Improving Eye Care In Rural India Communications Essay

Improving Eye Care In Rural India Communications Essay CATARACT refers to the clouding of the lens in the human eye, affecting vision. In the developing world, cataract is the cause for blindness in nearly half the blind population i.e. 50% of the recorded number of blindness cases. While problems of inaccessibility continue to plague many parts of the developing world nearly two-thirds of the population in many developing countries are unable to access quality medical resources infrastructure primarily because quality medical care or eye care in this case is still urban-centric all hope is not lost yet. In India too, where 90% of the cases are treatable, most Indians lack access to quality eye care. In the early 1990s, the country was home to a third of the worlds blind people and here too cataract blindness was the major cause in most cases. The World Bank decided to step in and help the Indian government deal with the problem, spending $144.8 million between 1994 and 2002 on the Cataract Blindness Control Project under which 15.3 million eye surgeries were performed. The World Bank-funded project was largely implemented in northern India and it helped reduce the incidence of cataract, in the states that were covered under this project, by half. But India is a very big country and it definitely needs a more sustainable approach to dealing with cataract blindness given that it has a sizeable ageing population. One such approach is the Aravind Eye Care System, a three-decade old campaign that has been fighting cataract blindness predominantly in the southern Indian state of Tamil Nad u. Working in the same direction is the L V Prasdad Eye Institue, operating from the neighbouring state of Andhra Pradesh. Both Aravind and LVPEI, setup in the mid 1970s and the mid 1980s respectively, have been focused on taking quality eye care to the rural masses from the very beginning, most of it free of cost. In the larger context, this paper discusses how private entrepreneurship is taking quality Eye Care to the rural masses in India. This paper will discuss the Eye Care delivery model aimed at fighting Cataract Blindness in the context of the Culture-Centered Approach (CCA). The Culture-Centered Approach advoates greater engagment with the local culture, â€Å"through dialogues with community members†, to ensure â€Å"equitable† and â€Å"accessible† healthcare across communities (Dutta-Bergman, 2004a, 2004b; Dutta and Basu 2007 as quoted in Dutta, 2008). Furthermore, this paper will use the Extended Technology-Community-Management (TCM) model (Chib Komathi, 2008) to explain the intersections between technology, community and the management of information communication technologies (ICT) in the context of the CCA and the Eye Care delivery model adopted by the private healthcare players i.e. the non-governmental organisations (NGOs). According to the TCM model (Lee Chib, 2008), the intersection of ICT characteristics of technology, along with the dimensions of software and hardware, project management dimensions of financial requirements, the regulatory environment, and stakeholder involvement, along with local community participation â€Å"will ultimately lead to sustainable ICTD interventions.† Culture-Centered Approach Globalisation has led to an increasing realisation that the Biomedical[6] model of healthcare is limited in scope when engaging in issues of global health (Dutta, 2008). Furthermore, Dutta (2008) says that many societies now feel the need to â€Å"open up the spaces of health communication to the voices of cultural communities† i.e. there is now greater awarness of the need for better engagement with marginalised communities. Culture is dynamic. That culture has an important role to play in health communication is better understood today. But this concept began attracting widespread attention only in the early 1980s, especially in the U.S. when healthcare practitioners felt a need to adopt multiple strategies to address the health-related issues of a multicultural population (Dutta, 208). â€Å"This helped question the universalist assumptions of various health communication programs† aimed at the developing nations and the so called third-world nations   (Dutta, 2008). The Culture-Centered Approach was born out of the need to oppose the dominant approach of health communication, located within the Biomedical model, where health is treated as a â€Å"universal concept based on Eurocentric[7] understandings of health-related issues, disease and the treatment of diseases† (Dutta, 2008). According to Dutta (2008), the CCA is a better alternative to understanding health communication because it is a â€Å"value-centered† approach. The CCA is built on the notion that the â€Å"meanings of health† cannot be universal because they are ingrained within cultural contextsm, he argues.  Ã‚   The CCA has its roots in three key concepts i.e. ‘structure, ‘agency and ‘culture. The term ‘culture refers to the local context within which so called health meanings are created and dealt with. ‘Structure encompasses food, shelter, medical services and transportational services that are all vital to the overall healthcare of various members of a community. ‘Agency points to the â€Å"capacity of cultural members† to negotiate the structures within which they live. It must be noted that ‘structure, ‘agency and ‘culture and entwined and they do not operate in isolation. Dutta (2008), in his book Communicating Health, further elaborates that the CCA throws light on how the dominant healthcare ideology serves the needs of those in power. Powerful members of society create conditions of marginalistaion. Therefore the focus of the CCA lies in the study of the intersections between ‘structure, ‘agency and ‘culture in the context of marginalised communities. To understand better the problems faced by the marginalised, the CCA advocates the healthcare practitioners engage in dialogues with members of the concerned community. Each community has its own set of stories to share and this is vital to understanding the local culture. The CCA also aims to document resistance, of any kind, to dominant ideologies as this helps strengthen the case of the CCA against the dominant healthcare model. The CCA, according to Dutta (2008), provides sufficient scope to study physician-patient relationships, in a bid to ultimately improve the healthcare deli very model. Adopting the CCA is just half your problem solved; the integration of the CCA with the Extended TCM model completes the picture.   