USA Phone: 409-880-8929 kabir.sen@lamar.edu

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TRACK FINANCE AND ACCOUNTING ISSUES IN HEALTHCARE

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FINANCIAL INCENTIVES: PAY FOR PERFORMANCE (P4P) AND THE CHRONICALLY ILL PATIENTS
David Conley, Marshall University Alberto Coustasse, Marshall University

ABSTRACT P4P is the reimbursement incentive that is based on quality improvement, efficiency, which is dominating the healthcare landscape and CMS. A literature review was conducted to search for and review significant information regarding P4P and how it pertains to chronic conditions and reimbursement methods. This literature review displayed while some programs were able to display a benefit/ profit for those involved such as insurance companies, hospitals, physicians and/or patients, most programs were unable to establish quality measures, cost effectiveness and positive program outcomes worth noting. Key Words: Pay-for-Performance, Chronic Care disease, Cost, Outcomes, Reimbursement

INTRODUCTION Pay for Performance (P4P) is a reimbursement method which bases payment on a number of categories including patient outcome, quality of care and overall patient satisfaction (U.S. Department of Health and Human Services 2011). It has been in practice in the United States (U.S.) more prevalently in the past decade but it has been developed in nationalized or socialized healthcare systems around the world, though especially in Europe, since early 1990s. A very good example of the usefulness and streamlining of the P4P initiatives are as a result of what many in the medical field regard as the birth place of the program, the United Kingdoms (U.K.) National Health Service (UKNHS), (Starfield, Shi, & Macinko 2005). Structured much like the Center for Medicare and Medicaid Services (CMS) programs, the UKNHS is one of the few reimbursement systems in the U.K., as few have privatized health care providers that are utilized by a vast majority of the population (Doran et al. 2006). The P4P program had its base in family medicine and primary care physicians groups, and has been used to promote early detection of diseases, proper nutrition and healthy lifestyles, immunizations and annual examinations. Coupled with this, P4P has been used to encourage quality and cost effective health care (Roland 2008). In the UKNHS system, there are many benefits to use this type of reimbursement system. All patients enrolled in the program have full life records, as the U.K. has utilized Health Information Technology (HIT) far better than the U.S. (Roland 2008). Primary care physicians, as to all physicians and facilities, undergo annual performance reviews based on both regional and national standards in healthcare (Doran et al. 2006). Financial incentives that are realized have been used to bolster the professional staff serving in the medical field to assist primary care physicians practices such as additional nursing and administrative staff to better handle the patient base under a nationalized program. Practitioners do have the ability, however, to exclude patients from the P4P programs for reasons ranging from missed appointments to disagreement on treatments to the physicians discretion on medical issues (Hoanhami, Schrag, Malley, Wu & Bach 2007). This practice, however, is still in its infancy in the U.S. A common use of P4P has been to streamline the efficiency of the practice of particular programs such as Medicare and Medicaid. Facilities and physician groups have also used P4P in an effort to boost quality while controlling and improving the quantity of said practices to benefit from higher reimbursement realization. When considering initiatives that have been part of the medical landscape for the past decade, there are many hurdles that still need to be found to achieve the goals of the P4P system. In a survey conducted by Rosenthal, Landon, Howitt, Song & Epstein (2007), found several physicians concerns including patient dumping, overpayment and payment without quality improvements. Likewise, physician resistance, distribution of incentive pools and funding issues were identified as challenges while early involvement in health policy making and adherence were considered as major issues of a P4P system not moving from the ground level of development (Rosenthal et al. 2007). Business and Health Administration Association Annual Conference 2012