The Extended TCM Model The TCM model (Lee Chib, 2008) argues that the larger question of social sustainability depends on both local relevance and institutional support. The TCM Model proposes that the intersection of ICT characteristics of technology, along with the dimensions of software and hardware, project management dimensions of financial requirements, the regulatory environment, and stakeholder involvement, along with local community participation, will ultimately lead to sustainable ICTD interventions (See Figure 1.1). The TCM model was further revised. Community was subdivided to include: modes of ownership of ICT investments and profits; training of community users both in the use and in technology management; and the basic needs of the community. Furthermore, Sustainability was also subdivided into financial and social (see Figure 1.2). Chib Komathi (2009) found that the TCM Model was inadequate as it could not examine the critical issue of vulnerability. Therefore, their study improved on this inadequacy by adding crucial factors and variables relating to vulnerability. They extended the TCM model, and called it the Extended Technology-Community-Management (Extended TCM) model (see Figure1.3).  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   This new framework on ICT planning accounts for community involvement, the management components, the overall design of technologies such as telemedicine or tele-consultation, and evaluation of existing vulnerabilities in the community where these technologies are implemented. It identifies four dimensions of vulnerabilities influencing technology implementation among the rural poor: economic vulnerability, informational vulnerability, physiological/psychological vulnerability, and socio-cultural vulnerability. Chib Komathi (2009) further explain each dimension of vulnerability: Physiological and psychological vulnerabilities refer to the physical and mental well-being of an affected person, or a specific community. Informational vulnerability deals with the access to and availability of information within affected communities. Informational resources include personal documents, books and critical data, opinion leaders and professional experts,. The lack of such resources affects the capabilities of people who are dependent on them. In a rural setting, informational vulnerability is further augmented by the low literacy levels and lack of pertinent â€Å"technological skills necessary to enable the learning and processing of information.† The economic vulnerability is sparked off by the loss of livelihood i.e. a loss of activities that otherwise financially support households and sustain economic growth in a rural setting. The socio-cultural vulnerability of communities is determine d by â€Å"the structure and values of a given society that define human relationships in communities.† Hierarchies in any society (gender, race, religion, caste, age and class egalitarianism within communities) or a community often dictate access to resources and assets, and the decision-making power of people. Cataract Blindness in India At the outset, one has to understand the sufferings of the blind in India, in a rural setting blindness, irrespective of the cause, results in a loss of livelihood for an individual. In rural India, like elsewhere, this would translate into one less earning member in the family, making the blind person a burden to his/her family. This leads to a loss of dignity and status in the family. In effect, blind people in rural India, like in many other societies, are marginalized. Enter Aravind and LVPEI, who continue to strive to help blind people in rural India and empower them by giving them back their sight. There are many causes of blindness, like Diabetes for instance. But Cataract is one of the leading causes of blindness in the developing world. Records in India show that Cataract is the most significant cause of blindness in the country (Nirmalan et al. 2002 Murthy et al. 2001).Cataract, reports say, is responsible for 50 to 80 per cent of the bilaterally blind (Thulsiraj et al. 2003 Thulsiraj et al. 2002).The elderly are more at risk of developing Cataract. India aims to eliminate needless blindness by 2020 in line with ‘Vision 2020: the right to sight initiative, launched jointly by the World Health Organisation (WHO) and the International Agency for Prevention of Blindness (IAPB). Many organisations worldwide are also working in the direction of eliminating needless blindness (Foster, 2001). The government in India and the World Bank launched the Cataract Blindness Control Project in seven states across India in 1994.From close to 1.2 million cataract surgeries a year in the 1980s (Minassian Mehra 1990), Cataract surgical output tripled to 3.9 million per year by 2003 (Jose, 2003). In 2004, World Health Organization (WHO) data showed that there was a 25 per cent decrease in blindness prevalence in India (Resnikoff et al. 2004) the reason(s) could be the increase in Cataract surgeries countrywide. But there is a larger problem here, that of population growth. The aged population in India (those aged over 60 years) population which stood at 56 million people in the year 1991 is expected to double by the year 2016 (Kumar, 1997). This ‘greying of Indias population only suggests that the number of people ‘at-risk of developing Cataract is constantly on the rises. In the larger sense, this paper aims to show how private entrepreneurship in India is taking quality eye care to the rural masses in that country. This paper aimed to discuss the same through two case studies, that of