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Since being used as incentive based reimbursement, P4P has been linked with geographic regions in the U.S. In doing so, the use of Primary Care Physicians (PCP) and family care physicians has been at the fore-front of these programs as the staple provider of preventative care (Pizer, Frakt & Iezzoni 2009). Health Managed Organizations (HMOs) are used in these practices representing a large majority of physician and PCP utilizing P4P. This reimbursement system was part of the Deficit Reduction Act of 2005, which was used as an overhaul of the CMS programs; and in the Patients Protection and Affordable Care Act of 2010 (PPACA) (Rosenthal et al. 2006; US Department of Health and Human Services 2010). Chronic diseases are diseases of long duration and slow progression. Chronic diseases, such as diabetes, heart disease, stroke, cancer, chronic respiratory diseases and many more, are by far the leading cause of mortality in the world, representing 63% of all deaths (World Health Organization 2011). In 2004, 133 million individuals or 50% of US people, lived with a chronic condition. By 2020, as the populations ages, the number will increase to 157 million (Johns Hopkins University 2004). The purpose of this study was to determine the economic value, if any, of a P4P reimbursement structure, for those who have a chronic and/or managed medical condition in the U.S. METHODOLOGY The methodology for this literature review was conducted using a systematic search of key words that were relative to the content of Pay-For-Performance, value, managed care, chronic diseases and or disabilities. The terms used for research were Pay for Performance OR P4P OR managed care OR chronic disease OR chronic disabilities, AND healthcare cost. Publications that were either written or translated in English were used and the search was limited within the last 25 years. To identify articles that were of the relevant matter, five databases were used to search for articles pertaining to this literature review and included PubMed, Ebscohost and Google Scholar search engines were explored for feasible content. Specific medical and economic journals and websites were surveyed for content relating to the topic including Health Affairs, The New England Journal of Medicine, European Journal of Health Economics, The American Journal of Managed Care, the American Medical Association and The Center for Medicare and Medicaid Services. The literature review yielded 17 articles and 6 federal websites which were assessed for information pertaining to this research project. Only articles written or translated in English were used. Reviews, commentaries and editorials were used as well as primary and secondary data. The literature search was conducted by DC and validated by AC for this research study. RESULTS Norton (1992) studied in the 1980s determining the effects of an incentive program in nursing homes geared towards patients in the U.S. who utilized managed care facilities covering overall health status and Medicaid expenditures. Variables for financial incentives in this study considered hospital admission for patients that were sick, outcome of patients health for prolonged stays at the facility and discharging patients in a timely fashion who did not require services. Norton concluded that death and hospitalization rates for patients were reduced while overall cost decreased approximately 20% for those in the intervention study group. However, there was an increase of nearly five percent on daily operation costs due to servicing a larger amount of patients (Norton 1992). In New York, a P4P pilot program was assessed during 2003 to 2007 by the Hudson Health Plan, and it was focused on immunizations for children aged two and younger. The physicians had the opportunity to increase their annual income by 15% to 25% with reimbursement bonuses for increasing the amount of children treated (Chien, Zhonghe & Rosenthal 2010). While the immunization rates increased over the four year period, the study showed no change in the amount of children that were immunized who had chronic conditions such as asthma, epilepsy or cancer. Quality seemed to have little effect over quantity in this program, with reimbursement rates only rising slightly (Chien et al. 2010). Lee, Cheng, Chen and Lai (2010) study was based on evaluating P4P programs and initiatives on the national level for patients receiving diabetes care in Taiwan. This study was compiled over a two year period and Business and Health Administration Association Annual Conference 2012

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took into account several facets including hospital and or physician visits, utilization and completion and medication regiments and the use of intervention and control groupings within the patients, physicians and facilities. The study concluded that although there was an overall savings of over $100 per year per patient, the in-patient costs rise while costs with those who participated in the intervention groups was reduced. Therefore, as one cost rose, another decreased determining the initiative to balance itself out, providing little economic benefit (Lee 2010). In 2006, Curtin, Beckman, Pankow, Milillo & Greene published a study dealing with evaluating the financial impact of P4P programs in diabetes care from 2003 to 2004 in the U.S. In this case, at the end of the year payments were considered based on annual physician measurements including efficiency, quality and patient satisfaction. To determine payout incentives, ten percent of capitation was withheld on a regular basis. The return of investment was calculated by insurance groups using filed data from two years prior to the study and compared with the years during the study to using reimbursement, cost and initial savings. The return of investment calculated was approximately 2.5 million dollars over this two year period (Curtin et al. 2006). One study was conducted by CMS in 2006 with the Arkansas Department of Human Services. This particular study was based on the quality outcomes of patients who suffered from one chronic condition specifically Heart Failure and also Pneumonia. To qualify for the bonus payments, hospitals had to meet and perform in the 75 th percentile when compared to the previous years data [CMS, 2009]. In the first year of the study, Medicaid paid approximately $3.9 million in bonus reimbursement to 21 hospitals that were considered high performance based on quality measures. In the second year of the study, the reimbursement levels were increased along with quality measures and performance rates with heart failure care rising from 61 % to 83 (CMS, 2011). CMS, as of 2007, has several pilot programs that are considering the benefits of P4P in chronic care and disease management care situations. One of these programs consisted of nine states and private insurance companies participating where a base population was reimbursed for care provided to patients who suffer from congestive heart failure or diabetes, or both (Integrated Healthcare Association, 2010). Reimbursement levels were dependent on patient outcome and satisfaction levels on treatment from both the patient and provider viewpoint. This particular program has been considered for cost reduction and potential savings in these two areas of chronic care and disease management (CMS, 2005). Four other states have participated in another initiative to study cost effective and overall health improvement strategies when considering patients with congestive heart failure, diabetes or coronary artery disease in a fee-for-service reimbursement. A monthly payment for beneficiaries enrolled in the program has given provided there is a reduction in CMS cost as a result of services rendered for said conditions (CMS, 2005). In 2010, the Robert Wood Johnson Foundation published a study determining the effects of chronic care in a primary care setting. The study was three fold incorporating practices that received bonus for meeting quality goals, had a third-party disease management care system staffed by nurses and had an onsite care coordinator who directly communicated between patients and physicians. The study took place from January 2004 to March 2007 in facilities that met the criteria in Alabama, Tennessee and Texas. The study found that care did improve overtime and patients were less likely to see a physician with follow-up complications, though care and incentives did not improve past the initial outlines of the study and there was no significant cost savings or increases for the facility or patients (Fangan et al. 2010). The PPACA has had the opportunity to reestablish primary care as the lifeline of the CMS programs and medical reimbursement in a P4P system. However, it has proved challenging since its passage as PCP are physicians making significantly lower compensation than specialists. Specialists have had the opportunity to see a larger increase in quality and effectiveness in the care when compared to PCPs (Boyd et al. 2007). DISCUSSION The overall findings were based on economic studies on financial incentives and P4P programs and could not demonstrate effective improvements in quality or efficiency. Additionally it provided limited reimbursement measures and positive outcomes in cost effectiveness for the physicians, their group practices and the patients and insurance agencies. This concurs with Emmert, Eijkenaar, Kemter, Esslinger & Schoffski (2011) who found in several case studies above that while significant payout were measured with physicians participating in individualized studies and programs, the overall impact of the P4P system had little bearing on the reimbursement programs.