the Aravind Eye Care system as well as the L V Prasad Eye Institute (LVPEI). Unfortunately, email correspondence with LVPEI failed to elicit responses from this organization. Given the limitations of this study, including time constraints, this paper will explain the Aravind Eye Care system in the context of rural Eye Care in India and the fight against Cataract Blindness all this within the framework of the CCA. Furthermore, this paper will critique the business model of NGOs like Aravind in the context of the Extended TCM model, including whether for-profit organisations are using the rural masses to support their business model. In particular, what is the role of the healthcare provider in this case disseminate knowledge to the grass-roots or live-off their healthcare delivery model? Aravind Eye Care Dr. G. Venkataswamy had a very simple vision when he first setup Aravind Eye Care in 1976: â€Å"Eradicate needless blindness at least in Tamil Nadu, his home state, if not in the entire nation of India.† Aravind began as an 11-bed private clinic in the founders brothers house in the southern Indian city of Madurai. Today, the Aravind Eye Hospital (AEH) at Madurai is a 1,500 bed hospital.   In addition to Madurai, there are four more AEHs in Tamil Nadu (Aravind.org) with a combined total of over 3,500 beds. By 2003 the Aravind Eye Care System as we know it today was up and running. The System continues to operate under the aegis of a nonprofit trust named the Govel Trust it comprises of a manufacturing facility (for manufacturing synthetic lenses, sutures, and pharmaceuticals related to eye care); eye hospitals; education and training (graduate institute of ophthalmology); research facilities (complete with an eye bank);) and a center for community outreach programs (Prahlad, 2004). A typical day at Aravind now has doctors performing about 1,000 surgeries including free surgeries; 5-6 outreach camps in rural areas where about 1,500 people are examined and close to 300 people are brought to an AEH for eye surgery (TED, 2009). How does Aravind do it? The organisation has setup ‘vision centers or clinics in remote villages, fitted with basic eye care equipment. Each clinic is manned by an ophthalmic assistant and â€Å"these clinics perform basic examinations; prescribe corrective lenses and treat minor ailments.† If an eye ailment can be cured by the application of eye drops, these clinics are equipped to do so.   For more complicated cases, such as Cataract Blindness, the patient consults an ophthalmologist based at an AEH in a nearby city via the videoconferencing route. If the patient needs corrective surgery, he/she is asked to hop onto a bus waiting outside the ‘vision centre that takes them to the nearest Aravind base hospital. The patients are operated upon the following day; they spend a day in post-operative care and then take a bus back to their villages all free of cost (Laks, 2009).[8] But it wasnt all gung-ho in the beginning; more hard work than anything else. There was no specific Outreach team. Everyone in the pool was asked to participate in Outreach programme. â€Å"In the beginning (in 1976-77) Dr. V and a small team would visit villages and conduct eye screening camps. Those who required Cataract surgery would then be advised to visit the base hospital for surgery. But Dr .V found that a majority of those advised to undergo surgery would dropout, owing to socio-economic factors like fear of surgery; lack of trust on restoration of sight; no money to spend for transport, food and post operative medical care and (their) resistance to western medicine,† according to the head of Outreach activities at Aravind, R. Meenakshi Sundaram in his email response to my queries. These barriers were gradually addressed through various strategies. â€Å"We decided to involve village chiefs and local organizations to take ownership of the Outreach programmes, in terms of identifying the right location for the Eye Camp and providing the required support facilities. Their help was key to community mobilization. We organized a team to standardize the quality in Eye Care service delivery. Furthermore, Dr. V focussed his attention on building hospitals like ones home where we normally expect basic culture and values,† said Mr. Sundaram. â€Å"Fear of surgery was a common barrier in addition to other factors. Perhaps the acceptance for surgery was low in the beginning. But it was constantly explained at the community level whenever camps were organized as the programme aims to serve people at large. Particularly, in the year 1992 the Intra Ocular Lens (IOL) was introduced and the rural community did not believe in having a ‘foreign particle in their eyes. We came across a lot of myths. Those issues were addressed thru counselling,† added Mr. Sundaram. Realizing the impact of counselling, a cadre was developed within the System in 1992 and seven counsellors were trained in the first batch of counsellors training. They were given a basic orientation about common eye problems with a special focus on IEC. ‘Patient counsellors i.e. patients who had undergone eye surgery were asked to help the Outreach team. â€Å"They played their role in explaining eye problems in the local language and tried to help others realize the consequences of failing to accept surgery. Considering the myths, a real IOL was used as education material to help the rural folk understand the concept of the IOL,† Mr Sundaram said. The number of counsellors has steadily risen ever since and stands at 179 at present. How is the Aravind Eye Care System possible? Financial self-sustainability was the primary focus from day one at Aravind. Initially, the organization was given a grant by the government to help subsidize the treatment costs for eye camp patients (Prahlad, 2004) and the Govel Trust also pledged properties to raise money from banks in the early days. Prahlad (2004) states that the Madurai AEH, the first, was always self-supporting as far as recurring expenditures were concerned. Within the first five years of operation, the Madurai AEH had accumulated surplus