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When considering patients with one or more comorbid disease, P4P, in the current structure, could lead to unsuitable or harmful diagnoses by degrading quality of care and not centering on the most important conditions. Take for instance clinical practice guidelines and a patient who has hypertension and hyperlipidemia, certain test and treatments might overlap, causing the physicians diagnosis only to be reimbursed for one disease (Pizer et al. 2009). While some chronic conditions can be treated in conjunction with others, using a combination of medication, this is not possible with all conditions. Such as taking anticoagulants to treat thromboembolic disorder while also suffering from peptic ulcer disease (Andreoli, Carpenter, Griggs, & Loscalzox 2007). Several questions must be considered when conducting implementation or continuation of P4P reimbursement including: demographics and affluence between physicians, their practices, patients and certain regions on the U.S. as when considering patients from rural based population centers, physicians who practice in such areas might be less likely to benefit from P4P programs. Typically, patients of these areas have been less likely to be able to attend follow-up appointments due to circumstances out of the physicians control, such as lack of public transportation or the inability to continue treatment because of lack of affluence. Because of these simple reasons, quality and efficiency has been affected on reported data (Goodson 2010). Another implication is that PCP family physicians have been strangled out of the market by higher salaried specialists. Additionally, if it is not possible to recruit new physicians into primary care because of a lower base salary and limited resources for incentive pay, the shortage of this field will continue, pushing much of the work onto the shoulders of physicians assistants and nurse practitioners. While these two professionals can be able to handle much of the load when it comes to primary care, there are still limitations in the scope of practice in each field. On the other hand, public insurance programs, such as Medicare and Medicaid have not filled the gap on the federal and state level for those who might be considered the working poor or who are simply unabl e to be insured by private insurance companies and who do not qualify for CMS program. These programs do however pose a significant problem for those who suffer from chronic conditions, as these programs cover only a small portion of the necessary costs (Wilper et al, 2009). CONCLUSION When considering reimbursement programs for treatment involving patients who suffer from one or more chronic conditions such as diabetes, hypertension, congestive heart failure and coronary disease, P4P is not the best fee for service payment system. Though, in some instances, one or more parties are able to find an efficient, cost effective and quality insured basis for utilization, this reimbursement method needs to be studied further to find positive finding regarding the best care possible for chronic patients, especially those who require continued and continuous treatment care as a result. REFERENCES Andreoli, T., Carpenter, C., Griggs, R., & Loscalzo, J. (2007). Cecil Essentials of Medicine. Philadelphia, PA. Saunders: El Sevier. Boyd, C., Darer, J., Boult, C., Fried, L., Boult, L., & Wu, A. (2007) . Clinical Practices Guidelines and Quality of Care for Older Patients with Multiple Comorbid Diseases. Journal of the American Medical Association. 294(5), 716-724. Retrieved July 2011 from http://www.ersnet.org/learning_resources_player/paper/RS/70.pdf. Chien, A., Zhonghe, L., Rosenthal, M. (2010). Improving Timely Childhood Immunizations through Pay for Performance in Medicaid-Managed Care. Health Services and Educational Trust. Retrieved August 2011 from http://onlinelibrary.wiley.com/doi/10.1111/j.1475-6773.2010.01168.x/abstract. Curtin, K., Beckman, H., Pankow, G., Milillo, Y., & Greene, R. (2006). Return on Investment in pay for performance: a diabetes case study. Journal of Healthcare Management. 51; 365-376. Retrieved July 2011 from http://www.meridios.com/Documents/Diabetes%20Case%20Study%20on%20P4P.pdf.

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Doran, T., Fullwood, C., Gravelle, H., Reeves, D., Kontopantelis, E., Hiroeh, U., et al. 2006 . Pay-for-Performance Programs in the Family Practices in the United Kingdom. The New England Journal of Medicine. 355(4): 375-384. Retrieved July 2011 from http://www.nejm.org/doi/full/10.1056/NEJMsa055505#t=article. Emmert, M., Eijkenaar, F., Kemter, H., Esslinger, A., & Schoffski, O. (2011) . Economic evaluation of pay-forperformance in health care: a systematic review. European Journal of Health Economics.Springer-Verlag. Retrieved July 2011 from http://www.springerlink.com/content/3814l4x3w3456l02/ Fagan, P., Schuster, A., Boyd, C., Marsteller, J., Griswold, M., Murphy, S., Dunbar, L. & Forrest, C. (2010). Chronic Care Improvement in Primary Care. Health Services Research. 45(6) 1763-1782. The Robert Wood Johnson Foundation. Retrieved August 2011. Goodson, J. (2010). Patient Protection and Affordable Care Act: Promise and Peril for Primary Care. Annals of Internal Medicine. 152, 742-744. Retrieved July 2011 from http://www.annals.org/content/152/11/742.full.pdf+html. Hoanhami, H., Schrag, D., Malley, A., Wu, B., & Bach, P. 2007. Care Patterns in Medicare and Their Implication for Pay for Performance. The New England Journal of Medicine. 356(11): 1130-1139. Retrieved July 2011 from http://publish.healthlawyers.org/SiteCollectionDocuments/Content/ContentGroups/Publications2/Health_Lawyers_ Weekly2/Volume_5/Issue_123/hscarticle.pdfhttp://www.iha.org/p4p_national.html. Integrated Healthcare Association, 2010. National Pay for Performance Overview: Evolution of Pay for Performance in the United States. Retrieved November 2011 from http://www.iha.org/p4p_national.html. Johns Hopkins University 2004. Making the Case for Ongoing Care. Partnership for Solutions . Retrieved September 2011 from http://www.partnershipforsolutions.org/DMS/files/chronicbook2004.pdf. Lee, T. Cheng SH, Chen CC, & MS Lai (2010). A pay-for-performance program for diabetes care in Taiwan: a preliminary assessment. American Journal of managed Care. 16(1): 65-69. Retrieved July 2011 from http://www.ajmc.com/media/pdf/AJMC_2010Jan_Lee_p65to69.pdf Norton, E. (1992). Incentive regulation of nursing homes. Journal of Health Economics. 11(2), 105-128 Retrieved July 15, 2011 from: http://www.sciencedirect.com/science/article/pii/0167629692900305. Pizer, S., Frakt, A., & Iezzoni, L. 2009. Uninsured Adults With Chronic Conditions or Disabilities: Gaps in Public Insurance Programs. Health Affairs. 28(6), 1141-1150. Retrieved July 2011. Roland, M. 2008. Lessons from the U.K. The New England Journal of Medicine. 359(20), 2087-2092. Retrieved July 2011 from http://www.nejm.org/doi/full/10.1056/NEJMp0805633. Rosenthal, M., Landon, B., Howitt, K., Song, H. & Epstein, A. (2007). Climbing Up the Pay-For-Performance Learning Curve: Where are the Early Adopters Now? Health Affairs. 26(6), 1674-1682. Retrieved July 2011 from http://content.healthaffairs.org/content/26/6/1674.full.pdf+html. Rosenthal, M., Landon, B., Normand, S., Frank, R., & Epstein, A. 2006. Pay for Performance in Commercial HMOs. The New England Journal of Medicine. 355(18), 1895-1902. Retrieved July 2011 from http://www.nejm.org/doi/pdf/10.1056/NEJMsa063682. Starfield, B., Shi, L., & Macinko, J. 2005 . Contribution of Primary Care to Health Systems and Health. Milbank Quarterly. 85:457 502. Retrieved July 1, 2011 from http://onlinelibrary.wiley.com/doi/10.1111/j.14680009.2005.00409.x/pdf The Centers for Medicare and Medicaid Services [CMS] (2005). Medicare Pay for Performance (P4P) Initiatives. Retrieved August 2011 from: http://www.cms.gov/MedicaidCHIPQualPrac/Downloads/qualitystrategy.pdf.

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The Centers for Medicare and Medicaid Services [CMS]. 2009 Medicaid and CHIP Promising Practices. Details for Pay for performance. Retrieved on November 2011 from https://www.cms.gov/medicaidchipqualprac/mcppdl/itemdetail.asp?itemid=CMS1224619. The Centers for Medicare and Medicaid Services [CMS]. (2010). Roadmap for Implementing Value Driven Healthcare in the Traditional Medicare Fee-for-Service Program. Retrieved on November 2011 from https://www.cms.gov/qualityinitiativesgeninfo/downloads/VBPRoadmap_OEA_1-16_508.pdf. The Centers for Medicare and Medicaid Services [CMS]. 2011. Medicaid Inpatient Quality Incentive Initiative. Retrieved August 2011 from http://www.cms.gov/MedicaidCHIPQualPrac/MCPPDL/itemdetail.asp?filterType=none &filterByDID=99&sortByDID=1&sortOrder=ascending&itemID=CMS1224619&intNumPerPage=10. U. S. Department of Health and Human Services. (2010). The Patients Protection and Affordable Care Act, HR 3590, PPACA. Centers for Medicare and Medicaid Services. Retrieved July 2011 from https://www.cms.gov/LegislativeUpdate/downloads/PPACA.pdf. U.S. Department of Health and Human Resources. (2011). Pay for Performance (P4P): AHRQ Resources. March 2006. Agency for Healthcare Research and Quality, Rockville, MD. Retrieved from http://www.ahrq.gov/qual/pay4per.htm. Wilper, A., Woolhandler, S., Lasser, K., McCormick, D., Bor, D., & Himmelstein, D. (2009). Hypertension, Diabetes, and Elevated Cholesterol Among Insured and Uninsured U.S. Adults. Health Affairs. 28(6), 1151-1159. World Health Organization 2011. Chronic diseases. Retrieved September 2011 from http://www.who.int/topics/chronic_diseases/en/.