revenues for further development and for the construction of four other hospitals in the Tamil Nadu state. He adds that over the years, the patient revenues generated from its five hospitals located in five cities finance the Aravind Eye Care System to a great extent. Furthermore, Aravind has also taken to the management-contract route and it manages two hospitals outside of its home-state. While city folk are charged market rates for each consultancy and for surgery, patients in remote villages pay just Rs. 20 for three consultancies or SGD 0.60. (TED, 2009). Those who can afford to pay, the urban folk who visit Aravinds hospitals in urban locations on their own, do not get discounted rates. Such a system of cross-subsidies ensures that only 45 percent pay while the rest are not charged at all i.e. about five out of every 10 patients examined at Aravind can be provided free eye care, including eye surgery (TED, 2009). A cross-subsidising financial model is not the only mantra[9] to Aravinds success. Having been in the business of delivering quality Eye Care for over three decades now, the System is well-positioned to leverage on the Aravind brand-name to attract donations. Over the years, the organization has received international recognition for its work and this includes the 2008 Gates Award for Global Health, and this years Conrad N. Hilton Humanitarian Prize that carries a US$1.5 million cash award. Last but not the least is the money that flows into Aravind in the form of specific project-funding. One such sponsor is the London-based ‘Seeing Is Believing (SiB) Trust, a collaboration between Standard Chartered Bank and the International Agency for Prevention of Blindness (IAPB). Since 2003, ‘Seeing is Believing has grown from a staff initiative to raise enough money to fund a cataract operation for each member of the Bank to a US$40 million global community initiative. I wrote to Standard Chartered Bank (SCB) asking them why they decided to partner with Aravind and LVPEI. â€Å"LV Prasad Eye Institute, Hyderabad, as well as Aravind Eye Hospital are premier eye care institutes in the country.   India has a vast geographic spread and both these institutions work in different geographic zones of the country.   LVPEI is prominent in the south-eastern states of the country while Aravind is prominent in the southern states of India,† said Pratima Harite, Manager (Sustainability), Corporate Affairs- India in her email response to my queries. The rationale behind the India Consortium Project is the ‘vision centre concept that a significant proportion of eye problems corrected or detected at the primary care level has substantial savings to the individual and to the communities.   â€Å"Based on the success of LVPEIs Vision Centre model, the India Consortium Project proposed scaling up the development of Vision Centres in a co-ordinated matter in six states across the country.   For this, LVPEI sought support from four key implementing partners premier eye care institutions themselves across the country,† added Ms. Harite. Singapores Temasek Foundation (TF) part-funds SiB activities in India, particularly in capacity building i.e. in enhancing the training component of the SiB programme. Is this a viable business model? Aravind has perfected the model over the last three decades. They have the technology, behind the video consultation, in place â€Å"a low-cost wireless long-distance network (WiLDNet)† put together by the Technology and Infrastructure for Emerging Regions (TIER) research group at the University of California, Berkeley, California, USA.[10] This was done to overcome the issue of zero internet connectivity or slow connections that do not support video consultations in remote villages (Laks, 2009). In 2004, a mobile van with satellite connectivity was introduced to facilitate Tele-Consultations. The Indian Space Research Organisations (ISRO)[11] help was sought to this extent. The ‘vision centres can easily communicate with the base hospital (some 30 to 40 kms.) via satellite. These ‘vision centres effectively address the issue of accessibility, affordability and availability of quality Eye Care. â€Å"A series of centres were started across the Tamil Nadu state. Each base hospital is connected with a group of vision centres. At present, we have 10 ‘vision centres that operate on WiFi. The rest run on BSNL[12] broadband connections,† Mr Sundaram said. Aravind has the delivery system in place. A sound understanding of the local culture that in many cases is averse to western medicine and where modern-day medicine is not the first and only option to treat any disease or ailment. Why would a villager trust a doctor who drives down one fine morning and says he would like to operate upon them? Aravind begins by appointing a volunteer group for each community; some of these volunteers are further trained to serve as ophthalmic assistants and even as nurses in Aravinds hospitals. In a rural setting, rural folk trust their friends, neighbors, and their own people first. It is about creating ownership to the problem, like Mr. Sundaram said, and then partnering with the community to solve the problem. Aravinds financial results for the year 2008-09 were healthy. It raked in (income) US$22 million and spent (expenditure and depreciation) US$ 13 million.