David Conley, MSc Lewis School of Business Marshall University E-mail: conley85@live.marshall.edu

Alberto Coustasse, MD, Dr.PH, MBA Marshall University E-mail:coustassehen@marshall.edu Phone Number: 304 476 1968

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INCREASED UTILIZATION OF DIRECT ACCESS TO PHYSICAL THERAPY: A MODEL FOR REDUCING HEALTHCARE EXPENDITURES
Adam W. Walker, Washburn University Zach Frank, Washburn University

ABSTRACT More states are allowing direct access to physical therapy services without the requirement of a physician referral. Currently, 46 states and the District of Columbia allow such access to physical therapy practitioners. Research has demonstrated the effectiveness of physical therapists in identifying musculoskeletal disorders in a direct access setting. Not only have they proven effective in diagnosis, but research indicates direct access leads to reduced number of visits and decreased overall costs per episode of care. This paper discusses the role direct access plays in physical therapy and how it can serve as a model for reducing healthcare expenditures in other areas.

INTRODUCTION Until 1957, every state required a physicians referral for any patient needing physical therapy (Crout, Tweedie, & Miller, 1998). Direct access to physical therapy services has been a major professional objective of physical therapy professionals for the last 20 years. According to the American Physical Therapy Association (APTA), currently, 46 states and the District of Columbia have granted consumers the freedom to seek physical therapy treatment without a referral (2011). This referral mandate can cause delays in the treatment of individuals by a physical therapist. Delays in care could potentially result in higher costs, decreased functional outcomes, and decreased satisfaction of patients seeking physical therapy treatment. This requirement does not recognize the professional training and expertise of the licensed physical therapist and physical therapist assistant; and, more APTA, 2011 importantly, it does not serve the needs of those patients who require physical therapy but must first be seen by a physician. Elimination of this referral mandate results in timely and more effective physical therapists' services (APTA, 2011). This paper examines the use of direct access by individuals in the majority of states that have some type of direct access; assesses the efficiency and effectiveness of the physical therapist to make the correct medical decision in the direct access setting; and analyzes the cost comparison associated with direct access versus restricted access.

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Utilization of Direct Access As the cost of health care rises in the United States, the amount of participation individuals and families exhibit in their own health care decision making process has similarly increased. Consumers are taking a more active role in their healthcare. They are paying a larger portion for services, reviewing provider quality through Web sites, and researching the increased availability of health information online (American Health Information Management Association [AHIMA] Personal Health Record Practice Council, 2006). This readily available information is allowing individuals to be more informed when selecting the best available health care provider for their needs. Within the scope of this ever-changing health care system and increased freedom, we find direct access to physical therapy. Nearly 20 years ago, Domholdt and Durchholz indicated physical therapists did not practice with direct access because of employer policies (49.1%), lack of insurance reimbursement (43.6%), patients without a physician's referral not presenting themselves for physical therapy (25.5%), and personal preference (23.6%) Concerns about the potential costs associated with malpractice liability have also been investigated, but the number of events was so low that no conclusions were reached (1992). Since this study was first published, the number of states allowing direct access to physical therapy in some manner has increased significantly, thereby increasing the availability of patients to consult a physical therapist without a referral from a physician. While availability has increased, the question becomes are consumers accessing these services? Research illustrates that the utilization of direct access to physical therapy varies widely among populations. A study by Crout et al. of physical therapists in Massachusetts found direct access patient care accounted for 8.8 percent of their practice (1998). A similar study revealed that 12.6 percent of 1,580 patients presenting with lower back pain reported treatment by a physical therapist through direct access (Mielenz, Carey, Dyrek, Harris, Garrett, & Darter, 1997). However, in a more controlled setting, Moore, McMillian, Rosenthal, and Weishaar observed 25 military health care sites over a 40-month period and found that 45.1 percent of new patients were seen through direct access without physician referral (2005). Within the smaller community associated with military bases, the level of direct access patient care increased four-fold compared to civilian patient care. This discrepancy in utilization rates in the public sector versus military settings could be due to the lack of public knowledge of the availability to directly seek care from a physical therapist. Research shows the publics knowledge of direct access and the role of the physical therapist is limited. Snow, Shamus, and Hill reported 67.3 percent of people have no knowledge of direct access, but 73.4 percent of respondents would seek direct care from a physical therapist if they needed one (2001). Thus, the pu blics lack of knowledge of direct access and the role of the physical therapist limit the possible use of physical therapy as a primary treatment option. Efficiency & Effectiveness One primary concern that opponents of direct access have is that of the clinical efficiency and effectiveness of the physical therapist. However, these concerns should be deemed unwarranted as physical therapists are educated with a post-baccalaureate degree and receive extensive training in the examination, evaluation, diagnosis, prognosis, and intervention of patients with functional limitations, impairments and disabilities; while the physical therapist assistant is trained with at least a 2-year degree that is highly specialized to the therapy field. Additionally, both clinicians must pass a state board exam to be certified or licensed to practice (APTA, 2011). The diagnosis and clinical decision-making ability of the physical therapist has always been an important aspect of the practice. Differential diagnosis and screening for medical disease is commonly taught in physical therapy programs and is a regular topic for physical therapy journals, continuing education, state conferences, home study courses, and the APTA Advanced Clinical Practice Series (Deyle, 2006). Furthermore, the APTA's Guide of Professional Conduct advocates that physical therapists should assist patients in receiving appropriate medical care when the physical therapist's examination and evaluation reveals signs and symptoms consistent with a condition that cannot be appropriately treated with physical therapy or that needs a physician's care and expertise (APTA, 2011). In regards to patient management, Jette, Ardleigh, Chandler, and McShea reported that physical therapists made these correct decisions 88 percent of the time when faced with non-critical medical conditions and 79 percent of the time for critical medical conditions (2006).

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Childs et al., 2005

Physical therapists are musculoskeletal specialists. The physical therapist is trained in and has extensive knowledge in the musculoskeletal system with many physical therapists expanding their knowledge base even further to specialize in specific areas such as: womens health, pediatrics, geriatrics, orthopedics, or the neurological or integumentary system. Musculoskeletal conditions account for roughly 25 percent of patient complaints in primary care settings. However, primary care physicians have been shown to lack confidence in their own evaluation and treatment skills with these patients (Childs, Whitman, Sizer, Pugia, Flynn, & Delitto, 2005). Conversely, musculoskeletal conditions account for approximately 90 percent of physical therapy episodes (Pendergast, Kliethermes, Fregurger, and Duffy, 2011). A study by Jette et al. found that physical therapists made the right decision 87 percent of the time regarding musculoskeletal conditions and that those decision-making percentages increased for physical therapists with orthopedic specialist certifications (2006). Childs et al. also found that both licensed physical therapists, with or without orthopedic or sport specialist certifications, and physical therapist students tended to have higher levels of knowledge in managing musculoskeletal conditions than medical students, physician interns and residents, and all physician specialists except for orthopedists (2005). Safety When evaluating change in health care policies, one of the first items that must be addressed is the safety of the patient. One indicator to judge the relative safety of a treatment is the volume of malpractice suits initiated. It has been reported there is no difference between physical therapist malpractice suits in states allowing direct access compared with states where it is prohibited (Sandstrom, 2007). Additionally, Moore et al. found that greater than 50,000 patients seen through military health care facilities are at minimal risk for gross negligent care when evaluated and managed by PTs, with or without physician referral. Furthermore, the authors reported no adverse events resulting from physical therapists diagnosis or management (2005). These results indicate no adverse effects are present, in regards to patient safety, when comparing a system with direct access to physical therapy to a system that requires physician referral.