[13] Discussion That Aravind and other NGOs working in a similar direction, like LVPEI for instance, use the Culture-Centered Approach, as elaborated by Dutta (2008), in delivering quality eye care to rural India is quite clear. Aravind, in particular, has successfully integrated the CCA with the Technology-Communication-Management (TCM) model, as elaborated by Lee Chib (2008) to create a sustainable model for Eye Care delivery. ‘Accessibility and ‘affordability are the key factors in such healthcare models. In taking this route, one has to ensure that the technologies chosen for the job are cost-effective and easy to implement because capital expenditure and operational expenditure do play a vital role in determining the cost of healthcare services. Aravind has been able to keep the cost of Eye Care delivery considerable low consistently for many years now. Critics argue that organizations like Aravind are feeding-off their model. At this point, it is important to understand the ground-realities. In India, the divide between the urban ‘haves, and the rural ‘have-nots is only getting wider with each passing year. According to UN projections released 2008, India would urbanize at a much slower rate than China and have, by 2050, 45% of its population still living in rural areas (Lederer, 2008). The Government in India is not doing enough to address the plethora of health issues that plague [the various regions and communities in] the country. The flagship scheme to improve healthcare services in rural India, the National Rural Health Mission    launched in 2005 as a seven-year programme has many of its goals yet to be achieved, and the government is now considering extending it to 2015, according to recent media reports. Despite many a government claims and many a government schemes several villages in states across India co ntinue to depend on the private sector for quality healthcare or in this case Eye Care. Given this situation, Aravind and LVPEIs work in the direction of providing affordable Eye Care and free eye surgeries to five out of every ten patients they examine is a commendable feat.   A second question raised in this study is, what is the role of the healthcare provider in this case disseminate knowledge to the grass-roots or live-off their healthcare delivery model? Aravind is doing its part in disseminating knowledge to the grass-roots. Most ophthalmic assistants who man the ‘vision centers are community members trained by Aravind. But one has to understand that the act of knowledge dissemination in a remote rural setting has its challenges i.e. tackling illiteracy, basic awareness among others and these challenges cannot be addressed in just a few years. The India Consortium Project, sponsored by SCB and Temasek Foundation, set a target to set up 40 ‘vision centres by 2010. So far, 32 ‘vision centres are operational and the remaining will be operational this year, according to Ms. Harite.   On the flip side, a study by Murthy et al. (2008) argues that the goals of the ‘Vision 2020: the right to sight initiative to eliminate Cataract blindness in India by the year 2020 may not be achieved. But this should not deter those working in this direction. Both the public and the private sector must continue to fight Cataract Blindness because that is the only way to tackle the problem at hand. Last but not the least, this study recommends that NGOs operating in the healthcare space look at both the CCA and the TCM model to ensure better service delivery. References Chib, A. Komathi, A.L.E. (2009). Extending the Technology-Community-Management Model to Disaster Recovery: Assessing Vulnerability in Rural Asia. Submitted to ICTD 2009. Dutta, M. J. (2008). Communicating Health. Polity Press, Cambridge, U.K. Foster A. (2001).Cataract and Vision 2020 the right to sight initiative. British Journal Ophthalmology, 85, 635-639. Jose R, Bachani D. (2003). Performance of cataract surgery between April 2002 and March 2003. NPCB-India;2:2. Kumar S. (1997). Alarm sounded over Greying of Indias population. Lancet, 350, 271 Lee, S., Chib, A. (2008). Wireless initiatives for connecting rural areas: Developing a framework. In N. Carpentier B. De Cleen (Eds.), Participationand media production. Critical reflections on content creation. ICA 2007Conference Theme Book (pp. 113-128). Newcastle, UK: Cambridge Scholars Publishing. Lederer, E.M. (2008). Mint. Retrieved April 16, 2010, from http://www.livemint.com/2008/02/27231012/Half-the-world8217s-populat.html Laks, R. (2009). Videoconferencing and Low-cost Wireless Networks Improve Vision in Rural India. Comminit.com. Retrieved April16, 2010, from http://www.comminit.com/en/node/301452/307 Minassian DC, Mehra V. (1990). 3.8 Million blinded by cataract each year: Projections from the first epidemiological study of incidence of cataract blindness in India. Br J Ophthalmol, 4, 341-3. Murthy GV, Gupta S, Ellwein LB, Munoz SR, Bachani D, Dada VK. (2001). A Population-based Eye Survey of Older Adults in a Rural District of Rajasthan: I, Central Vision Impairment, Blindness and Cataract Surgery. Ophthalmology, 108,679-85. Nirmalan PK, Thulasiraj RD, Maneksha V, Rahmathullah R, Ramakrishnan R, Padmavathi A,et al. (2002). A population based eye survey of older adults in Tirunelveli district of south India: Blindness, cataract surgery and visual outcomes. Br J Ophthalmol, 86, 505-12. Prahlad, C. K. (2004). The Fortune at the Bottom of the Pyramid. Wharton School Publishing, Pennsylvanial, U.S. Resnikoff S, Pascolini D, Etyaale D, Kocur I, Pararajasegaram R, Pokharel GP,et al. (2004). Global data on visual impairment in the year 2002. Bull WHO, 82, 844-51. TED. (2009). Thulasiraj Ravilla: How low cost eye care can be world class. Retrieved April 16, 2010, from http://www.ted.com/talks/lang/eng/thulasiraj_ravilla_how_low_cost_eye_care_can_be_worl

Clinical Reasoning: Combining Research and Knowledge to Enhance Client Care

Making sound and client-centered clinical decisions in an area that demands accountability and evidence-based practice requires not only scientific knowledge, but also a deep knowledge of the practice of one’s profession and of what it means to be human in the world of combined strength and vulnerability that is health care. Every clinician must understand the importance of applying best research evidence to client care, the essence of evidence–based practice, to improve the overall quality of healthcare. Research continues to find that using evidence-based guidelines in practice, informed through research evidence, improves patients’ outcomes (Dykes et al, 2005). The literature is replete with definitions of evidence-based practice. Simply stated, evidence-based practice is the process of applying research to practice. Originating from the medical field in 1991, the term evidence-based medicine was established to ensure that medical research was systematically evaluated in a manner that could â€Å"inform medicine and save lives and that is superior to simply looking at the results of individual clinical trials† (Wampold & Bhati, 2004). An evidence-based practice is considered any practice that has been established as effective through scientific research according to a set of explicit criteria (Drake, et al, 2001). The term evidence-based practice is also used to describe a way of practicing, or an approach to practice. For example, evidence-based medicine has been described as â€Å"the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients† (Sackett, Rosenberg, Gray, et al, 1996). Evidence-based medicine is further described as the â€Å"integration of best research evidence with clinical expertise and patient values† (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). Rather than a relationship based on asymmetrical information and authority, in evidence-based practice the relationship is characterized by a sharing of information and of decision-making. The clinician does not decide what is best for the client, but rather the clinician provides the client with up-to-date information about what the best-evidence is regarding the client’s situation, what options are available, and likely outcomes. With this information communicated in culturally and linguistically appropriate ways clients are supported to make decisions for themselves whenever and to the extent possible. According to Burns and Grove evidence-based practice is nothing more than a problem-solving approach to the care that we deliver that takes into consideration the best evidence from research studies in combination with clinical expertise and the patient’s preferences and values (Burns & Grove, 2004). Pierce described in â€Å"Evidence-Based Practice in Rehabilitation Nursing† that â€Å"making patient-care decisions with current information and one’s clinical expertise enhances the ability to provide the best practice†. The author added that â€Å"evidence-based practice is a process that begins with knowing what clinical questions to ask, how to find the best evidence, and how to clinically appraise the evidence for validity and applicability to the particular care situation†. Then, the best evidence must be applied by a clinician with expertise in considering the patient’s unique values and needs. As stated by Law& MacDermit, â€Å"evidence for practice is not only about using research evidence, but using it in partnership with excellent clinical reasoning and paying close attention to the client’s stated goals, needs, and values†(Law & MacDermit, 2008). Although the terms best practices and evidence-based practice are often used interchangeably, these terms have different meanings. Evidence-based practice can be a best practice, but a best practice is not necessarily evidence-based; best practices are simply ideas and strategies that work, such as programs, services, or interventions that produce positive client outcomes or reduce costs (Ling, 2000). In order to bring research and knowledge into someone’s practice, it’s necessary to think critically. Becoming a critical thinker is a prerequisite of becoming an evidence-based clinician. But what is critical thinking? Critical thinking involves the application of knowledge and experience to identify patient problems and to direct clinical judgments and actions that result in positive patient outcomes. Critical reflection requires that the thinker examine the underlying assumptions and radically question or doubt the validity of arguments, assertions, and even facts of the case. Critical reflective skills are also essential for clinicians; however, these skills are not sufficient for the clinician who must decide how to act in particular situations and avoid patient injury (Wheatley DN, 1999). Critical reasoning is a process whereby knowledge and experience are applied in considering multiple possibilities to achieve the desired goals (Noll et al, 2001) while considering the patient’s situation (Fowler, 1997). According to Simmons it’s a process where both inductive and deductive cognitive skills are used (Simmons et al, 2003). Each client’s problem is unique, a product of many factors, including the client’s physical health, lifestyle, culture, relationship with family and friends, living environment, and experiences. Thus, a health care professional does not always have a clear picture of the client’s needs when first meeting a client. Because no two clients have identical problems, a clinician is always challenged to observe each client closely, search for and examine ideas and inferences about client problems, consider scientific principles relating to the problems, recognize the problems and develop an approach to client’s care. When clinicians make healthcare decisions for a population or group of clients using research evidence, this can be described as evidence-based healthcare practice. Another prerequisite to becoming an evidence-based clinician is to be a reflective professional. Reflection is an important aspect of critical thinking. As described by Miller & Babcock reflection is â€Å"the process of purposefully thinking back or recalling a situation to discover its purpose or meaning. With reflection, a clinician seeks to understand the relationships between theoretical concepts and real-life situations. The importance of reflecting on what you are doing, as part of the learning process, has been emphasised by many researchers. The concept of reflective practice was introduced by Donald Schon in his book named â€Å"The Reflective Practitioner† edited in 1983, however, the concepts underlying reflective practice are much older. John Dewey was among the first to write about Reflective Practice with his exploration of experience, interaction and reflection (Dewey, 1933). Schon described the concept as a critical process in refining one's artistry or craft in a specific discipline. The author recommended reflective practice as a way for beginners in a discipline to recognize consonance between their own individual practices and those of successful