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The Cost Comparison With direct access, there is a potential argument that the cost and usage of physical therapy services increase when there is no physician to act as the gatekeeper for referral (Sandstrom, 2009). This does not seem to be true in regards to utilization rates or overall cost of services. Mitchell and deLissovy showed that direct access involved 65 percent fewer physical therapy visits and 68 percent lower paid claims for services (1997). A more recent and comprehensive study also found that self-referred physical therapy episodes of care were less than those for physician-referred episodes (Pendergast, et al., 2011). Furthermore, Leemrijse, Swinkels, Veenhof, found that patients utilizing direct access resulted in an average of 2.3 fewer physical therapy treatment sessions than patients who were referred by their physician (2008). A reduction in visits does not necessarily result in a decrease in overall costs as the cost per visit can potentially be inflated. However, Mitchell & deLissovy reported a 57 percent reduction in paid claims compared to physician referral physical therapy (1997). They reported total paid claims were reduced from $2,236 per episode of care to $1,004 for (Mitchell & deLissovy, 1997). A Model for Cost Reduction The public policy objective for direct access statutes is to give the consumer the ability to select the most appropriate source of care. Freedom of choice, which was seen as an important advantage of direct access satisfies a need (Leemrijse, et al., 2008). Allowing individuals to make decisions regarding their health care is not only good policy but also cost effective. Direct access allows educated consumers to take a more active role when making decisions regarding their health care. In an age of consumer-directed health plans designed to educate the consumer and provide substantial cost cutting measures for companies, increased usage of direct access to physical therapy can prove beneficial. Eliminating the physician referral requirement is one step to making health care more accessible to more people and reducing overall healthcare costs. Effectiveness and efficiencies are used as evaluative criteria for health care policies. Childs et al. demonstrate physical therapists are more effective than typical first contact health care providers, such as family practice physicians, when diagnosing musculoskeletal dysfunctions (2006). Use of these health care providers as frontline contacts for diagnosing and treating musculoskeletal dysfunctions could serve to improve access to care for those suffering from common ailments. Direct access to physical therapy services has not only proven effective but also efficient. The reduction in number of visits and overall costs associated with each episode of care associated with direct access (Mitchell & deLissovy, 1997, Leemrijse, et al., 2008, & Pendergast, et al., 2011) prove this system can serve as one method of reducing overall health care costs. Direct access to physical therapy services can serve as a model of how increasing timely access to effective and efficient care helps manage the ever inflating costs of health care. The direct access to physical therapy model serves as an example of how increasing accessibility to services can actually result in decreased expenditures and improved outcomes with no increase in risk to the patient. It can serve as a model for other programs wanting to not only reduce costs but ensure quality. REFERENCES American Health Information Management Association [AHIMA] Personal Health Record Practice Council. Helping consumers select PHRs: Questions and considerations for navigating an emerging market. Journal of AHIMA. 77(10), 50-56. American Physical Therapy Association [APTA]. (2011). Direct access to physical therapy services. Retrieved July 09, 2011 from http://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Direct_Access/DirectAccessMap.pdf American Physical Therapy Association [APTA]. (2011). FAQs: Direct access at the state level. Retrieved July 09, 2011 from http://www.apta.org/StateIssues/DirectAccess/FAQs/

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Childs, J.D., Whitman, J.M., Sizer, P.S., Pugia, M.L., Flynn, T.W., & Delitto, A. (2005). A description of physical therapists knowledge in managing musculoskeletal conditions. BMC Musculoskeletal Disorders. 6:32. Crout, K.L., Tweedie, J.H., Miller, D.J. (1998). Physical therapists' opinions and practices regarding direct access. Physical Therapy. 78(1), 52- 61. Deyle, G. (2006). Direct access physical therapy and diagnostic responsibility: The risk-to-benefit ratio. Journal of Orthopaedic & Sports Physical Therapy. 36(9), 632-634. Domholdt, E. & Durchholz, A.G. (1992). Direct access use by experienced therapists in states with direct access. Physical Therapy. 72(8), 569-574. Jette, D.U., Ardleigh, K., Chandler, K., & McShea, L. (2006). Decision-making ability of physical therapists: Physical therapy intervention or medical referral. Physical Therapy. 86(12), 1619-1629. Leemrijse, C.J., Swinkels, I.C.S., Veenhof, C. (2008). Direct access to physical therapy in the Netherlands: results from the first year in community-based physical therapy. Physical Therapy. 88(8), 936-946. Mielenz, T.J., Carey, T.S., Dyrek, D.A., Harris, B.A., Garrett, J.M., & Darter, J.D. (1997). Physical therapy utilization by patients with acute low back pain. Physical Therapy. 77(10), 1040-1051. Mitchell, J.M., & deLissovy, G. (1997). A comparison of resource use and cost in direct access versus physician referral episodes of physical therapy. Physical Therapy. 77(1), 10-18. Moore, J.H., McMillian, D.J., Rosenthal, M.D., & Weishaar, M.D. (2005). Risk determination for patients with direct access to physical therapy in military health care facilities. Journal of Orthopaedic & Sports Physical Therapy. 35(10), 674-678. Pendergast, J., Kliethermes, S.A., Fregurger, J.K., & Duffy, P.A. (2011). A comparison of health care use for physician-referred and self-re