practitioners. He also stated that reflective practice â€Å"involves thoughtfully considering one's own experiences in applying knowledge to practice while being coached by professionals in the discipline† (Schon, 1996). As it was earlier said, there are a few steps toward evidence-based practice and rehabilitation. The first and the most important step in evidence-based practice is to determine a well-designed question that not only affects quality care but is of interest to the rehabilitation clinician and is encountered in practice on a regular basis. A useful ramework for formulating an appropriate clinical question is suggested by Sackett & colleagues. (Sackett, 2000). They proposed that a good clinical question should have at least three and sometimes four components: Patient or Problem; Intervention; Comparison (not mandatory); Outcome of interest. This has been referred to as the PICO (Patient /Problem, Intervention, Comparison, Outcome) or PIO (Patient / Problem, Intervention, Outc ome) approach. The question usually comes from diverse sources. As stated by Pierce, â€Å"the most common source is the rehabilitation practice itself†. Once the question in searching of evidence was formulated, the next and probably the most important step is to find the relevant evidence in the literature that will help in answering the question. It can be difficult to distinguish relevant from irrelevant information and to decide which source contains the most credible information and research data. Using research findings in practice improves care. Research utilization occurs at three levels—instrumental, conceptual, and symbolic: 1. Instrumental utilization is the direct, explicit application of knowledge gained from research to change practice (Gills & Jackson, 2002). 2. Conceptual utilization refers to the use of findings to enhance one’s understanding of a problem or issue in nursing (Gills & Jackson, 2002). 3. Symbolic utilization is the use of evidence to change minds of other people, usually decision makers (Profetto-McGrath, Hesketh, Lang, & Estabrooks, 2003). According to Hameedullah & Khalid, â€Å"all evidence must be appraised in the following areas: validity, importance and applicability to the clinical scenario† (Hameedullah & Khalid, 2008). Performing the previous steps will result in the appearance of a concrete piece of evidence which should be valid and important for the question in consideration. Now is the time to combine the clinical expertise and experience with the evidence generated to improve the outcome of specific client scenarios. It is also important to remember client’s values and circumstances while making such decisions. The evidence regarding both efficacy and risks should be fully discussed with the client in order to allow them to make an informed decision. This approach allows the formation of a decision in consultation with the client in the presence of good evidence and is consistent with the fundamental principle of evidence-based practice i. e. ntegration of good evidence with clinical expertise and patient values (Hameedullah & Khalid, 2008). Whether the intervention was appropriate and resulted in good clinical outcome for a certain group of clients, in a particular clinician’s hands, will only be answered by careful prospective outcome research. As Strauss and Sackett have suggested, we need to ask whether we are formulating answerable qu estions, finding good evidence quickly, effectively appraising the evidence, and integrating clinical expertise and patient’s values with the evidence in a way that leads to a rational, acceptable management strategy (Straus & Sackett, 1998). Although the importance of research-based practice was identified decades ago and has gradually been adopted by rehabilitation professions, there are a number of challenges for clinicians who are attempting to be use research to aid in clinical decision-making. According to Bohannon and Leveau most challenges can be grouped under one of three areas: research methods, clinicians’ skill, and administrative factors (Bohannon & Leveau, 1998). The research procedures of randomly assigning patients to an experimental or control group, using standardized outcomes measures that may not have real-world relevance, and the difficulty of blinding investigators and clients to the research procedures all make research results difficult to be implemented, interpreted and utilized clinically (Ritchie, 2001). Evidence-based practice requires clinicians to read current research literature, understand research methodology, and incorporate best evidence into practice as appropriate. As Sumison noted in one of his studies, it may be difficult to use in client-centered practice. The research literature may be difficult to access and relevant information is often not compiled in one place (Sumison, 1997). Interpreting and implementing research evidence also requires clinical skill, judgement, and experience. Deciding what constitutes evidence that justifies a change in practice can be challenging and the opportunity for bias exists at every stage of the process as Pomeroy observed in one of his articles from 2003 (Pomeroy, 2003). There are many other factors that present challenges to clinicians who are attempting to use evidence to guide their practice. Time constraints are almost universally identified as a primary limiting factor. Schreiber and Stern stated that â€Å"clinicians refer to pressures of today’s health care environment and administrators’ emphasis on productivity as factors that directly inhibit their ability to seek out, gather, read, and integrate cientific information relevant to daily practice† (Schreiber and Stern, 2005). The concept of evidence-based practice is of great importance for rehabilitation and physiotherapy to allow for increased insight for all involved including patients, clinicians, third-party payers, and government and health care organizations, into the clinical decision-making processes. The purpose of promoting this paradigm is optimum quality of care with conservation of professional autonomy.

Internet Censorship Research Paper Essay

Imagine a place where you had access to any information you needed, at any time. Some might say that this place may not exist, but others could say that this defines the Internet. The Internet gives you access to all sorts of wonderful knowledge and other content, but with good comes some bad. Countries throughout the world have begun, or are trying to begin, censoring the Internet of these bad things. Many countries in the Middle East and North African States have taken to filtering entire websites on religious grounds (Dobby) and just last year, several bills, such as SOPA (Stop Online Piracy Act) and Protect IP (Prevent Real Online Threats to Economic Creativity and Theft of Intellectual Property act) proposed shutting down â€Å"rogue† websites that contained copyrighted property, but Internet censorship walks the fine line between protecting the public and preventing free speech. The problem with censorship is that once it starts, there may be no stopping it, and would violate the First Amendment, freedom of speech. Mariam Adas, a Facebook campaign organizer for Jordanians against censorship, believes that there’s no way to do it right. Government will use blocking offensive/copyrighted/pornographic material as a precedent and then further block and filter other political, social and media websites (Ghazal). The aforementioned American bills, SOPA and Protect IP, where so carelessly written, that they would have the power to entirely shut down full websites, such as Facebook, Wikipedia and YouTube for content submitted by users (Hitzik). To pass censorship laws like these would totally contravene our own Amendments. Free speech is the right to speak you opinion in public without censorship. To take away that right would be unconstitutional, and un-American. For example, the British Matthew Woods, 19 years old, was sentenced to 12 weeks in jail for simply posting drunken, distasteful jokes about a recent abduction of two girls. While the remarks where horribly offensive, no one should be prosecuted for using their voice, and that voice should not be censored. Doing such will lead our culture into believing it has a right not to be offended (Chu). One of the main reasons for supporting Internet censorship is to protect children from seeing indecent materials, such as pornography. This is understandable, but it is unfair to hinder adults from viewing adult materials, and for this reason there are many ways that parents and guardians can protect their children from such things, says Adas. One may contact their internet provider, or download applications to filter out inappropriate websites (Ghazal). Filters are also placed on moral and religious standing. The dilemma is that there are many different moral and religious standings, and attempting to filter the Internet to a point that pleases every group would be impossible. People should be afforded the right to use their own discretion and self-adjudicate on what they would like digest. In the end, the issue of Internet censorship is always controversial. Nevertheless, America is a society based on freedom, and the right to free speech does not belong only to the press, but to each individual person. This freedom of should be extended to the Internet, no exceptions. A quote, by Robert A. Heinlein comes to mind: â€Å"The whole principle is wrong [censorship]; it’s like demanding that grown men live on skim milk because the baby can’t eat steak. † Works Cited Chu, Henry. â€Å"Britain Wrestles with Free Speech on Web. † Los Angeles Times. 09 Nov 2012: A. 1 SIRS Issues Researcher. Web 05 Mar 2013 Dobby, Christine. â€Å"Muslim Countries Filter Web on Faith Grounds, Report Says. † National Post. 04 Aug 2011: FP. 12. SIRS Issues Researcher. Web. 05 Mar 2013. Ghazal, Mohammed. â€Å"Internet Freedom Activists See Bad Precedent in Drive to Censor Porn Sites. † Jordan Times. 02 May 2012. N. P. SIRS Issues Researcher. Web. 27 Feb 2013. Hitzik, Michael. â€Å"Big Guns Take Aim at Internet Piracy. † Los Angeles Times. 11 Dec 2011: p. B. 1. SIRS Issues Researcher. Web 25 Mar 2013.

Asia Pacific Region The Largest Tourist Destination Essay

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